Program and Operations Analysis

Final Report forCancer Center Staffing Analysis

April 20, 1998

Chester JeanShalin Sanghvi

Abraham Schwarzberg

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Industrial and Operations EngineeringThe University of Michigan

Ann Arbor, MI

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TABLE OF CONTENTS

Pag

r Executive Summary 1

Introduction 2[ Methodology 3

[ Clinic Summary 5

- Individual Team Analyses

-Team2 22- Team 3 28-TeamS 33

Conclusions 40

Recommendations 42

Appendices:

L - Work Sampling Data A- Phone Data B- Data Collection Sheets CL- Volume Review D- Study Plan E[ - Work Redesign Materials F

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/ EXECUTIVE SUMMARYRecently the Cancer Center has undergone an extensive work redesign by implementingj teams and redefining employee roles. This study reviews and documents the activities ofthe staff in the clinic. The analysis includes observing, interviewing, and performing awork distribution (random beeper) and phone study of the RNs and MAs in teams 2, 3,and 5. The focus is centered on RNs, clinic coordinators, and MAs. The specific[ objectives are to identify staffing concerns, improve team efficiency, determine staffmgneeds, and suggest role definitions. The goal of this work is to help further the Cancer[ Clinic along its move towards its work redesign goals, and its overall goal of meeting theneeds of its patients.

L The investigation successfully identifies several areas for potential change. While there aregood practices identified in the report, the key findings that are barriers to fullyaccomplishing the goals of the work redesign are:• Each team focuses almost exclusively on their team, not realizing the need forcross-team support and communication. As an example, there are no inter-teammeetings, other than those established by Ely Kuo for the clinic coordinators of

each team. The lack of cross-team support forces teams to rely on CSR to meettimes of excess demand.

• The roles of identical positions within different teams fluctuate widely, with littlesharing of efficient practices.• Within the teams there is insufficient communication and mutual understanding dueto a basic lack in intra-team meetings, resulting in insufficient work coordination.• The RNs do not understand their administrative role in delegating responsibilities

and reminding the staff of their roles.• The clinic coordinators have very little required interaction with RNs or MAs,

which tend to isolate them from the flow of the overall team.• The MAs do not completely understand their part in helping the RNs in such

activities as clinic coordination and nursing activities.• The clinic lacks a constant feedback system for teams as a whole as well as

individual employees, preventing any positive feedback or constructive criticism.• The workload and staffing are unevenly balanced from day to day, causing periods

of overwhelming staffing demands as well as other periods of staffing inactivity.This is a major obstacle to any consistency, or standardization of role definition.

Viable solutions to these concerns do exist which include the following:• The first step is to standardize inter and intra-team meetings, ensuring

understanding of the overall Cancer Center mission and the staff’s respective roles.This greater communication would directly address many of the problems.• Clustering affiliated teams. These clusters could assist during times of excess

demand and replace the current reliance on CSR.• Re-educate the staff on their respective roles, detailing the overall mission of the

work redesign.• Cross-train the staff to handle activities not typically associated with their position.

This analysis prompts the need for further study. Future projects should be focused on thefeasibility of farming certain team clusters, the identification of the activities within eachstaff position which may realistically be distributed to other staff positions, anddevelopment of standardized meetings of different teams and their respective staffpositions.

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INTRODUCTION

In consolidating cancer clinics and moving into a new building, the University of MichiganComprehensive Cancer Center has undergone a work redesign by implementing teams andredefining employee roles. The Cancer Center is subdivided into six clinic teams, eachconsisting of physicians, clinic nurses (RN), clinic coordinators (CC), medical assistants(MA), and clerks. These teams are currently facing challenges of balancing the needs ofcost reduction, role responsibility, and staffing concerns in addition to meeting patientneeds. While most of the work redesign was successful, some barriers exist that hinder theeffort from being completely accomplished. Much of this is to be expected due to theextensive endeavor.

A group of JOE 481 students have been requested to review and document the activities ofthe staff in the clinic. A meeting with Ely Kuo, Mary Duck, and Paula Snyder, on January27, 1998 occurred to determine the scope of the project. Due to limited time, the focus ofthe review is Teams 2, 3, and 5 and on clinic RNs, clinic coordinators, and MAs. Agreater emphasis is placed on reviewing the RN’s and MA’s since they provide the greatestextent of direct patient care and their workload is more variable. The RN’s studied islimited to the CN l’s and 2’s who are managed by the Cancer Center’s Nurse Manager.Advanced practice nurses managed by the divisions are not included. The analysis includesobserving, interviewing, and performing a random beeper and phone study. The goals areto identify staffing concerns, improve team efficiency, determine staffing needs, andsuggest role definitions.

The key issues focused on in this report fall into two categories:

• Staffing Concerns1. Discrepancy between daily staffing needs and originally planned staffmg levels.2. The use of nurses from central staffing resource department.3. Staff working overtime.4. Employee work satisfaction.

• Work Redesign Concerns1. Overlap between RN, clinic coordinator, MA, and clerk responsibilities.2. Possible inefficient time allocation.3. Communication within teams and between teams for team leader, RNs, clinic

coordinators, MAs, and clerks.

Scope of Project

In this project we:• Determine the daily activities of clinic RNs, clinic coordinators, and MAs.• Document the time distribution of RNs and MAs.• Defined the points of discrepancy between job descriptions and actual daily activities.• Evaluate efficiencies of daily activities.• Develop team model.• Analyze teams strengths and areas in need of improvement.• Determine RNs, clinic coordinators, and MAs phone time allocation.

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METHODOLOGY

In order to gain a better, in depth, understanding of each of the three teams, the teams weredivided amongst the project consultants. The clinic RNs, clinic coordinators, and MAswere interviewed and observed. Additionally, phone surveys and random beepers wereused to collect data on the MAs and RNs. In Appendix pg. El we have included a GanttChart which details the dates of our activities for this project. A further description of thestudies and their objectives are as follows:

Documenting and Interviewing - 6 weeks per teamObjectives:

1. Determine the day to day activities of RNs, clinic coordinator, MAs, andclerks.

2. Define the points of discrepancy between job descriptions and actual dailyactivities for the RNs and MAs.

3. Observe communication between team leader, RNs, clinic coordinators, MAs,and clerks.

4. Observe when overtime occurs.5. Observe pulling from the central staffing resource department.6. Gain an understanding of the clinic flow.

Method:Observing and interviewing the RNs, clinic coordinators, and MAs.

• Phone Surveys - 1 week per teamObjectives:

1. Determine the type of calls and the frequency of the different types of calls.2. Determine the time allocation per call and total phone time allocation for the

RNs and MAs.3. Determine which staff answers what type of call.4. Determine time spent on patient calls vs. staff calls.5. Determine the percentage of accurately routed calls.6. Determine the differences between the teams for all of the above.

Method:Through interviews and observation an initial list of the various phone calls all

the teams answered was devised. A phone survey was created from this initial list(see Appendix C pg. C5). Each teams RNs and MAs were to complete the sheetafter each call (either incoming or outgoing) for five working days. The checklistallowed an “other” category to amend to the list. Before performing the survey,each teams staff verified the list was an actual representation of their calls.

• Random Beepers - 1 week per teamObjectives:

1. Determine distribution of time on daily activities.2. Define time distribution differences between teams.3. Determine the actual daily activities of the RNs and MAs.4. Determine the overlap of staff activities.

Method:Through interviews and observation an initial list of the daily activities of the

RNs and MAs was devised. A checklist for the random beeper time study wascreated from this list. The random beeper sounded on the average of 3 times perhour. The RNs and MAs of each team collected data for five working days. Thechecklist allowed an “other” category to amend to the list. Copies of the RN and

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MA random beeper sheets can be found in Appendix C pg. Cl and C3. Definitionsfor the individual activities are also in the Appendix A, pg. C2 and C4. Beforeperforming the study, each teams staff verified the list was an actual representationof their daily activities.

