We all know the complexity in healthcare from medical billing, medical coding, medical transcription to actual patient care. This article onÂ Lean Healthcare Time and Motion Study shows the surprising results of how nurses spend their time.
A fascinating study of how medical nurses spend their time was published in 2008 by Kaiser Permanente and conducted by Ann Hendrich, RN, MSN, FAANÂ Marilyn Chow, DNSc, RN, FAAN, Boguslaw A Skierczynski, PhD, Zhenqiang Lu, PhD. I share those findings here and add the lean perspective on those findings. But, let me share some context.
Lean: Value and Waste
In Lean Thinking, knowing where and how time is spent is important. Lean Six Sigma practitioners often distinguish activity into three categories:
- Value-Add: As defined by the customer.
- Non-Value Add (waste): As defined by the customer – adds no value to the customer.
- Non-Value Add but Necessary (waste): Adds no value to the customer, but still has to be done.
There are 7 types of wastes, namely:
- Transportation (conveyance)
With that as a backdrop, here is the study protocol and the results.
Medical Nurse Time and Motion Study
- Context: Nurses are the primary hospital caregivers. Increasing the efficiency and effectiveness of nursing care is essential to hospital function and the delivery of safe patient care.
- Objective: Undertook a time and motion study to document how nurses spend their time. The goal was to identify drivers of inefficiency in nursing work processes and nursing unit design.
- Design: Nurses from 36 medical-surgical units were invited to participate in research protocols designed to assess how nurses spend their time, nurse location and movement, and nurse physiologic response. In the end, 767 nurses participated.
- Main Outcome Measures: Nursesâ€™ time was divided into categories of activities (nursing practice, unit-related functions, nonclinical activities, and waste) and locations (patient room, nurse station, on-unit, off-unit). Total distance traveled and energy expenditure were assessed. Distance traveled was evaluated across types of unit design.
Results: Medical Nurse Time and Motion Study
According to the study, the results were as follows:
A total of 767 nurses participated. More than three quarters of all reported time was devoted to nursing practice. Three subcategories accounted for most of nursing practice time:
- documentation (35.3%; 147.5 minutes),
- medication administration (17.2%; 72 minutes),
- and care coordination (20.6%; 86 minutes).
- Patient care activities accounted for 19.3% (81 minutes) of nursing practice time,
- and only 7.2% (31 minutes) of nursing practice time was considered to be used for patient assessment and reading of vital signs.
Based on their findings and from the perspective of Lean Thinking, the patient, of the items above, would consider patient assessment, patient care activities, medical administration value-add; whereas care coordination and documentation as most likely waste that is currently necessary.
In other words, most of the nurses time is spent in activities that the patient would not consider value-add.
Regarding Patient Documentation, the report states:
Documentation is an essential part of nursing practice and accounts for a major portion of the nursesâ€™ time. The documentation process in many hospitals is also rife with inefficiencies. For example, nurses and other care providers often must transfer information between data collection systems, consuming nursing time and contributing to transcription errors. Documentation is often duplicated between departments and disciplines because of the lack of a single patient problem list for all providers. The result is fragmentation of care, duplication of data sets, and the inability to quantify the outcome of the care provided. Evolving regulatory and public policy requirements for documentation (such as â€œpresent on admissionâ€) may exacerbate these problems.
The efficiency of documentation is a multifactorial problem, and solutions remain varied and controversial. Health care systems will need robust processes driven by caregivers to improve efficiency and reduce time dedicated to documentation.
The Hospital Time and Motion Study results are shown below:
Regarding Patient Care Coordination, the report states:
Care coordination (communication regarding the patient) accounts for approximately one-fifth of nursing practice time. The benefits of timely and efficient communication between team members have been documented by other investigators. However, inefficiencies in communication may consume nursesâ€™ time and put patients at risk. Failure to rescue–death following the occurrence of an adverse event–is a nurse-sensitive outcome that has been correlated with nurseâ€“patient ratios, communication, and patient surveillance, among other factors. Indeed, many failure-to-rescue situations can be traced back to communication delays or omissions.
The efficient flow of patient information and status updates could reduce wasted time and the potential for errors. Proposed technology solutions include wireless networks, hand-held and ear devices for the delivery of patient information, and intelligent systems that automatically track the physical location of a medical provider.
Most care coordination time is spent at the nurse station. Indeed, the nurse station itself may represent an opportunity for design and process improvement. The location of terminals and/or wireless devices for data entry, for example, could reduce the need for and time spent at the nurse station. Such changes could reduce walking time between patient rooms and the nurse station, and increase the amount of time available in the patient room.
The Hospital Nurse Time and Motion Study is a great read – many elements of Lean Thinking in the article. Studies like this and changes made to patient care will help both patient and healthcare practitioners.
Below is a video that describes how Lean is being applied to Warwick Hospital and the impact it has made on the hospital employees and the patient experience: