Ambulatory Care NursingAnalysis of Payroll Operations

April 25, 1990Industrial and Operations Engineering 481

Management Systems

,4cIw My

• EDIGLM1lGANCER

MANAGEMENT SYSTEMS

EXECUTIVE SUMMkRY

The objective of this project, was to analyze the AmbulatoryCare Nursing payroll system, with the following goals:

‘To produce a flowchart of the current payroll system

‘To identify areas in the current process that can beimproved

‘To make recommendations for improvement

Our investigation consisted of interviewing on site andsatellite nurse managers, payroll clerks, and relatedhospital and campus personnel; and observing the payrollprocess itself.

The results of our investigation can be seen in the flowcharts, Figures 1 through 5 in the body of the report. Thepayroll process is complex and time consuming. We found thatdue to hospital and campus constraints, the payroll processinvolved procedures that resulted in more opportunities forerrors to occur. Hospital and campus constraints, such asthe payroll deadline and the payroll forms are not changeableunder the scope of our project.

Theteam then consulted the nurse managers The purpose of

these interviews was to gather and record processes andopinions of the nurse managers The team then reviewed theinformation and found that some nurse managers are spendingconsiderable time collecting and entering the payroll timesinto ANSOS, the Automated Nurse Staffing Office System. Ouranalysis showed that a lack of ANSOS terminals combined withthe extremely slow ANSOS operations, “computer illiteracy,”the new nursing contract, and lack of teamwork are majorattributes to this problem. Furthermore, the nurse managersmake several trips to deliver information to the payrollclerk, Connie Kidder. This underutilization of the nursemanagers time may be corrected by a more efficientinformation storage, retrieval, and transmission and/orclerical help.

The scope of the assigned project also includes the satelliteM—Care Centers. The nurse managers at these remote clinicsrecord their nurses’ hours without the aid of ANSOS andeither fax or telephone in their records, using a variety offorms. Common among all nurse managers is a lack ofunderstanding of exactly what information is required byConnie, and when it is due.

We recommend a quality approach for the improvement of thecurrent payroll system. The term quality is defined here asa freedom from defects, or a freedom from inaccurate

•

• $‘MDICAL1 MIlUNCENfER

MANAGEMENT SYSTEMS

timesheet information being submitted to payroll. Thisapproach is typified by our recommendations for improving theaccuracy and timeliness of the current system:

•Standardization of the payroll forms and satellitetimesheets

•Docurnentation for all nurse managers listing standardrequirements and deadlines concerning the payrollprocess

•Delegation of authority to nurse managers and/or theirassistants for “Authorized Signatures”

•Simplifying and automating much of Connie’s manual work

Each of these recommendations address a link where we havefound an information/communication breakdown. If theserecommendations are implemented, we expect the AmbulatoryCare Nursing payroll system to run more effectively at adecrease in costs and an increase in productivity.

tMVEI9Y rs’EDICAL2 MiCHIGAN CENTER

MANAGEMENT SYSTEMS

INTRODUCTION

The Ambulatory Care Nursing Payroll System is currently beinganalyzed by a group of students acting under the direction ofManagement Systems. This project team is made up of MichaelFee, Sherry Hailer, Andrea May, and Irfan Virk.

PROJECT DEFINITION

Purpose: Analyze the payroll system in the ambulatory carenursing unit

Goals: •To produce a flowchart of the current payrollprocess in Ambulatory Care Nursing unit.

L•To identify areas in the current process that canbe improved.

•To make recommendations for improvement.

Background: Continuous problems with timeliness, efficiencyand accuracy of payment process. New nursecontract and ANSOS (the Automated Nurse StaffingOffice System) implemented for scheduling andtracking of nurses’ work times.

INVESTIGATION

The team initiated their project by first meeting with theclient, Joan Robinson, the Director of Ambulatory CareNursing; and the Assistant Director of Ambulatory CareNursing, Candia Laughlin. The result of this meeting was ageneral understanding by the student team members of thecurrent payroll system and associated problems. The teamthen proceeded to write a preliminary project proposal.After several weekly meetings with Candia Laughlin, a finalproject proposal was written and signed by clients and teammembers.