Through reviewing the data, interviewing, observing, and documenting activities we wereable to compare the teams’ strengths and areas of improvement. These strengths and areasof improvement were used as pivotal factors to assess the teams and achieve our goals. Nophone surveys were taken on Team 3 nurses because they were conducted in a study priorto this project. That data was retrieved and analyzed. The random alarms were notperformed on clinic coordinators because of the large amount of their time is spent onscheduling and meetings.

A flow chart attached in Appendix E pg. E2 outlines our thought process in analyzing thethree cancer clinics. Please note, the subjective opinions of the staff were considered and,in addition, each team was respected in their specialty and how this may cause deviationfrom team to team.

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FINDINGS

The findings are broken into two sections. The first section, titled Clinic Summary, is acompilation of the findings from the three teams studied in this report. Within this sectionthe findings are separated into sub-sections, according to the different job categories thatwere studied as well as one sub-section for the general clinic. Within these subsections, thedata collected, the discrepancy between the original role definitions and actual roleactivities, current areas for improvement, and best practices are discussed. Not allcomments apply to all of the teams, but were found to have applied to at least one of theteams studied.

The second section, titled Team Analysis, addresses the specific findings from theindividual teams. The results and discussion are organized in the same manner as in theclinic summary.

It is important to note that due to the breadth of the project and the nature of the datacollection this report is meant as a guide. The report provides an effective resource,highlighting areas of inefficiencies and sources of concern. Use this report as a startingpoint to conduct further studies which are more narrow in scope. This report inconjunction with further studies will enable the Cancer Center to improve the efficiency,productivity, and organization of the clinic.

Clinic Summary

Overall Clinic

‘Best Attributes’ and ‘Areas for Improvement’ for the clinic in general. These lists applymostly to the procedural and organizational aspects of the clinic.

Best AttributesThe following are the best atthbutes evidenced in the three teams studied:

• Staff support the newly redesigned structure of the Cancer Center.• High quality and efficiency of patient care exists with team organization.• Structure of teams allows for flexibility of work coordination and team

communication.

Areas for ImprovementThe following areas could use improvement to increase the operational efficiency of thecancer clinics based on the following existing barriers:

• A lack of understood role definitions exists for RNs, Clinic Coordinator, andMAs exists.

• A lack of understood task breakout exists between the advance practice nursesand the clinic nurses.

• The scheduling imbalance creates non-uniform workload.• Minimal communication exists between RNs, Clinic Coordinator, and MAs of

different teams.• There is minimal cross-team support.

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• Minimal empowerment is provided to support staff resulting in underutilization.

• A lack of continued education, mentoring and documentation for RN’s andMA’s is in place to allow empowerment to support staff.

• Overemphasis is placed on individual teams as opposed to overall CancerCenter.

• Lack of a constructive feedback system exists for RNs.

RN

This section is subdivided into1. Discussion of the results from the random beeper and phone studies2. Comparison of actual staff activities with job descriptions3. Discussion of RN best practices4. Discussion of the potential areas for improvement related to RNs.

ResultsFigures 1 and 2 below are the results found from the random beeper study. Figure 1 is abreakdown of where, on average, the RNs spend their day. This chart shows that most ofa RN’s activities are spent with either patient or clinic coordination, comprising together64% of a RN’s total time. Surprisingly, direct patient care and symptom related callscombine to only 29% of an RN’ s total time. (The “Other” category consists of manydistinct activities, not falling under any of our established categories, occurring with toolittle frequency to be considered by themselves.)

FIGURE 1. Average RN’s Distribution of Activities

Figure 2 shows how the RNs from different teams compared to one another. Team 2 and 3RNs spend the most amount of time performing patient coordination, whereas Team 5 RNsspend the majority of their time performing clinic coordination . This graph shows thesignificant variation between Teams 5, 2 and 3. This most likely results from basicvariations in the team’s organization and areas of specialty. For example, Team 5 focuseson surgical oncology whereas Teams 2 and 3 focus on medical oncology. Additionally,Team 5 has more support from advance practice nurses for the clinic RNs and MAs.

RN Average

OtherSymptom Calls 7%

8%

Clin Coord31%

Dir Pat Care21%

Pat Coord33%

6

FIGURE 2. Summary of RN Activities From Team to Team

RN Summary

50%45%40%35%30% •Team2

25% Team3

20% DTeam5

15% —

_____

Average

Dir Pat Pat Clin Symptom OtherCare Coord Coord Calls

Figures 3 through 8 are results from the phone study. No data was collected by the Team 2nurses. The data used for Team 3 RN’s phone study was collected during a previousphone study performed in September ‘97. Additionally, note that these results wereobtained solely from level 1 and 2 nurses, not including advance practice nurses and this isnot studied or included. This should be considered when reviewing Team 5’s data, basedon the fact that most symptom management calls are handled by Team 5 advance practicenurses. For a more detailed breakdown of the phone study data refer to the individual teamanalyses are discussed later in the report. Other than for Team 3, for accurate data, thephone study should be re-done.

Figure 3 is a breakdown of the number of phone calls the average RN handles per day.This figure shows that RNs from Team 3 spend substantially more time handling phonecalls than team 5 RNs. Again Team 5 advance practice nurses were not considered in thisstudy, and therefore most likely account for the relatively small number of calls per day forTeam 5 RNs..

FIGURE 3. Number of Calls Handled by RN’s per Day

Figure 4 displays the average length of RN phone calls for Teams 3 and 5. Team 5 isspending approximately 1.5 the amount of time per call that Team 3 RNs spend. This is

I I

RN Phone Study Summary- Phone use per day

Z 30

25a).2 20

a)

10

a)00

Team 2* Team 3*Team 2 data is unavailable.

Team 5

7

probably due to the nature of most of Team 5 calls. (Refer to the individual team analysesfor this data.)

FIGURE 4. Average RN Call Length

Figure 5 shows the distribution of RN phone calls. The pie chart illustrates the percentagesof the major call type categories. Again, the RN’s phone call data was not collected fromTeam 2, thus the data will be skewed placing a greater weight on Team 3’s data. Thecategory “Other” denotes or describes many distinct types of phone calls, not falling underany of our established categories, occurring with too little frequency to be considered bythemselves. As may have been expected, the most frequently occurring calls are thoserelated to patient symptom management. The next greatest investment of time was inscheduling, representing 16% of total time spent on the phone.

FIGURE 5. Team Summary: Distribution of RN Phone Calls

Figure 6 shows the breakdown of the percent of outgoing calls versus incoming calls. Asshown, outgoing calls far outweigh incoming calls. These results are based only on

RN Phone Study Summary- Average Call Length

C4 5-J

—4= C

,

1

>0

*Team 2 data is unavailable.

Team 2* Team 3 Team 5

RN Phone Study SummaryCall Type Distribution

Intake InformationOther10%18%

Scheduling16%

\)est ResultsSimple Triage27% 15%

Doctor callRecords 9%

Complex Triage14%

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L8

distinct calls as opposed to being weighted for the amount of time spent on each call. Thelarge percentage of outgoing calls indicate that RNs have some control in decreasing theamount of time they spend on the phone during busy periods.

FIGURE 6. Team Summary: Incoming Versus Outgoing Calls

Figure 7 shows the percent of calls routed appropriately. This data, as was all the phonedata, is based on the responses of the RNs themselves. Therefore, the data are notobjective measures of the accuracy of routing. The data may simply show that the RNs arerouted the phone calls they feel they should be routed. This may relate to the bigger issueof what the RNs may understand as their role definitions. The RN’s appear to beanswering calls that other staff members could be or should be answering, even thoughthey feel the calls are properly routed (i.e. scheduling calls).

FIGURE 7. Team Summary: Accuracy of Call Routing to RN’s

Figure 8 shows the percentage of calls made to patients versus staff. Evidently most callswere made to staff, however this again (as in figures 6 and 7) is based on the sheer numberof calls and not on any weighted factor considering time.

