Continuing Care Services DepartmentWork Effort Analysis
by
Vivek Gupta Sonia Raheja Julie Simmons
The University of Michigan, Ann ArborIndustrial and Operations Engineering 481
“Special Projects in Hospital Systems”Client: Karolyn Brewer
Coordinator: Dolorese Umar
TABLE OF CONTENTS
Executive Summary 1
Introduction 2
Background 3
Purpose 4
Methodology 4
Statistical Database Analysis 4Coordinator Observations and Survey 7
Results 8
Statistical Database 8Categorized Summary of Work Effort 10
Conclusions 16
Recommendations 17
Appendix 20
H
ACKNOWLEDGEMENTS
We would like to thank the following people for their time, effort andsupport:
Continuing Care Services Department:
Management Systems:
Dolorese Umar, Management Systems Programmer/AnalystDr. Richard 3. Coffey, Director
Karolyn Brewer, ManagerElizabeth Wagoner, Assistant Manager
Louise Cole, Executive SecretaryPamela Wong, Secretary
andthe Continuing Care Coordinators
PROJECT INTRODUCTION
Operating Entities:
The University of Michigan Medical Center:Continuing Care ServicesManagement Systems
Involved Parties:
Client:Karolyn Brewer, Continuing Care Services Manager
Continuing Care Services Staff:Elizabeth Wagoner, Assistant ManagerLouise Cole, Continuing Care Services Executive SecretaryPamela Wong, Continuing Care Services SecretaryContinuing Care Coordinators
Project Coordinator:Dolorese Umar, Management Systems Programmer/Analyst
Management Systems:Vivek GuptaSonia Raheja - Industrial and Operations Engineering ConsultantsJulie Simmons
EXECUTIVE SUMMARYr
The Continuing Care Services department arranges for post-discharge patientcare for the University of Michigan Medical Center. By developing home care,equipment, and facility placement discharge plans, early in a patient’s stay,the department can reduce the number of placement days. Since the transferof the facility placement responsibility to the Continuing Care Servicesdepartment in August 1988, the average number of placement days hasdeclined by 25% resulting in a net decrease of $250,000 in annual costs. Sincethe activities of this department greatly influence the University of MichiganMedical Center, it is necessary that they utilize their resources effectively.
Currently, management uses a standardized variance report to evaluate howclosely the required resources match the expended resources based uponestimates of the units of service and weighting factors. The Continuing CareServices department needed an updated analysis of their work effort thatwould reflect the change in workload resulting from the addition of facilityplacement services. This project has provided the department with a tool touse as a baseline for monitoring and predicting the future workload.
To create an unbiased work measurement tool, the project was approachedfrom three different perspectives: statistical database analysis, observationalinvestigation of elemental times, and Coordinators’ personal tasks assessment.Statistical quality control methods were used to determine the standard unitof service and revised weighting factors for the units of service calculationfrom the Continuing Care database. Coordinator observations were conductedto determine the elemental task times for a referral and identify processimprovements. To supplement the observations, a detailed survey wasconducted to obtain coordinator input on the referral processes and tasks.
The results of this study have indicated that management’s assumption thatthe weighting factors were incorrectly assessed is true to a point. Theweighting factors were actually overestimated, but not the cause of theunderrepresentation of the department’s workload. This project hasillustrated that the estimation of the Standard per Unit of Service wasactually the source of the problem. Management estimated that the expectedcost (time) to deliver one unit of service was .99 hours, however, thisanalysis has indicated that the actual Standard per Unit of Service is 2.23hours.
In summary, this project has provided the Continuing Care Servicesdepartment with a tool to use as a baseline for monitoring and predicting thefuture workload based on the units of service and categorized summary ofthe work effort of theContinuing Care Coordinators.
INTRODUCTION
The Continuing Care Services Department arranges for post-dischargepatient care for University, Mott, Women’s and Holden hospitals. ContinuingCare Services is prepared to activate and facilitate home care referrals, theacquisition of home medical equipment, and assist the patients and familieswith the decisions and procedures related to long term placement in arehabilitation, nursing home, or adult foster care facility.