The next stage of the project was to consult the nursemanagers who play a role in the current payroll process. Thepurpose of these interviews was to gather and recordprocesses and opinions of the nurse managers regarding thepayroll. The team then reviewed the information and foundthat the nurse mangers seem to have varied opinions about thepayroll process. Some nurse managers believe that it istheir responsibility to ensure that each nurse in theirrespective department is paid correctly. These nursemanagers who typically have no problems with payroll eitherare very familiar with ANSOS, or they are responsible forsmall departments. For example, one nurse manager, who has

3 MICHIGAI’ L4 CENIER

MANAGEMENT SYSTEMS

no problems with payroll, reported that it takes her 30minutes to complete payroll without any interruptions, andthen she calls in her amendments on Monday morning.

On the contrary, some nurse managers believe that payrollshould be completed by “someone who has a knack for numbers”.Nurse managers with this particular attitude report thatpayroll is too time consuming, very tedious, and in generalit takes away from other nursing responsibilities. Thisburden could be relieved by part—time clerks. At the time ofour observations, however, dissatisfaction was high becauseof the demands based on the new nursing contract. Some ofthe nurse managers were optimistic that the exorbitant amountof time spent on what they considered to be clerical work——the data entry——would be reduced once they became familiarwith the new contract and its effects on the ANSOS symbols.

The new nursing contract is only one factor affecting theamount of time spent on data entry. Two other factors areinadequate computer experience, and ANSOS itself. Some ofthe nurse managers do not have much experience on computers.They are not of the generation that is growing up oncomputers, thus if they have not taken the time to learn howcomputers can be an asset, the have found themselves at aslight disadvantage, not just at the hospital, but in today’sworld, which is highly computerized. ANSOS is notparticularly user—friendly, and if one had to becomeacquainted with computers and the ANSOS system at the sametime, one could expect to spend a great deal of time on dataentry. Another reason for the complexity of the ANSOS systemis that the University of Michigan Hospitals exceed allparameters for computer programs such as ANSOS, which putslimitations on what can be effectively done. Preliminaryanalysis showed that a lack of ANSOS terminals combined withthe extremely slow ANSOS operations are also major attributesto the problem.

Furthermore, the nurse managers make several trips to deliverinformation to the payroll clerk, Connie Kidder. Thisunderutilization of the nurse managers time may be correctedby a more efficient information storage, retrieval, andtransmission and/or clerical help. One major step towardsthis goal would be to install ANSOS equipment in Connie’soffice. This would allow her to print out ANSOS in heroffice, thus saving Nurse manager time because the Nursemanagers would not have to hand-deliver the information.

The scope of the assigned project also includes the satelliteM—Care Centers. The nurse managers at these remote clinicsrecord their nurses hours without the aid of ANSOS and eitherfax or telephone—in their records, using a variety of forms.Common among all nurse managers is a lack of understanding ofexactly what information is required by Connie, and when itis due.

NJE flJj4 MICHIGAN CENTER

MANAGEMENT SYSTEMS

Concurrently, the team also reviewed the process which isfollowed by Connie Kidder, the payroll clerk. Thisinformation was translated into the flow chart, Figures 1 and2, pages 6 and 7. The process, which requires much manualdata calculation and entry, begins on Wednesday (nine daysbefore payroll checks are issued) . Connie first prepares theofficial payroll timesheets of the university, hospital, andvarious grants by reviewing names and the account breakdownfrom which they are paid. (Copies of these timesheets areincluded in Appendix A) On Thursday and Friday, timeinformation is received from the nurse managers as describedabove. Connie then transcribes this information to theprepared timesheets. Since actual hours worked can differfrom information delivered to Connie, the nurse manager mustnotify Connie of these changes by Monday morning. Beforethese timesheets are given to payroll, most nurse managersreturn to Connie’s office to initial the timesheets for theirnurses. Each timesheet also requires authorized signature.Initially, this required either the director or assistantdirector of Ambulatory Care Nursing to sign each timesheet.