RN Phone Study SummaryIncoming vs. Outgoing Calls

Incoming calls22%

Outgoing calls78%

RN Phone Study Summary- Call Routing

Calls routedinappropriately

5%

Calls routedappropriately

95%

9

FIGURE 8. Patient versus Staff Calls

Comparison With Planned Role DefinitionsBelow is a list of the RN’ s daily activities that were documented during our study of Teams2, 3, and 5. The list was established from the random beeper time study, staff interviews,and our observations. To the right of the current daily activities we have listed the originalrole definition of what was expected of the RNs when the clinic organization was defined.Please refer to pg.l&2 in Appendix A for the FTE detailed analysis of RNs.

Current Daily Activities Original Role Definition*

Direct Patient Care:Draw Blood/Wound CareChaperonePost Exam EducationNew Patient EducationPre-Surgery Consultation

Patient Coordination:Symptom Management CallsOther CallsSchedule Next VisitProcedure PrepPatient History - ComputerReview Lab ResultsPrepare and send ordersContacting PatientsChart ReviewConsulting Physician

Blood Draws/Wound CareChaperoneExplain Care PlanNew Patient EducationPre-Surgery Consultation

Symptom Management CallsOther CallsReport Test ResultsProcedure PrepComm. Pt. Care to FamilyReview Lab ResultsPrepare and send orders

(1)(2)(2)(2)(2)

(2)(2)(2)(2)(2)

RN Phone Study Summary- Patient vs. Staff Calls

Calls to patient34%

Calls to staff’66%

(l)&(2)(2)

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10

Clinic Coordination:Liaison Liaison (1)Organization and Patient Flow Take Pt. from exam room to checkout (2)Medical Records Team Organizational Activities (1)Office Clean-up Work-up Hard Copy Schedule (1)

Secure Supplies/Equipment for Med. (2)Procedure

* (1) = primary responsibility; (2) = secondary responsibility

While there is variation among teams, the overall time breakout of RN activities follows:

Current PlannedDirect Patient Care 21 % 50 %Patient Coordination 40 % 30 %Clime Coordination 31 % 20 %

Reviewing the two prior comparisons indicates that a few major discrepancies existbetween the original role definitions and current daily activities. The direct patient carecurrently performed by RNs coincides with the planned list of activities; however, in ourstudy, we have observed MAs involved in many of these activities (e.g., chaperoning,blood draws, wound care.) These activities, which can be performed by the MAs, allowgreater flexibility for the RNs to focus their attention on other activities.

Areas of discrepancy under patient coordination include “scheduling next visit” and “patienthistory”, both of which are currently performed but were not in the original job description.Referring to Appendix A pg. 1, it is observed these activities require up to 11% of the RNstime, and should be minimized now..

In the area of clinic coordination, we see the RNs are focusing on many short-term issues.The FTE breakdowns in Appendix A pg. 1 & 2 show no time organizing with the cliniccoordinator or focusing on any other long term activities. The current activities are dailymaintenance whereas the original role definition stressed greater long term focus. If thefocus was in fact long term, there would be less of a need to perform current cliniccoordination activities such as “medical records” and “office clean-up”, in addition toprevention of other emergencies (i.e. short staffing, pulling from CSR), and allowing forsmooth flow of the clinic. A current concern is that there is no time for long term focusbecause of the time demand for daily activities. As mentioned in the previous paragraph,delegating certain activities will provide for this time. However, for greater long termfocus there must ultimately be a change in mind-set of the RNs.

Best PracticesWe have highlighted the activities that some RNs presently perform that are above andbeyond their required job descriptions, but should be performed by all RNs in order toenhance team efficiency and productivity. Not all of the comments apply to all teams, but

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were found to have applied to at least one of the teams studied. The following list detailsthose activities:

• RNs teach MAs how to perform RN tasks to help on busy days. (staffinterviews)

Mas perform the following:- Wound care- Blood draws- Hickman’s and port blood draws- Assist basic patient procedures- Pull up DMI’s so when RN makes phone calls the necessary information

is at their disposal.- Discharge patients- Answer phone calls- Makes needed phone calls to depts.- Ancillary coordination- Patient flow/satisfaction

• Meets with clinic coordinator on a weekly basis to coordinate activities.• Pivotal member for team organization and unity• Role flexibility and adaptability to needs of given day.• Recognizes importance of clinic coordination to RN role.• Lead nurse realizes importance of clinic efficiency

- Printed phone routing list for clerks- Writing on board staff - location.

• Some verbalized constructive feedback to MAs as to their performance

Areas for ImprovementHere we have noted all practices related to RNs which should be considered as possibleareas for improvement to increase clinic, team, and/or RN role efficiency. Not all of thecomments apply to all teams, but were found to have applied to at least one of the teamsstudied. The following list details those practices:

• Little long term focus, most activities focus on daily issues.• Minimal coordination and communication between RN and CC.• Need to focus more on continuous feedback to other staff members to educate

staff as to their performance and productivity.• Need to remind staff about role definition.• Minimal management of support staff.• Not clear on work redesign roles and need to develop better understanding of

what is expected.• Minimal communication between RNs of the different teams.• Too team specific.• Lack clinic culture which instills consistent positive attitude.

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MA

This section is subdivided into1. Discussion of the results from the random beeper and phone studies2. Comparison of actual staff activities with job descriptions3. Discussion of MA best practices4. Discussion of the potential areas for improvement related to MAs.

ResultsFigures 9 and 10 below are the results found from the random beeper study. Figure 9 is abreakdown of where, on average, the MAs spend their day. This chart shows that almostall of an MA’s time is spent with direct patient care or patient coordination, comprisingtogether 91% of an MA’s total time. Clinic coordination surprisingly amounts to very littletime and combined with all other activities account for only 9% of an MA’s total time. (The“Other” category is made up of many distinct activities, not falling under any of ourestablished categories, occurring with too little frequency to be considered by themselves.)

FIGURE 9. Average MA’s Distribution of Activities

Figure 10 shows how the MAs from different teams compare to one another. Evident fromthe graph, MAs from team to team show very little variation. All MAs focus upon directpatient care and patient coordination, with Team 5 MAs spending the most time with directpatient care and the least with patient coordination. Team 2 MAs show slightly more timespent with clinic coordination. The clinic coordination category for Team 2 includedoccasional floating to help other teams during busy periods, an activity not seen with theother teams’ MAs.

Average MA

CNn Coord Other

6%

Pat Coord54%

Dr Pat Care37%

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FIGURE 10. Summary of MA Activities From Team to Team

Figures 11 through 16 are results from the phone study. Figure 11 is a breakdown of thenumber of phone calls an MA handles per day. This figure shows that the MAs from Team3 handle a minimal amount of phone calls, and the MAs from Team 5, in fact, do not usethe phone. The MAs for Team 2 handle a larger amount of phone calls during the daybecause Team 2 RNs share responsibilities with MAs, which enables the RNs to focusmore of their time on other activities. Overall, in comparison with the RNs, the MAshandle few phone calls.

FIGURE 11. Number of Calls Handled by MA’s per Day

Figure 12 displays the average length of MA phone calls for Teams 2 and 3. Team 2 and 3phone calls are approximately the same duration. When considered in combination withFigure 11, it is evident that the Team 2 MAs not only handle more calls, but spendsubstantially more time on the phone than Team 3 and 5 MAs.

MA Summary

70%

60%

50%

40%

30%

20%

10%

0%

Dir Pat Care Pat Coord Clin Coord Other

•Team2

Team3

OTeam 5mAverage

—1

MA Phone Study Summary- Phone use per day

430

25a).S 20

15

10

a)oO

Team 2 Team 3 Team 5**Team 5 MA’s show no use of phones.

I

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FIGURE 12. Average MA Call Length

Figure 13 shows the distribution of MA phone calls. The pie chart illustrates thepercentages of the major call type categories. It is important to note that their was no MAphone call data from Team 5, and because Team 2 had a large amount of phone calls, thedata will be skewed placing a greater weight on Team 2’s data. (Refer to the individualteam analyses for the more specific team results.) The “Other” denotes or describes manydistinct types of phone calls, not falling under any of our established categories, occurringwith too little frequency to be considered by themselves. The most frequently occurringcalls are calls related to patient test results, at 68% of total time spent on the phone. Thenext greatest investment of time and only other significant source of phone time is doctorcalls, which accounts for 11% of the total time spent on the phone.

FIGURE 13. Team Summary: Distribution of MA Phone Calls

MA Phone Study Summary- Average Call Length

• 5-j

Team 2 Team 3 Team 5*

*Team 5 MA’s show no use of phones.

I

MA Phone Study Summary -- Call Type Distribution

Test Results68%

Film/Radiology Other scheduling2% 12% 3%

Records

Pharmacy 1%1%

Symptom Related2%

Doctor Call11%

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Figure 14 shows the breakdown of the percent of outgoing calls versus incoming calls. Asshown, the number of outgoing calls are greater than incoming calls. Note that theseresults are based only on distinct calls as opposed to being weighted for the amount of timespent on each call.

FIGURE 14. Team Summary: Incoming Versus Outgoing Calls

Figure 15 shows the percent of calls routed appropriately. This data showing that almostall calls were routed appropriately, as was all the data, based on the responses of the MAsthemselves. Therefore, they are not objective measures of the accuracy of routing.The data indicates that the MAs are routed the phone calls they feel they should be routed.As with the RNs this may relate to the bigger issue of what the MAs may understand astheir role definitions.

FIGURE 15. Team Summary: Accuracy of Call Routing to MA’s

Figure 16 shows the percentage of calls made to patients versus staff. Evidently most callswere made to staff, however this again (as in figures 14 and 15) is based on the sheernumber of calls and not on any weighted factor considering time.

MA Phone Study Summary -- Incoming vs.Outgoing Calls

Incoming calls32%

Outgoing calls68%

MA Phone Study Summary --

Call Routing

Calls routedinappropriately

6%

Calls routedappropriately

94%

16

FIGURE 16. Team Summary: Patient versus Staff Calls

L[[[[J.

IZ[UUL

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MA Phone Study Summary -- Patient vs. StaffCalls

Calls to patient25%

Calls to staff75%

Comparison with Planned Role DefinitionsBelow is a list of the MA’s daily activities that were documented during our study of Teams2, 3, and 5. The list was established from the random beeper time study, staff interviews,and our observations. To the right of the current daily activities we have listed the originalrole definition of what was expected of the MAs when the clinic organization was defined.Please refer to pg. 2&3 in Appendix A for the FTE detailed analysis of MAs.

Current Daily Activities Original Role Definition

Direct Patient Care:Height, Weight & Vitals Height, Weight, & Vitals (1)Chaperoning Chaperoning (1)Patient Tests Set up Rooms for Med. Procedure (1)Route Patients Route Patients (1)Prep Pt. for Med. Procedure Prep Pt. for Med. Procedure (1)“Nursing” ProceduresCollecting Patient Information

Patient Coordination:Chart Location Chart Location (1)Ancillary Coordination Ancillary Coordination (1)Going to Ancillaries Going to Ancillary (1)Prep Patient Paperwork Prep Patient Paperwork (1)Room Turnover Room Turnover (1)Computer Work Computer Work (2)Patient List/Flow Patient List/Flow (1)Lab Work Lab WorkTest Results

Clinic Coordination:Stocking Rooms Stocking Rooms (1)Updating Rolodex Office Preparation (1)Looking for referring DoctorsOffice preparationAssisting other teamsVoice Mail

* (1) = primary responsibility; (2) = secondary responsibility

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While there is variation among teams, the overall time breakout of MA activities follows:

Current PlannedDirect Patient Care 37 % 30 %Patient Coordination 54 % 50 %Clinic Coordination 6 % 20 %

Comparing the actual vs original role descriptions, there is not much discrepancy. Onoccasion, MAs have performed activities in addition to their original definitions such as“nursing procedures” and “assisting other teams”. We recommend that these activities,which assist other staff members and allow smoother flow of the clinic, occur to a greaterdegree. For a detailed analyses refer to pg. 3 & 4 of Appendix A. Team 5 appears to bethe role model for direct patient care with 57%, and Team 2 was the only team assistingother, with only 1% of their total time.

Best PracticesWe have highlighted the activities that the MAs from the teams studied presently performthat are above and beyond their required job descriptions but should be performed by allMAs in order to enhance their teams efficiency and productivity. It is important to keep inmind that the activities listed under the sections best practices and areas for improvement donot apply to all the teams but were applicable to at least two of the teams that were studiedThe following list represents the best practices of the MAs observed for this report:

• Take on some “nursing” activities.- wound care- blood draws- EKG’s- Hickman’s and port blood draws- sigmoidoscopy- suture/staple removals- injections

• Occasionally assist other teams when not busy.• Demonstrate Proactiveness

- Prepare for day by pulling up patient list/info prior to workday needed.- Checks presence of charts and lab work at beginning of day.

• Call in prescriptions.• Articulate complaints to physicians or RNs to quickly resolve issues.

Constantly monitor patients to assure customer satisfaction (for example, bringsthem coffee, discuss visit).

• Assist nurses by answering phone calls.• Usecomputer for records if chart is missing.

Areas for improvementThe following list details areas to focus upon for improvement:

• Minimal tasks performed outside of team responsibilities when not busy.- i.e. Help other teams.

• Limited knowledge of areas capable of assisting RNs during busy periods.

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• Minimal phone call assistance to RNs.• Minimal communication with MAs on other teams to learn best practices.• Maintain reactive rather than proactive stance in team structure.• Lack clear understanding of role responsibilities

Clinic Coordinator

This section is subdivided into best practices and areas for improvement. Not all of thecomments apply to all teams, but were found to have applied to at least one of the teamsstudied.

Best PracticesWe have highlighted the activities that some clinic coordinators presently perform that areabove and beyond their required job descriptions, but should be performed by all CCs toenhance team efficiency and productivity. The following list details those activities:

• Demonstrate accurate understanding of role and the essential flexibility which itentails.

• Meets with RN once a week to coordinate activities.• Perform new patient transition - scheduling, calling, and confirming (front

loading).• Moving to computerized database for intake information data collection,

allowing easier collection and organization.• Are housed in staff room to provide support during periods that are extremely

busy.- schedule CAT scans, MRI’s- assist with patient flow- take messages for RNs or MAs

• Educate and cross-train clerks to take on more responsibilities.• Delegate responsibility of calling returning patients the day before their visit to

Clerks.• Use calendar on wall to allow physicians to notify staff about irregularities

during week.• Moving to larger format scheduling templates, to allow easier visualization of

relative physician schedules.• Provide constructive feedback to Clerks.

Areas for improvement:We have noted all practices related to CCs which should be considered as possible areas forimprovement to increase clinic, team, and/or CC role efficiency. Not all of the commentsapply to all teams, but were found to have applied to at least one of the teams studied. Thefollowing list details those practices:

• Role of Clinic Coordinator drastically differs between teams.• Minimally assist RN and MAs.• Exhibit minimal long term focus.

- Seldom remind clerks about role definition.- Minimally manage clerks.

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- Poor templates exist for physician scheduling.• Minimally share best practices with other CC.• Endanger of abuse of clinic coordinator as a resource by RN and MA, due to

constant presence in staff room.

Clerk

In this section we summarize the basic activities of the Clerks. Based on time limitationswe were unable to spend adequate time analyzing their efficiencies or inefficiencies.

Clerk Activities and ResponsibilitiesThe following represents the basic activities of the Clerks deduced through interviews:

• Complete check-out paperwork.• Perform check-in paperwork.• Complete all billing information.• Call patients the day before their visit.• Answer any last questions the patients may have.• Take phone messages of the doctors I nurses.• Schedule tests.• Schedule, reschedule, or cancel returning visits.• Schedule new patient appointments.• Enter new patient information into computer.• Distribute mail.

21

Individual Team Analysis

TEAM 2

Data is based upon a random beeper study of Team 2 RNs and MM, a phone study of theRNs and MAs, simple observation, and multiple interviews with RNs, MAs, and the Team2 clinic coordinator. Refer to methodology section for a more in depth description. Team2 clerks were not studied in sufficient detail to include in the following team analysis. Allrandom beeper and phone study data were reviewed with the RNs and MAs to insureapproximate accuracy.