The services provided by the Continuing Care Department greatly influencethe length of a patient’s stay. By developing discharge plans early in thepatient’s stay, the department can reduce the number of placement days.Since the transfer of the facility placement responsibility to the ContinuingCare Services Department in August 1988, the average number of placementdays has declined by 25% (from 2.49 days to 1.86 days). The impact of thereduction in placement days results in a decrease in net costs of $250,000.1
In order for the Continuing Care Services department to be efficient,management must have a clear understanding of the work effort to utilizeits resources effectively. This project was performed to facilitate this need.
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“Final Report of Placement Days Study”, Management Systems,University of Michigan Medical Center, Ann Arbor, June 19, 1989
BACKGROUND
Prior to August 1988, the Continuing Care Services department coordinatedthe home care and equipment needs for patients in the University ofMichigan Medical Center. In August 1988, the facility placementresponsibility was transferred from the Social Work department to theContinuing Care Services department. To accommodate the increasedworkload, management estimated the additional staff required to performthe new services.
Currently, management uses a standardized variance report to evaluate howclosely the required resources match the actual expended resources basedupon comparisons of the department’s performance with historical data.Continuing Care has a categorization system which weights patientsaccording to complexity and length of referral (time). These weightingfactors are used to determine the units of service2. However, due to therecent expansion of services, Continuing Care did not have historical dataupon which to base their Units of Service and standard per unit of service3.These measures were estimated by management’s impressions of thereferral time. In order to correctly utilize the standardized variance reportand obtain accurate resource consumption figures, statistics for the units ofservices and Standard per Unit of Service needed to be obtained.
2Thc Units of Service is a method of measuring the amount of servicedelivered by weighting procedures for resource consumption.
3The Standard per Unit of Service is the expected cost consumed todeliver one unit of service.
PURPOSE
r The main objective of this investigation was to create a tool to be used as abaseline for monitoring and predicting the future workload based on theUnits of Service and categorized summary of the work effort of theContinuing Care Coordinators.
METHODOLOGY
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To create an unbiased work measurement tool, the project was approachedfrom three different perspectives: statistical database analysis,observational investigation of elemental times, and coordinators’ personaltasks assessment. Statistical quality control methods were used todetermine the Standard per Unit of Service and revised weighting factorsfor the Units of Service calculation from the Continuing Care database.Coordinator observations were conducted to determine elemental task timesfor a referral and identify process improvements. To supplement theobservations, a detailed survey was conducted to obtain Coordinator inputon the referral processes and tasks.
STATISTICAL DATABASE ANALYSIS
Five hundred and eighty-six referrals from the month of September wereanalyzed to obtain referral times. The month of September was chosenbecause it was the most recent data least affected by the July nursing strike.In addition, the evaluation of the rest of the months in 1989 indicated thatthere was little variation in the contact distribution of referrals.
The Continuing Care Services department’s database includes pertinentinformation on each processed referral such as Coordinator, patientregistration number, hospital unit, disposition (type of referral), admissionand discharge dates, referral response and disposition dates, referral agency,and type of contact4. The data was initially summarized by disposition,hospital, and type of contact. The analysis showed little variation betweenhospital or disposition, in terms of the referral times. Therefore, thehospital and disposition information was combined and analyzed by type ofcontact only.
4The type of contact is the rating based on the patient categorization system. Itclassifies a patient by A,. B, C, D, or E, where A is the simplest referral and E is the
most complex.
STATISTICAL DATABASE ANALYSIS. continued
Using the referral response and disposition dates, the average number ofdays per case and the standard deviation were calculated for each type ofcontact (A, B, C, D, E). The number of days was chosen as the timemeasurement because it is directly retrievable from the database therebyproviding an unbiased estimate of the time for a referral. (The number ofdays is based on concrete time whereas the number of hours has to beestimated.) Please refer to Table 1.
In order to obtain a range for the time for a referral, statistical qualitycontrol methods were employed in analyzing this data. Due to the largenumber of samples, the normal distribution was assumed from the CentralLimit Theorem5. The upper control limit was approximated using thenormal distribution6.The formula is
UCL = Average Number of Cases + (3 x Standard Deviation)
Table 1. Statistical Oualitv Control Calculations.