The payroll forms for Ambulatory Care Nursing are due Mondayby 11:00 a.m. Between Monday afternoon and Friday, thepayroll process on campus and at the hospital is similar. Atthe hospital, Monday is used primarily for screening commonerrors, rechecking Connie’s work, and posting adjustments.Hospital payroll sends their payroll sheets to Campus payrollby 4:30 Monday afternoon. Campus then sends their owntimesheets for Ambulatory Care Nursing, along with Hospitals’timesheets for Ambulatory Care Nursing to Datacheck inSouthfield. Datacheck proceeds to keypunch the necessarypayroll information, and the batches of keypunchedinformation is returned over the telephone lines by Tuesdayevening.

Hospital and Campus Payroll receive the payroll batches onWednesday morning. Payroll is checked once again for errorsand efforts are made to make sure that everyone will receivea paycheck. Copies of the payroll report are then sent toeach department for verification, and finally the checks aredispatched Thursday, and imprest checks are cut. Hospitalreported that they cut an average of 364 imprest checks amonth, which cost approximately $100 each to process.

Currently, Campus Payroll is working on designing newtimesheet documents so that the payroll can be keypunched inAnn Arbor. In the long run, both Campus and Hospital Payrollhope to cut out the intermediate steps of downloading payrollinformation from ANSOS and keypunching. The goal is to havechecks issued straight from ANSOS.

The payroll system which was documented is, in fact, alreadyobsolete. Throughout the course of the project, there have

MEDICAL5 MICHIGAN 4CENTER

MANAGEMENT SYSTEMS

Present Situation Flow Chart (part 1)

f’Start PayrolProcess

CollectPayroll Forms(4 different

forms)

sheets to prep..-. appointm.nt / Wednesday (Week 1)Phone—in time Connie begins Data about /

(Ch.ls.) tim..h..ts perc.ntag.s /Satellites ANSOS sheetsfax time hand

d.liv.red to Thursday/Friday (Week 1)sheets (5 —

Connieforms)

different[4

-

Connietranscribes Thursday (Week 1) thru Monday (Week 2)hours to (Including Saturday)various

t imesheets

Comoute “TimeOvertime Yes RecodingPatient PayrollCare? Adustment for

new contract

No

4

Memo returned /hours managers to

acknowledge // delivered jf notify Connie

/ Changes ,// Nurse

they occur /of any

LNflY MEDICALMICHIGAN h-ii1 CENTER6MANAGEMENT TEMS

Figure 2. Present Situation Flow Chart (part 2)

Nrs.Managersreturn to Monday (Seek 2)authorize

t ia.sh..ts

JrAest. Director

or Director(Candia/Joan) Monday (Week 2)

sign eachtimesh..t

Delivered to -

Payroll (drop Monday (Week 2) 11:00 A.M.box)

__________________

Jriquests for / Payrollimprest I information

checks as I processed by Monday (Week 2) thru Friday (Week 2)needed / the

jUniversity

‘I,Checks issued Thursday/Friday (Week 2)

Yes ErrorReported by

Employee?

C No

EDIGL7 MICHIG±N4CENUER

EndMANAGEMENT SYSTEMS

been modifications in the payroll process, such as thetransference of signature authority from the director andassistant director of nursing to the head nurses (althoughthe assistant head nurses in some instances are the onesdoing the payroll for some units, they have not been givensignature authority by Joan Robinson, the use of electronicmail by Connie, and the addition of a third server.

According to hospital information services, Connie is in theprocess of getting ANSOS in her office, although it will taketwo to three months to obtain all the hardware. Once she hasANSOS in her office, she will be able to print off the ANSOStimesheets directly in her office, which will save the headnurses and/or assistant head nurses the wait time forprinting and the travel time for delivering. This is themethod that was found to be the most time efficient for theMott/Women’ s/Holden payroll system.