A general discussion is presented first, followed by an analyses of RNs, clinic coordinator,and MAs. (Note that the clinic coordinator was less rigorously studied.) The analysesconsist of our data (if available), a listing of best practices, and a listing of areas forimprovement.

General Team Discussion

Team 2 strives to epitomize what the team structure was originally designed to establish.The team consists of individuals with different skill levels and areas of expertise, but allwork together to maximize each others abilities and talents to provide the most satisfactoryand thorough patient care they are capable of providing. The physicians have empoweredall of the staff members and this has enabled them to take on activities within the teamsetting which exceeds what is expected of their positions. There is mutual respect betweenall members of the team which has led to open communication within the team so thatproblems and concerns can be addressed without delay. The staff is willing to help oneanother during busy periods and this demonstrates their role flexibility.

The clinic coordinator plays a large role in the team success. Because the CC is in the staffroom, she plays an influential role in maintaining patient flow, handling phone calls, andhelping out where ever required during busy periods to help the team function moresmoothly. However, this can be a hindrance when the CC has tasks of her own to performand is unable to perform them because she is preoccupied helping the other team members.

There are a few other areas that the team could improve upon. There is some confusionwithin the team on role definitions. For example, the MAs do not feel that they areresponsible for searching for missing records, while in their original job description theywere supposed to look for records. The MM do a good job of handling issues once theyarise during the work day but could be more proactive and prevent the problems fromoccurring in the first place.

Both the RNs and CCs do not spend enough time organizing and delegating responsibilitieson a long term basis. It would prevent much of the daily time wasted addressing recurringproblem which could have been avoided. On Wednesdays, as shown in figure 18, there isan exorbitant amount of time allocated to handling patient coordination that could beavoided by planning and preparing more adequately for the issues that arise on busy days.Also, taking preventive steps to preempt problems that arise during a day will enable moretime to be re-focused towards direct patient care and other daily problems that cannot beprepared for beforehand. The daily inefficiencies that presently exist cause the staffaggravation, increase patient waiting time, increase the overtime needed to complete theworkday, and reduced job satisfaction. Much of this could be avoided with better directedfocus and more long term clinic management. The steps that can be taken to redirect theirfocus are listed in the recommendation section of this report.

22

RN

Data Collected:The following graphs, figure 17 and figure 18, come from the data collected during therandom beeper study of the Team 2 RNs. The data in the first figure represents thepercentage breakdown of the average Team 2 RNs during a typical day. Most of the day isspent performing activities that fall under the category of patient coordination. Morespecifically, that time is spent reviewing lab results (13%), preparing and sendingorders(1O%), and handling non-symptom related phone calls(1O%). As indicated by thelarge amount of time spent performing patient coordination(45%), the RN’s focus ispredominantly short term in scope. The figure also shows that little time is spentperforming clinic coordination(19%).

FIGURE 17. Average Team 2 RN’s Distribution of Activities

Figure 18 is the daily breakdown of the data collected on Team 2. Due to the low patientvolume on Mondays, there is very little direct patient care performed by the RNs on thatday. However, due to the randomness of the beeper time study, none of the direct patientcare time was observed although we know it was performed. Wednesdays are the busiestdays for Team 2 and most of the time that day is devoted towards patient coordination. Thiscould be reduced if more long term planning was performed to better prepare for the issuesthat arise on Wednesdays. A more detailed breakdown of this data can be found inAppendix A on pg. 1.

OtherSymptom Calls 8%

9%

Clin Coord19%

Team 2: RN

Dir Pat Care19%

Pat Coord45%

23

FIGURE 18. Team 2 RN’s Daily Activities

Best Practices:The following list represents the best practices of Team 2 RNs:

• RNs teach their clinic coordinator and MAs how to perform RN tasks to helpout on busy days. (staff interviews)

Mas perform:- Wound care- Blood draws- EKG’s- Hickman’s and port blood draws- Assist basic patient procedures- Pull up DMI’s so when RN makes phone calls the necessary information

is at their disposal- Discharge patients

CC performs:- Scheduling diagnostic tests- Answering phone calls- Making needed phone calls to depts.- Ancillary coordination- Patient flow/satisfaction

• Verbalize constructive feedback to MAs as to their performance.• Provide staff with positive reinforcement to let them feel appreciated.• Maintain a good attitude and addresses staff with respect.

Areas for Improvement:The following list represents potential areas for improvement for Team 2 RNs:

• Display minimal long term focus, therefore only deal with issues when theyarise during work day.

• Seldom remind staff about role definition.i.e. MAs don’t spend time locating records the day prior to a patientsvisit.

100%

Team 2RN Daily

80%

60%

40%

20%

0%

• OtherClinic Coordination

D Symptom CallsQ Patient Coordination9 Direct Patient Care

24

• Seldom focus more on team coordination creating minimal organization duringbusy periods.

MA

Data Collected:The two graphs below figure 19 and figure 20 come from the data collected during therandom beeper study of the Team 2 MAs. The data in the first figure represent thepercentage breakdown of the average Team 2 MAs during a typical day. Most of the day isspent performing activities that fall under the category of patient coordination(62%). Morespecifically, the MAs spend their time doing patient flow activities (18%), handling testresults(2 1%), and ancillary coordination(8%). These activities are in accordance with whatis expected of MAs under their original role definition. However, the Team 2 MAs performmore direct patient care activities then they are expected to. They draw blood, care forwounds, assist in basic medical procedures, etc. All of these activities free up more timefor RNs to dedicate more of their attention to their daily patients and team organization.

FIGURE 19. Average Team 2 MA’s Distribution of Activities

The figure 20 is the daily breakdown of the data collected on Team 2. Due to thelow patient volume on Mondays, there is very little direct patient care performed by theMAs on that day. Wednesday is the busiest day for the team and most of this day is spenthandling patient coordination. If the MA were better prepared for the high patient volumethere could be less time spent on patient coordination and more of a focus on direct patientcase. This would decrease their daily frustration with problems that arise which could havebeen prevented with better planning and a more proactive approach to preparing forWednesdays.

Team 2: MA

Clin Coord12%

Pat Coord62%

25

FIGURE 20. Team 2 MA’s Daily Activities

The phone study for this team was inconclusive due to the minimal amount of datacollected. However, the data that was collected was attached to Appendix A pg. 12 forreview. In the future, a more thorough phone study should be performed to obtain a moreaccurate study of team 2 MA phone time allocation.

Best Practices:The following list represents the best practices of Team 2 MAs:

• Occasionally assist other teams when not busy.• Call for prescriptions.• Articulate complaints to physicians or RNs to quickly resolve issues.• Write on board to let staff know which room the patients are in and when theywere put in the room.• Constantly monitor patients to ensure customer satisfaction, i.e. bring them

coffee, answer question if possible, positive attitude.• Perform “nursing” activities during busy periods..

Areas for Improvement:The following represents the areas for improvement for Team 2 MAs:

• Seldom perform tasks outside of team responsibilities when not busy.• Lack of accountability for overall team organization and daily success.• Minimal communication to MAs from other teams to learn best practices.• Minimal display of proactivity.

Clinic Coordinator

Best Practices:The following list represents the best practices of Team 2 CC:

• In staff room to provide support during periods that are extremely busy.• Display great role flexibility.• Exhibit great attitude and desire to provide a high level of patient satisfaction.• Educate and train clerks to take on more responsibilities.• Confirm all new patients day before visit.

100%

80%

Team 2MA Daily

60%

40%

20%

0%

•Other I

D Clinic CoordinationPatient CoordinationDirect Patient Care

Mon Tues Weds Thurs Fri

26

• Delegate responsibility of calling return patients the day before their visit toclerks.

• Uses calendar on wall to allow physicians to notify staff about irregularitiesduring week or if physician has added patient to schedule without appointment.

• Provides constructive feedback to clerks.