Type Number Avg. Number Std. Upperof Contact of Cases Days/Case Dev. Control Limit
A 69 3.88 5.83 21.37B 397 4.34 7.91 28.07C 96 11.8 14.29 54.67D 18 29.4 31.82 124.86E 6 64.5 74.57 288.21
(The lower control limit was calculated to be zero. However, based upon thedata, the minimum time for a referral is one day.)
5me Central Limit Theorem states that the nonnal distribution canapproximate large samples regardless of the underlying distnbuuon
6The Upper Control Limit signifies that 99 7% of the cases will fall below thecalculated value
STATISTICAL DATABASE ANALYSIS. continued
Using the average number of days per case, revised weighting factors werecalculated. Please refer to Table 2. The Type A contact was used as thestandard so that its weighting factor = 1.000. The weighting factor formulais
WF = (Average number of days per case)13.88
Table 2. Standard Weighting Factors.
Type of Contact Weighting Factor
A 1.000B 1.119C 3.041D 7.577E 16.624
Using the revised weighting factors, the revised Standard per Unit of Servicewas computed. The formula for Standard per Unit of Service is
Standard per UOS = Total Production Hours iTotal Units of Service
where
Total Units of Service = E WF x No. of Cases by Type of Contact
= # of A’s x 1.000#ofBsx 1.119#ofC’sx3041#ofD’sx 7577
+#pfE’sxl6.624
This Standard per Unit of Service is based upon September data. It should beupdated yearly to reflect changes in resource consumption.
(. The Units of Service formulas has also been revised based on the newweighting factors. The formula for estimating the Units of Service is
Average Units of Services=Total Units of Service/Total No. of Cases
rL COORDINATOR OBSERVATIONS
To provide a clearer definition of the work effort, eleven of the eighteenCoordinators were observed for a total of forty-four hours. Each Coordinatorr. was observed for one-half of a working day during which the times andelemental tasks and processes were documented. The Coordinators werechosen to obtain a mixture of seniority levels, hospital unit assignments, andpercentages of referrals processed. In addition, the observations weredistributed evenly throughout the week and day. The goal of thismethodology was to obtain an unbiased mixture of information.
COORDINATOR SURVEY
To obtain additional input on the referral processes and tasks, a detailedsurvey was developed and distributed to all of the coordinators. From thenineteen Coordinators, eight responses were received. Please refer to theAppendix.
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RESULTS
The main objective of this investigation was to create a tool to be used as abaseline for monitoring and predicting the future workload based on theUnits of Service and categorized summary of the work effort of the ContinuingCare Coordinators.
STATISTICAL DATABASE
Through the analysis of the database, revised weighting factors wereobtained to use in the Units of Service and Standard per Unit of Servicecalculations. Please refer to Figure 1.
--- Weithting Factor Comparison.
As illustrated in Figure 1, the current weighting factors were overestimated.The weighting factors are shown below. Please refer to Table 3.
Table 3. Predicted and Actual Weighting Factors.
PredictedWeightingFactor
1.0002.0006.00015.00030.000
ActualWeightingFactor
1.0001.1193.0417.57716.624
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30
25
20
15
10
5
0
Actual Values
Predicted Values
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B C
Fipri,r •I
Types of ContactD E
TypeofContact
ABCDE
STATISTICAL DATABASE. continued
From the computation of revised weighting factors, an updated statistic forthe Standard per Unit of Service was calculated7.The expected cost (time) todeliver one unit of service for the 1990 Fiscal Year is
Standard per Unit of Service = 2.23 Hours per Unit of Service.
With the new weighting factors, a revised formula for calculating the Units ofService was obtained. The formula is
Average Units of Services=Total Units of ServiceiTotal No. of. Caseswhere
Total Units of Service = WF x No. of Cases by Type of Contact
= #ofA’sx 1.000#ofB’sx 1.119#ofC’sx 3.041# of D’s x 7.577
+ #ofE’sx 16.624
For the month of September, the average units of service was found to be1.78.
Based on this information, a revised Patient Categorization System has beendeveloped. The Standard per Unit of Service and Weighting Factors were usedto update the predicted time per patient referral8. The range was obtainedby using the Upper Control Limit calculations. The Lower Control Limit wasbased on the weighting factors.