An alternative system that supposedly runs more smoothly thanour clients’ system is the Mott/Women’s/Holden payrollsystem. We were, therefore, asked by our client, CandiaLaughlin, to observe the two clinics (Pediatrics and OB/GYN)in the Mott/Women’s/Holden payroll system to determine thecause of their alleged efficiency over the Ambulatory CareNursing payroll system. One major difference between the twosystems is the Mott/Woen’s/Holden has two payroll clerkslocated in the Clinical Faculty Office Building who haveaccess to ANSOS in their office. They print the ANSOStimesheets there, instead of the nurse managers printing themand bringing them to the clerks. The nurse managers in theclinics work with the payroll clerks as a team to get aquality product (i.e. accurate payroll sheets) into thedropbox by 11 a.m. Monday morning.

The Ambulatory Care nurse managers do not seem to make an as—effective team with Connie. In some instances, there seemsto be a lck of understanding for what Connie does, which inturn, does not allow Connie to have “pride of workmanship,”as per W. Edwards Deming’s twelfth point of continualimprovement. This did not seem to be the case with theMott/Women’ s/Holden payroll system.

Deming’s ninth point is, “Break down barriers between staffareas,” and his fourteenth point is, “Put everybody in thecompany to work to accomplish the transformation.” (Deming,1986, pp. 23-96) Improving the quality and the costeffectiveness of an organization is not just uppermanagement’s job. The improvement of quality and costeffectiveness can be accomplished by teamwork among everyone——the nursing staff, nurse managers, and the payroll clerk.The nurses must work with the payroll clerk to get a qualityproduct out on Monday.

MEDICAL8 CE1\TER

MANAGEMENT SYSTEMS

“Deming, Juran, Crosby, and other quality experts agree thatapproximately 85% of the quality problems and opportunitiesfor improvement relate to changes in the systems andprocesses to produce and deliver the service or product, orworking smarter. Only 15% of the improvement potentialrelates to employees working harder or more diligently.Therefore, the focus for quality improvements should be onimproving systems and processes.” (ICE 481 course pack, p. 9—11) This would be typified by our recommendations forimproving the accuracy and timeliness of the current system:standardization of the payroll forms and satellitetimesheets, simplification and automation of much of Connie’smanual work, and documentation for all nurse managers listingstandard requirements and deadlines concerning the payrollprocess.

RECOMMENDAT IONS

Our first recommendation is to standardize the timesheetswhich are used by the satellite care centers. The version wesubmitted is shown in Appendix B.

In comparison with the Mott/Women’s/Holden payroll, theAmbulatory Care Nursing payroll seems to lack effectivecommunication between nurse managers and the payroll clerk.Therefore, to improve the quality of communication, werecommend that the following guidelines for thestandardization of the payroll process be issued:

•ANSOS data must be accurate by 3:00 P.M. on Thursday.

(Untill Connie Kidder has ANSOS at her desk:•Payroll timesheets from on site locations are due in

Connie Kidder’s office by 3 P.M. on Thursday.)

•Payroll timesheets from satellite locations must befaxed to Connie by 3 P.M. on Thursday.

•Hospital and campus payroll sheets must be checked andsigned by on site nurse managers by 5 P.M. onFriday.

‘Changes in payroll information must be sent byelectronic mail from on site locations to Connie nolater than 8 A.M. Payroll Monday.

‘Changes in payroll information must be phoned in fromsatellite locations to Connie no later than 8 A.M.Payroll Monday.

As discussed in the investigation, the Director or theAssistant Director of Ambulatory Care Nursing are theauthorized signers of the campus and hospital timesheets. We

MEDICAL9 MlH1GAN CENTER

MANAGEMENT SYSTEMS

recommend that the authority be delegated to the actual nursemanager or assistant nurse manager who is entering the datainto ANSOS and knows better who is actually working.therecorded hours.