Areas for Improvement:The following represents the areas for improvement for Team 2 CC:• Lacks ability to leave staff room to focus on individual responsibilities• Exhibits limited communication with other team’s CC.• Minimal time is focused on long term issues which leads to more day to day

handling of problems, such as:- inventory levels of supplies- bad templates for scheduling physician visits

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TEAM 3

Data is based upon a random beeper study of team 3 RNs and MAs, a phone study of theRNs and MAs, simple observation, and multiple interviews with RNs, MAs, and the Team3 clinic coordinator. Refer to methodology section for a more in depth description. Team3 clerks were not studied in sufficient detail to include in the following team analysis. Allrandom beeper and phone study data was reviewed with the RNs and MAs to insureapproximate accuracy.

A general discussion is presented first, followed by analyses of RNs, clinic coordinator,and MAs. (Note that the clinic coordinator was less rigorously studied.) The analysesconsist of our data (if available), a listing of best practices, and a listing of areas forimprovement.

General Team Discussion

The RNs, clinic coordinator, and MAs analyzed for Team 3 show a solid movementtowards the work redesign goals; however, in this analysis we have located potential areasfor further improvement related to both individual staff positions and to Team 3organization as a whole. Here we discuss the organizational problems of Team 3 as awhole.

After observing the team for 6 weeks, their cohesiveness was apparent. The lead nurserecognizes many important issues that must be addressed. However, the lead nurse canbetter utilize the authority of the role. In order for responsibilities to be delegated, the leadnurse must empower the MAs, and the MAs must take the initiative. An example could bephone calls. The need should be stressed for MAs to answer any phone calls within theircapability, whether symptom related or “other”. The MAs should regularly andconsistently check the phone messages for phone calls which they can answer.

The team needs to develop an optimistic and supportive culture. Long term focus by thenurses will increase work satisfaction by minimizing much of the daily clinic coordination,and emergency scenarios (i.e. understaffing). Delegating responsibilities will also allowtime for team organization and direct patient care which will additionally increase jobsatisfaction. Support from other teams will continue to aid in alleviating the daily workload.

The lead nurse should coordinate better with the clinic coordinator. Additionally there islittle team-work and communication between the clinic coordinator and lead nurse.Overcoming this challenge will result in better team dynamics and will ultimately lead toreaching team goals.

RN

Data Collected:The following graphs came from the data collected from the random beeper study of Team3. The results have been verified with the staff for the accuracy. Further details of thisdata can be found in pg. 1, Appendix A. This will indicate the FTE’s for the RNs forTeam 3, as well as Teams 2 & 5 for comparison purposes.

Figure 21 is the percentage breakdown of the average Team 3 RN during a typical day.Referring to Appendix A, pg. 1, it can be seen that 10% of the clinic coordination time is

28

spent on organization and clinic flow. This is an area that the long term focus, workplaceefficiency, and communication will minimize.

The symptom related calls constitute approximately 19% of the average day. Additionally,11% of patient coordination is “other calls”, which totals the phone calls for the teamsnurses to 30%. If the role definition of the other staff (clinic coordinators, MAs) includedperforming all the calls within their capability this percentile will be reduced.

FIGURE 21. Average Team 3 RN’s Distribution of Activities

Figure 22 gives the RNs daily time allocation. The percentiles do not vary substantiallyfrom day to day. No data was available for Friday because both of Team 3 RNs attended aconference on this day during the random beeper time study. After consulting the nurses,they felt the Friday was comparative to a Monday with respect to time demands.

FIGURE 22. Team 3 RN’s Daily Activities

The phone survey results (Appendix B pg. 1) were tabulated from a study performed inSeptember. Since this time, there has been a phone list given to the clerks, of what phonecalls to send to the nurses. Additionally there has been a shift to allocate these phone callsto the CC and MAs. Therefore, these results may not be completely indicative of thecurrent calls.

Symptom Calls19%

Clin Coord15%

Team 3: RN

Dir Pat Care17%

Pat Coord45%

Team 3RN Daily

100% -

90%

80%

70%60%

50%40% -

30% -

20%10%

0% -

jUOther

I a Clinic Coordination

Symptom Calls• Patient CoordinationDDirect Patient Care

Mon Tues Weds Thurs Fri

LL

29

The results indicate the following:• 17% of the phone time is on scheduling related issues. Nurses should not have to

answer this many scheduling related phone calls.• The majority of the phone calls were routed correctly. This may relate to the bigger

issue of what the RNs may understand as their role definitions. i.e. The RN’s areanswering calls that other staff members could be or should be answering.

• Outgoing calls far outweigh incoming calls. Note that these results are based only ondistinct calls as opposed to being weighted for the amount of time spent on each call.The large percentage of outgoing calls indicate that Team 3 RNs have some control indecreasing the amount of time they spend on the phone during busy periods.

• The amount of time I call and the amount of calls nurses answers far outweigh the callsof the MAs.

Best Practices:The following list represents the best practices of Team 3 RNs:

• Lead nurse realizes the importance of clinic efficiency.- Produce printed phone routing list for clerks- Writes on the board location of staff - this prevents wastage of time looking

for staff• Displays flexibility and adaptability to needs of given day.• Does good job of assigning tasks on a daily basis, i.e. when the team is busy

one MA is assigned to chaperone, another will be assigned to lab work and soon.

• Provides opportunity for Clinic Coordinators and MAs to undertake additionalresponsibilities, i.e. allow MAs to answer phones and other activities that mightrequire decision making.

• Documents areas for improvement.• Focuses on employee satisfaction.

Areas for Improvement:The following list represents potential areas for improvement for Team 3 RNs:

• Shows minimal authoritativeness.• Consumed with daily activities of team therefore having minimal long term

focus- Time spent performing clinic coordination centers on daily issues and notpreventive methods and team organization to reduce the occurrences of dailyproblems.

- Team does not meet on a consistent basis• Lacks Cancer Center culture to instill consistent positive attitude.• Minimal communication exists between RN and CC within and between teams.

LL

30

MA

Data Collected:The graphs below came from the data collected from the random beeper study of Team 3.The results have been verified with the staff for the representativeness. Further details ofthis data can be found in pg. 3, Appendix A. This will indicate the FTE’s for the MAs forTeam 3, as well as Teams 2 & 5 for comparison purposes.

The data in Figure 23 represents the percentage breakdown of the average Team 3 MAduring a typical day. Observing the graph only 2% of daily activities are focused on cliniccoordination. Figure 24 is a daily analysis of the MAs, which does not vary substantiallyfrom day to day. On Monday and Friday, when the team is not as busy, additional cliniccoordination will allow smoother flow on the busier days.

______FIGURE

23. Average Team 3 MA’s Distribution of Activities

The results of the MA phone survey are presented in Appendix A pg. 11. The MAs do notanswer many phone calls. The majority of the phone calls which the MAs answer areincoming. The smaller percent of the outgoing calls may indicate the MAs do not check thephone messages consistently and regularly for phone calls which they can answer.

Team 3: MA

Clin Coord2%

Other2%

Dir Pat Care38%

Pat Coord58%

FIGURE 24. Team 3 MA’s Daily Activities

Team 3MA Daily

100%

90%

80%70%

60%

50%40%

30%

20%10%0%

•Other

0 Clinic CoordinationD Patient Coordination0 Direct Patient Care

Mon Tues Weds Thurs Fri

31

Best Practices:The following list represents the best practices of Team 3 MAs:

• Assist nurses by answering phone calls, blood draws.• Designate duties on the busy days allowing smoother, efficient clinic flow.

- one MA per doctor- doctors assigned designated area => reduce time spent on flow- MA designated for lab activities while another designated to work in cysto

room on Tues.• Display proactive attitude - verifying charts, obtaining films, etc. the day prior

to patients visit.

Areas for Improvement:The following represents the areas for improvement for Team 3 MAs:

• Minimally perform tasks that are not specifically MA activities on a moreconsistent basis.

- Blood draws- Phone calls- Schedule medical procedures, etc.

• Seldom perform tasks outside of team responsibilities when not busy- Help other teams- Communicate and share best practices with other team’s MAs

Clinic Coordinator

The clinic coordinator of Team 3 is located within the staff room. However, still isolatesherself from the group. The communication and team work between the RN and CC isvery little.