The new patient categorization system will provide a qualitative andquantitative method of evaluating the type of contact for a referral. Thispatient categorization system should be implemented in order for this tool tobe effectively utilized. Please refer to Table 4.
7The Standard per Unit of Service is a statistic that needs to be updatedyearly.
8The Average Hours/Case = Std. UOS x Weighting Factor (by contact)The Lower Limit Hours/Case = i x Weighting Factor (by contact)
(Assumption: Type A takes at least one hour)The Upper Limit Hours/Case = Average Hours/Case + (3 x Std. Dev.)
STATISTICAL DATABASE. continued
Table 4. Patient Cate2oHzation System
PREDICTED ACTUALTYPE TIME/PATJENT TIME/PATIENT
A 10-60 Minutes 1 - 12 Hours(Average: 2.23 Hours)
B 1 -3 Hours 1 - 16 Hours(Average: 2.50 Hours)
C 4- 10 Hours 3 -31 Hours(Average: 6.79 Hours)
D 11-20Hours 7-72Hours(Average: 16.91 Hours)
E 21 -40 Hours 16- 166 Hours(Average: 37.09 Hours)
CATEGORIZED SUMMARY OF WORK EFFORT
The Coordinator observations and surveys were used to fmd the timesassociated with the elemental processes and tasks of a referral. Based uponthis information, a flowchart was developed to trace the referral process.Please refer to Page 11 The analysis indicated that there was little variancein the process times and tasks for a specific referral between the hospitals.Although the study indicated little difference between the processes for homecare/equipment and facility placement referrals, there was a significantincrease in the facility placement process times. Please refer to Pages 12 and13.
In addition, the Health Supervision referral process was examined and foundto vary between Mott/Holden and Women’s hospital in terms of processesand task times. Please refer to Pages 14 and 15.
CONTINUING CARE SERVICES: 12-22-89
HOME CARE REFERRAL. EQUIPMENT REFERRAL. AND FACILITY PLACEMENT
C START D4
r Formal referralfrom Physician!N u rse!PT/RT/UTetc...
Case finding byContinuing CareCoordinator
4Patient needs areassessed:-Nursing & Therapy-Medical Equipment-Third Party Payor-Other Community
Resources-Documentation-Acuity
Coordinator obtainsinformation fromfamily (Availabilityof care-giver)
Coordinatordiscusses aProposed DisCharge Plan withother UMMCProfessionals:PT, RT,Nutritionists,Other HealthTeam Members
CoordinatorassistsPatient!Family withdecision!acceptanceof plan
Coordinator obtainsService!Reimbursementinformation from HomeHealth Agencies,Equipment Vendors, ThirdParty Payors, OtherCommunity Resources, andPlacement Facilities
Coordinatorrevises ProposedDischarge Plan
Yes
Coordinatorfinalizes thearrangements
cD.Patient Discharge
4Patient Followup
UNIVERSrrY!MOTrIWOMEN’S/HOLDEN HOSPITALSHOME CARE AND/OR EQUIPMENT REFERRAL
Type of Activity Time (Mm)
I. Response to formal referral or case finding by 5-30continuing care coordinator.
2. Assess patient needs for nursing andtherapy, medical equipment, third party payor,other community resources, documentation, andacuity. More specifically, the processes involved are