Lastly we recommend further automation of manual work. Thisincludes the use of electronic mail, or E—mail, by all nursemanagers and payroll clerk, the use of ANSOS by the payrollclerk to print out timesheet information, and also the use ofa fax machine and standard timesheet by all satellites.

By applying these recommendations to the present situationflow chart, Figures 1 and 2, we developed a new flow chart.This is shown as Figures 3 and 4, pages 11 and 12. Alsoincluded is an “optimistic” flow chart, Figure 5,page 13,which is the result of the university developing a systemwhich could down load the timesheet data directly from ANSOSto their check processing computers. This would eliminateall of the transcribing steps and further reduce thepossibility of error as well as allow time data to be enteredafter the period has ended.

If these recommendations and guidelines are implemented, weexpect the Ambulatory Care Nursing payroll system to run moreeffectively. In detail, the amount of re—work will bereduced, the quality will be improved (defects decrease),andthe work environment will be improved. In turn, this willlead to a reduction in costs and an increase in productivity.

LN1VERSY MEDICAL10 CEMER

MANAGEMENT SYSTEMS

Figure 3. Flow Chart Reflecting Recommendations (part 1)

Start PayrollProcess )

Satellitesfaxin

imesheets ona standard

form

By Thursday 3:00 P.M.(Week 1)

Nt ices

N1 MEDICALMICHIGAN CENTER

CollectPayroll Forms(4 different

forms)

I--- IWednesday (Weak 1)

On site nursemanagers

input payrolldata into

ANSOS

Connie printsout ANSOS

t imesheets

‘I,

Thursday After 3:00 P.M.

Thursday (Week 1) thru Monday (Week 2)

Connietranscribeshours topauroll

t imesheets

Nursemanagers

notify Connieof anuchances

// /

MANAGEMENT SYSTEMS

Hligure 4. Flow Chart Reflecting Reccmenaacons part 2)

Nurse Managers?AssistantsAuthorize Friday (W..k 1)

(Sign)Timesheets

‘I,Deliver to

Payroll Monday (Week 2) 11:00 A.M.Dropbox

____________________

1Requests for / Payroll

Imprest / informationChecks as / processed by Monday (week 2) thru Friday (Week 2)needed University.

‘I.Checks issued Thursday/Friday (Week 2)

Yes ErrorReported by

Employee?

No

9’ MEDICAL12 CEMER

MANAGEMENT SYSTEMS

Flaure 5. Optimistic Future Flow Cbart

Qroc:

All nursemanagers

input payroll By Wednesday at 11:00 A.M.data Into

ANSOS

Transmittimeshe.t datafrom ANSOS to Wednesday Afternoon

PayrollComputer

_____________________

‘I,I Re uests for / Payroll

Ymprest / information

Checks as / processed by

/ needed / University.

C” IChecks Issued Thursday/Friday

Yes ErrorReported byEmployee?

No

czNIVERSHY MEDICAL

13 MICHIGAN CEER

MANAGEMENT SYSTEMS

APPENDIX A

Campus and HospitalTimesjieets

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MANAGEMENT SYSTEMS

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PAY DATE

TO 06—11-88

06—17—88

RETURN TO PAYROLL OFFICE BY MONDAY NOONFOLLOWING CLOSE OF PAY PERIOD

PAYROLL USE ONLY

REASON:

• CERTIFY THAT THE EFFORT DISTRIBUTION SHOWN ABOVE REASONABLY REFLECTS MYCTUAL EFFORT FOR THE 81-WEEKLY PERIOD COVERED BY THIS TIME REPORT.

IF DISAGREE. SEE INSTRUCTION 6 ON REVERSE SIDE.