Best Practices:The following list represents the best practices of Team 3 CC:

• Assists the clerks when needed• Handles overbooking of patients , when necessary, in a methodical manner

creating a minimal amount of confusion and providing smoothest flow possible• Occasionally assists RNs and MM when busy

Areas for Improvement:The following represents the areas for improvement for Team 3 CC:

• Minimal assisting of RNs and MAs.• Minimal communication with staff.• Displays little role flexibility.• Lacks optimistic team attitude.• Provides minimal constructive feedback to RNs and MAs.• Performs little team coordination with RN.

LL

32

TEAM 5

Data is based upon a random beeper study of teamS RNs and MAs, a phone study of theRNs and MAs, simple observation, and multiple interviews with RNs, MAs, and the Team5 clinic coordinator. Refer to methodology section for a more in depth description. Team5 clerks were not studied in sufficient detail to include in the following team analysis. Allrandom beeper and phone study data was reviewed with the RNs and MAs to insureapproximate accuracy.

A general discussion is presented first, followed by analyses of RNs, clinic coordinator,and MAs. (Note that the clinic coordinator was less rigorously studied.) The analysesconsist of our data (if available), a listing of best practices, and a listing of areas forimprovement.

General Team Discussion

The RNs, clinic coordinator, and MAs studied for TeamS show a solid movement towardsthe work redesign goals; however, in this analysis we have located potential areas forfurther improvement related to both individual staff positions and to TeamS organization asa whole. Here we discuss the organizational problems of Team 5 as a whole.

A basic obstacle to optimal team dynamics in TeamS is the insufficient communicationamongst the staff. Although this communication currently exists it does not take placepredictably throughout the team. Greater communication would be fostered with regularteam meetings, which although part of the original work redesign goals, has been difficultto implement on a regular basis. This difficulty stems from Team 5’s focus on surgicaloncology, therefore limiting the regular availability of the physicians. However, teammeetings are nevertheless possible, although possibly with a more limited attendance --team leader (if available), RNs, clinic coordinator, and MAs. Currently, the lead RN andclinic coordinator meet on a weekly basis, showing the feasibility of such regular,proactive, communication. This communication is basic to furthering the goals of theclinic.

A second obstacle preventing Team 5 from implementing the work redesign (mostpronounced on certain days) is their current disproportionate staffing. For example, onMondays Team 5 RNs often bring in CSR nurses for assistance; however, these nurses (orthe Team S nurses) often perform organizational tasks, or help with clinic flow to the extentthat almost 50% (see below) of the RN’s time is spent with clinic coordination. Theseactivities could and should be distributed to MAs to create the desired balance within theteams. However, the Team 5 MAs are currently occupied with more patient focused tasks(direct patient care or patient coordination). Because the goal is to distribute the workloadamongst the staff consideration should be given to reducing the number of CSR nurses,while strengthening the MA staffing, and farther developing their roles. Refer to theindividual position analyses for more detailed descriptions of current RN, cliniccoordinator, and MA roles.

RN

Data CollectedFigures 25 and 26 below are the results found from the random beeper study performedwith Team 5. This data was collected over a five day period, where the random beeper wasset to go off on average of three times per hour. Figure 25 is a breakdown of where, onaverage, the RNs spend their day (with a more detailed breakdown in the appendix).

33

Interestingly, this chart shows that a large bulk of Team 5 RN’s time is spent with cliniccoordination, comprising 47% of a RN’s total time. (The “Other” category consists ofmany distinct activities, not falling under any of our established categories, occurring withtoo little frequency to be considered by themselves.)

FIGURE 25. Team 5 RN’s Daily Activities

Figure 26 shows the distribution of RN activities throughout the week. This graph showsthat direct patient care is greatest on Monday, which was expected based on the heavypatient load on this day. Tuesday, as expected, shows no direct patient care, based on theusual absence of patient visits on this day. The direct patient care on Wednesday andThursday is comparable, probably due to the comparable workload on those days. Fridayshows approximately the same amount of direct patient care as Wednesdays andThursdays; however, on this day only one MA is present, forcing the single RN on duty todo typically MA tasks when the MA is occupied. The patient volume on Friday is normallysimilar to Tuesdays; however, for this particular day, it evidently was not. As expectedfrom figure 1, clinic coordination is a significant part of each day; although to a lesserdegree on Mondays where direct patient care is more significant.

FIGURE 26. Team 5 RN Distribution of Activities through Week

Figures 27 through 30 are the results from the phone study. Note that these results wereobtained solely from level 1 and 2 nurses, not including nurse practitioners. This should

Team 5: RN

Other8%

Dir Pat Care29%

Clin Coord47%

Pat Coord16%

Team 5RN Daily

100%

90%80%70%

60%

50%40%

30%20%10%

0%

•OtherO Clinic Coordination

Patient Coordination0 Direct Patient Care

Mon Tues Weds Thurs Fri

34

be considered when reviewing Team 5’s data, based on the fact that all symptommanagement calls are handled by Team 5 nurse practitioners, resulting in a negligibleamount of time spent with symptom management by the RNs studied. Intake Information,as shown in figure 27, refers to calls made by RNs to patients to collect symptomaticinformation relevant to their upcoming visit (usually performed for only breast carepatients.)

FIGURE 27. Team 5 RN Distribution of Phone Calls

Figure 28 shows the breakdown of the percent of outgoing calls versus incoming calls. Asshown, outgoing calls far outweigh incoming calls. Note that these results are based onlyon distinct calls as opposed to being weighted for the amount of time spent on each call.The large percentage of outgoing calls indicate that Team 5 RNs have some control indecreasing the amount of time they spend on the phone during busy periods.

FIGURE 28. Team 5 RN Incoming versus Outgoing Calls

Figure 29 shows the percentage of calls made to patients versus staff. Evidently most callswere made to staff, however this again (as in figures 6 and 7) is based on the sheer numberof calls and not on any weighted factor considering time.

Team 5 RNCall Type Distribution

RecordsScheduling 5%

17%

Intake Information78%

Team 5 RNIncoming vs. Outgoing Calls

Incoming calls13%

Outgoing calls87%

35

FIGURE 29. Team 5 RN Patient versus Staff Calls

Figure 30 shows the percent of calls routed appropriately. This data, as was all the data,based on the responses of the RNs themselves. Therefore, the data are not objectivemeasures of the accuracy of routing. The data may simply show that the RNs are routedthe phone calls they feel they should be routed. This may relate to the bigger issue of whatthe RNs may understand as their role definitions.

FIGURE 30. Team 5 RN Routing Accuracy

Best PracticesThe following list represents the best practices of Team 5 RNs:

• Lead nurse communicates well with MAs, teaching them RN activities. (Referto MA analysis below to see a list of specific activities the MAs areperforming.)

• Recognizes the importance of clinic coordination, and acts accordingly.

• Displays good communication between lead RN and other nurses.• Contacts patients to perform pre-visit analysis to expedite upcoming visit.

• Meets with clinic coordinator on a weekly basis to coordinate activities.

Team 5 RNPatient vs. Staff Calls

Calls to staff16%

Calls to patient84%

Team 5 RNCall Routing

Calls routedinappropriately

0%

Calls routedappropriately

100%

36

L

Areas for ImprovementThe following list represents potential areas for improvement for Team 5 RNs:

MA

. Minimally communicates with MAs.• Insufficient delegation of clinic coordination to MAs.• No distribution of phone calls to MAs.• Not enough modification of role to reach work redesign goals.• Insufficient regular communication with MAs to gain and give feedback.

Data CollectedFigures 31 and 32 below are the results found from the random beeper study performedwith Team 5. This data was collected over a five day period, where the random beeper wasset to go off on average of three times per hour. Figure 31 is a breakdown of where, onaverage, the MAs spend their day. This chart shows that almost all of TeamS MAs’ time isspent with direct patient care and patient coordination, together comprising 94 % of a MA’stotal time. Note that there was no clinic coordination shown for Team 5 MAs. (The“Other” category consists of many distinct activities, not falling under any of ourestablished categories, occurring with too little frequency to be considered by themselves.)