A. Chart review . 10-45
B. Documentation 10-60
C. Medical professional meetings 15-180
D. Patient and family meetings 10- 180
3. Contact third party payors and other community 10-120resources to receive reimbursement information.
4. Obtain service information from home health 10-60agencies, equipment vendors, and other communityresources.
5. Develop proposed discharge planand discuss with the following people:
A. UMMC medical professionals 10-30
B. Patient and Family 15-30
6. Monitor patient’s hospital stay through patient 30-180care conferences and rounds. (per week)
7 Maintain patient records and note unresolved 15-90issues
8 Fmahze arrangements upon notification ofdischarge.
A Complete CPC and/or Equipment Order Forms 15-60
B Obtain M D signature 5-30
9 Update statistical sheets upon completion of referral 5-10L
10. Follow up patient’s progress after discharge. 10-30
Type of Activity
1. Response to formal referral or case finding bycontinuing care coordinator.
2. Assess patient needs for nursing andtherapy, medical equipment, third party payor,other community resources, documentation, andacuity. More specifically, the processes involved are
A. Chart review
B. Documentation
C. Medical professional meetings
D. Patient and family meetings
3. Contact third party payors and other communityresources to receive reimbursement information.
4. Obtain service information from home healthagencies, equipment vendors, and other communityresources.
5. Develop proposed discharge planand discuss with the following people:
A. UMMC medical professionals
B. Patient and family (obtain consent forms)
6. Monitor patient’s hospital stay through patientcare conferences and rounds.
7. Maintain patient records and note unresolvedissues.
8. Finalize arrangements upon notification of discharge.
A. Complete forms and arrange for sending records
B. Obtain M.D. signature
C. Arrange for transportation
9. Update statistical sheets upon completion of referral.
10.Follow up patient’s progress after discharge.
UNIVERSITYIMOTT!HOLDEN HOSPITALFACILITY PLACEMENT REFERRAL
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Time (Mm)
5-30
30-60
10-60
60-180
60- 240
10-120
15-600(max =10 hours)
10-30
15-60
60- 180(per week)
15-90
60- 180
5-30
5-60
5-10
10-30
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WOMEN’S HOSPITALHEALTH SUPERVISION REFERRAL
Type of Activity Time (Mm)
1. Response to formal referral or case finding by 10-60continuing care coordinator using census report.
2. Assess patient needs for nursing andtherapy. The processes involved are
A. Chart review 10-20
B. Documentation (Discharge Summaries) 5-10
C. Medical professional meetings (Patient Care Rounds) 30-60
D. Patient and family meetings 15-20
3. Contact third party payors and other community 10-20resources to receive reimbursement information.
4. Collect referrals from other clinics 15-30
5. Process referral
A. Obtain a signature from M.D.
B. Fill out necessary forms
Update statistical sheets upon completion of referral. 10-30
Follow up patient’s progress after discharge. 10-30
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MOTIHOLDEN HOSPITALHEALTH SUPERVISION REFERRAL
Type of Activity Time (Mm)
1. Response to formal referral or case finding by 15-30continuing care coordinator.
2. Assess patient needs for nursing andtherapy. The processes involved are
A. Chart review 15-20
B. Documentation 10-20
C. Medical professional meetings 10-25
D. Patient and family meetings 15-30
3. Contact third party payors and other community 10-30resources to receive reimbursement information.
4. Obtain service information from home health 10-30agencies, equipment vendors, and other communityresources.
5. Monitor patient’s hospital stay through patient 10-30care conferences and rounds. (per week)
6. Finalize arrangements upon notification of discharge.
A. Complete forms and arrange for sending records 20-30
B. Obtain M.D. signature 5-30
7. Update statistical sheets upon completion of referral. 5-10
8. Follow up patient’s progress after discharge. 10-30
CONCLUSIONS
The Continuing Care Services department needed an updated analysis of theirwork effort that would reflect the change in workload resulting from theaddition of facility placement services. In order to utilize its resourceseffectively, management must have a clear understanding of the work effort.Currently, the Continuing Care Services department analyzes its work effortthrough a standardized variance report. To be effective, the statistics need tobe accurate numbers based on the current workload not estimations.
Management felt that the weighting factors were underestimated causing theUnits of Service statistic to underrepresent the workload of the department.However, this study has shown that the estimation of the Standard per Unit ofService was actually the source of the problem. Management estimated that
r the expected cost (time) to deliver one unit of service was .99 hours, however,this analysis has indicated that the actual Standard per Unit of Service is 2.23hours.
C- --
In addition, this study provided management a detailed analysis of thereferral processes’ times and tasks to use for resource allocation.Management wifi now be able to analyze the processes and tasks todetermine areas of improvement based on the distribution of theCoordinato?s time.
In summary, this project has provided the Continuing Care Servicesdepartment a tool to use as a baseline for monitoring and predicting thefuture workload based on the units of service and categorized summary ofthe work effort of the Continuing Care Coordinators.