MEDICAL.iicnic. CENTERMANAGEMENT SYSTEMS

THE UNIVERSITY OF MICHIGAN— PAYROLL OFFICE

81-WEEKLY TIME REPORT

SOCIAL SECURITY NUMBERNAME (PRINT LAST. FIRST)

SEE REVERSE SIDE FOR INSTRUCTIONS

70007 5

PAY PERIOD

JOBCLASS 30578

DAILY TIME REPORT — ENTER FRACTONAL HOURS IN DECIMAL FORM ON A TENTH OF AN HOUR BASIS

EXCEPTION TIME SUMMARYFIRST SCHEDULED SHIFT OVERTIME HOURS ATWEEK HOURS WORKED NM/S HOURS CODE HOURS CODE

. REG.RATE

SUNDAY — ———— 11/2RATE

MONDAY — — — — — — — — — — — —

— OVERTIME HALF RATETUESDAY — — . — — — — — — — — — — (CODE 17) — —

WEDNESDAY — —. — — — — — — — — —

— ON CALL HOURSTHURSDAY — — • — — — — — — — — — — — —

FRIDAY — — — — — — — — — — — — . —

— SHIFT PREMIUM HOURSSATURDAY — — — — — — — — — — —

— AFTERNOONREG. RATE — —

. EXCEPTION TIME AFTERNOONSECOND SCHEDULED 1½ RATE — — . —

WEEK HOURS WORKED HOURS CODE HOURS CODESHIFT PREMIUM HOURS

. MIDNIGHT/Special Sch

SUNDAY — — — — — — — — — — — —

— REG. RATE — . —

MONDAYMIDNIGHT/Special Sch

—

—— 1VzRATETUESDAY — . —— . ——

WEDNESDAY — — — — — — — — —

— PLACE X” IN BOX IF:

TAKE EXCESS SICK TIMETHURSDAY — — . — — — — — — -— — — — — FROM THE BALANCE OF

MY ACCUMULATEDFRIDAY — — — — — — — — — — — — —

— VACATION TIME.

SATURDAY — — — — — — — — — . — — —

TOTAL ACCOUNTS HOURS DESCRIPTION

64.0 275424 64.0 UMIMA OUTPATIENT CLINIC

PAY PERIODSCHEDULEDHOURS

EXCEPTION CODESSEE REVERSE SIDE

EMPLOYEE SIGNATURE3057-i88

DATE DEPARTMENTAL AUTHORIZATION

Emergent Work Form

MNA Shill Rotation Premium

MNA Weekend Premium

Incentive Pay?Transcriptionist

Medical Legal Fees

On Call Special Adjustment

MNA Mandatory O.T.

Other Ispecity)

Other specify)

MEDICAL CAMPUS DEPARTMENT OF HUMAN RESOURCESUNIVERSITY OF MICHIGAN HOSPITALS

TIME RECORDING/PAYROLL ADJUSTMENT REQUEST

FOR HOSPITAL PAYROLL USE ONLY BY

IMPRESTREQUEST Imprest Check Add to next paycheck DATE

GROSS AMOUNT LI S and V FILE ADJUSTED

FOR HOSPITALS PAYROLL USE ONLY

By DateL tNIVEI NEDICAL

MICHWAN i?- CFNFER

1S-2015742/167 Rev. 6/89 HOSPITAL PAYROLL COPY

NAME

REQUESTORPHONE NUMBER

[ EMPLOYEE INFORMATIONNAME

SUPERVISOR’S SIGNATURE DATE

SOCIAL SECuR’v NUMBER

ACCOUNT NUMBER LOCATION CODE

PAY TYPE LI MONTHLY LI 81-WEEKLY LI TEMPORARY

D TIME RECORDING AMENDMENT-PAY DATE

___________

Please change the time reported for the above employee as follows:

Calendar Date(s)

Time Recorded As

Time Should Be

SOCIAL SECURITY NUMBER

D PAYROLL ADJUSTMENT

Pay Date:

ACCOUNT SUFFIX I EXTENSION TOTALS

Complete this section to report dollar amount adjustments to pay.

(Attach this form to the monthly or bi-weekly timesheet on which the employee is reported).

CIRCUMSTANCE I HOURS AFFECTED X DIFFERENCE PAID = ADJUSTMENT AMT I

APPENDIX B

Standardized SatelliteTimesheet

INIVE rpjj19 iicrna CENTER

MANAGEMENT SYSTEMS

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