RECOMMENDATIONS
Project Suggestions:
In order to obtain an accurate representation of the Coordinators’ work effortand calculate the staffing requirements, management should implement thefollowing strategies:
1. Patient Categorization System:
The Coordinators should use the new system to determine the type of contactfor a referral. The new system offers a more qualitative and quantitativeevaluation thus providing a more accurate representation of the actual workeffort.
2. Variance Report:
( I - Adopt new weighting factors into Units of Service formula to reflectcurrent situation.
- Utilize the Standard Unit of Service for the 1990 Fiscal Year.(2.23 Hours/UOS)
3. Elemental Processes and Tasks:
The distribution of processes and tasks should be examined to determine theduties that clerical and other support staff can assume.
RECOMMENDATIONS
Process Suggestions:
1. Some other resource should assume the responsibility of Blue Crossinsurance phone verifications (e.g. clerical).
Result:
Decrease in phone time providing more time for actual patient contact.
2. The filing of completed referrals should be performed by the clerical staff.A box should be placed in a central location to collect the referrals.
Result:
Increase in actual time spent on referral.
Layout Suggestions:
1. Move the face sheet computers and printers to a central location (e.g. CopyRoom) in order to provide convenient access for the coordinators.
Result
Reduction in transit time
2 Investigate placing coordinators on their assigned units permanently
Result:
Reduction in referral completion time due to increased contact withpatients and medical professionals. More specifically, decreases casefinding time and transit time.
RECOMMENDATIONS
Departmental Suggestion:
There should be a clearer definition of the responsibilities of relateddepartments (Social Work, Medical Staff on unit, etc...). More specifically,Social Work and Continuing Care should define their relationship in orderto distribute the duties effectively.
Result:
Provides a more efficient and productive work effort.
Personnel Suggestion:
Reduce the number of part-time personnel and hire more full-time peopleto carry the workload.
Result:
Eliminates time spent updating coordinators of referral and hospital unitstatus.
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CONTINUING CARE SERVICESCOORDINATOR SURVEY
As a part of Management Systems’ analysis of the work processes, thissurvey is being conducted to obtain coordinator input on the tasks beingperformed. Please be as specific as possible when answering the questions(include meetings, telephone conversations, etc...). Please answer onlyquestions that apply to your job. Please complete this survey andreturn to Louise Cole by Tuesday, December 5, 1989. ‘JJankJiu!
Name:
____________________________
Hospital(s):
___________________________
Unit(s):
____________________________________
(For example: 5A)
• 1. Please approximate the percentage of your day spentperforming the following tasks:
Percentage
Home Care Referrals:
Equipment Referrals:
Facility Placements:
Health Supervision Referrals:
2. Please approximate the percentage of your week spent doingthe following activities Please also document the amount oftime per week associated with each activity
Percentage Time
Department Meetings:
Training Seminars
L Special Programs
3. Please document the activities associated with a HomeCare Referral in order of occurrence. Please be as specific aspossible by including information such as telephone contactand meetings with family, insurance companies, and medicalprofessionals and type of paperwork involved in the referral.Please give an approximate time associated with the task youdescribe.
Type of Activity Time
Please continue on the back of the page fnecessary.
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4. Please document the activities associated with an EquipmentReferral in order of occurrence. Please be as specific aspossible by including information such as telephone contactand meetings with family, insurance companies, and medicalprofessionals and type of paperwork involved in the referral.Please give an approximate time associated with the task youdescribe.
Tvne of Activity Time
Pleas,e continue on the back of the page fnecessary.
5. Please document the activities associated with a FacilityPlacement in order of occurrence. Please be as specific aspossible by including information such as telephone contactand meetings with family, insurance companies, and medicalprofessionals and type of paperwork involved in the referral.Please give an approximate time associated with the task youdescribe.
Type of Activity Time
L
Pleas continue on the back of the page fnecessary.
6. Please document the activities associated with a HealthSupervision Referral in order of occurrence. Please be asspecific as possible by mcludrng information such astelephone contact and meetings with family, insurancecompanies, and medical professionals and type of paperworkinvolved in the referral. Please give an approximate timeassociated with the task you describe.
Type of Activity Time
I
Please continue on the back of the page fnecessary.