FIGURE 31. Team 5 MA’s Daily Activities

Figures 32 shows the distribution of MA activities throughout the week. Thisgraph shows that MA responsibilities are relatively constant throughout the week, witheach day well represented by Figure 32. Although MAs are normally present on Fridaymornings, no data was collected for this day.

Team 5: MA

Other

Pat Coord36% Dir Pat Care

58%

37

FIGURE 32. Team 5 MA Distribution of Activities through Week

Although a phone study was conducted with Team 5 MAs, their minimal handling of phonecalls (on average less than 5 phone calls with each less than 3 minutes per week) preventedany data from being collected. There is therefore no data for the Team 5 MA phone study.

Best PracticesThe following list represents the best practices of Team 5 MAs:

• Take on a lot of “nursing” activities (sigmoidoscopy, suture/stapleremovals, injections, and glucose checks).

• Prepares for longer days by pulling up patient lists/info prior to workdayneeded.

• Uses computer records if chart is missing.• Checks presence of charts and lab work at beginning of day.

Areas for ImprovementThe following list represents the areas for improvement for Team 5 MAs:

• An insignificant number of phone calls are presently handled, leaving potentialto help nursing complete intake information calls (described above for RNs.)

• Minimally understands clinic coordination and organizationalresponsibilities.

• Seldom help other teams when not busy.• Minimally accept accountability for overall team organization and daily success.• Minimally communicates with MAs from other teams to learn best practices.

Clinic Coordinator

Best Practices:The following list represents the best practices of Team 5 CC:

• Accurately understands role and the essential flexibility which it entails.• Meets with RN once a week to coordinate activities.• Routinely teaches or helps clerks.• Moving to computerized database for intake information data collection for

easier collection and organization.

Team 5MA Daily

100%

90%80%

70%

60%50%40%

30%

20%10%

0%

•OtherO Clinic Coordination• Patient Coordination0 Direct Patient Care

Mon Tues Weds Thurs Fri

38

• Moving to larger format scheduling templates, allowing easier visualization ofrelative physician schedules.

• Exhibits aggressive and optimistic attitude.

Areas for Improvement:The following represents the areas for improvement for Team 5 CC:

• Minimally communicates with physicians to insure their understanding ofrescheduling demands and needs.

LLC

CONCLUSIONSThe following addresses our conclusions after analyzing the data presented in this report,interviewing staff members from teams 2, 3, and 5, and observing clinic activitiesfirsthand. This section attempts to highlight the issues that the general clinic and theindividual employees could improve upon. These are the items that prohibit the cancerCenter from fuiiy realizing all goals of the work redesign, especially the items outlined inAppendix F.

General Clinic

The following list details our conclusions about the general clinic.• Staff focus almost exclusively on individual team to the detrement of the overall Cancer

Center.• The scheduling of patients is not evenly dispersed throughout the week. This creates

periods of overwhelming patient demands as well as other periods of inactivity.• Teams use replacement staff from CSR when RNs and MAs from other teams are not

busy and could help.• Employees are sometimes rigid with their responsibilities and can be unwilling to play

dynamic role in patient care during visits.• No common culture exists throughout entire Cancer Center clinics.• Communication is virtually nonexistent between teams; therefore, best practices of

teams are not shared.• Clinics lack a constant feedback system so that teams as a whole as well as individual

employees can receive positive reinforcement for good practices and constructivecriticism in areas that need improvement.

RN

The following list details our conclusions about the RNs.• Could shift more procedural activities to MAs and CC.• Lack ongoing constructive feedback from clinics.• Little focus is placed on long term team goals and organization. This results in having

to deal with problems when they arise during the daily clinic. Problems could beprevented.

• Almost no communication and sharing of ideas exists between RNs from differentteams.

• Focuses little attention on management role in team.• Re—education may be necessary of individual role definition and job expectation.• Needs to acquire a better understanding of other team members’ role definitions in

order to be a better team manager.

Clinic Coordinator

The following list details our conclusions about the clinic coordinators.• Provides minimal coordination with lead RN for team organization• Underutilized by teams during busy periods, since could handle more responsibilities.

40

• Receives minimal constructive feedback from RN on an ongoing basis.• Lacks understanding of clinic’s expectation ofjob performance.• Little focus on long term goals and team organization.• Limited sharing of information between CCs on different teams about best practices and

problem areas.

MA

The following list details our conclusions about the MAs.• There is little time spent helping other teams, even when not busy.• Lack clear understanding of role definition.• Display minimal proactivity and initiative.• Almost no communication and sharing of ideas between MAs from different teams.• Not accepting accountability for their role in team and Cancer Center success.

41

RECOMMENDATIONSThese recommendations are made after reviewing the data collected, interviewingemployees, and performing firsthand subjective analyses of the teams studied. Themanagement lead team should develop an action plan to use the results of this project todetermine necessary steps to fully realize the goals of the intended work redesign(Appendix F). Involve staff in specific efforts of the project. The following 4 sectionsinclude specific items to consider in this effort.

General Clinic

The following highlights the items that could be taken by the clinic in general, to improvethe efficiency, productivity, and quality of service administered in the Cancer Center:• Establish cross-training between RNs, clinic coordinators, MAs, and clerks.• Establish protocols with team Physicians to empower support staff and allow them to

take on more responsibility.• Emphasize the need for mutual respect from all employees to all employees.• Encourage open and honest monthly meetings.• Require physician attendance at monthly meetings.• Encourage meetings between other staff members, regardless of team leader’s

availability.• Focus even more on patient satisfaction during visit:

- show educational videos in patient waiting room.- consider placing coffee pot in waiting room for patients- provide supplemental survey sheets so patients can provide feedback about their visits

• Instill Cancer Center culture -- teach mission statement, provide feedback to employeesabout expectations and clinic focus, and hold clinic social gatherings.

• Cluster teams to allow busy teams to pull staff from non-busy teams. See Appendix D,pg. 1.

• Re-educate employees as to their responsibilities, i.e. MA need to deal with cliniccoordination (records, team organization, etc.), RN need to deal more with long termclinic organization and management roles.

• Provide policies and procedures in writing to staff.• Improve scheduling program so it is user friendly and more easily adjusted.

Additionally, improve system of dealing with last minute patient add-ins.• Attempt to cover for RNs and MAs first from other teams then from CSR.

RN

The following list highlights the steps that could be taken by the RNs, to improve theefficiency, productivity, and quality of service administered in the Cancer Center:• Place more emphasis on long term focus, such as:

- Develop team goals for efficiency and productivity.- Organize before visits who handles which calls during busy periods and make sure

r the individuals who route the calls know where to route them.L - Develop system to ensure that all charts, records, etc. are ready the day before busy

days so that valuable time is not wasted during the clinic searching for anything.

L42

- Discuss with staff who will be responsible for which tasks during clinic so that nooverlap of responsibilities occurs and everyone is focused on their responsibilities.

- Focus more on management activities.• Establish monthly meetings between RNs from all teams to maximize best practices

used in all teams and allow RNs time to focus collectively on long term goals.• Develop system to receive constructive feedback on performance. Continually refine

what is expected from RNs because as time goes on the expectations will change andthe RNs need to constantly adapt.

• Cross-train MAs and CCs to enable them to play greater role during busy times.• Delegate more phone calls to MAs and clinic coordinator.• Improve management skills.

Clinic Coordinator

The following highlights the items that could be taken by the CCs, to improve theefficiency, productivity, and quality of service administered in the Cancer Center:• Train clerks to perform more tasks and therefore help out more during busy periods.• Learn more appropriate RN and MA activities to reduce demands on RN and MA

during busy periods.• Meet regularly with lead nurse to coordinate activities.• Meet bi-weekly with CC from other teams to learn best practices.• Meet with physicians to continually improve scheduling and deal with scheduling

problems.

MA

The following highlights the items that could be taken by the MAs, to improve theefficiency, productivity, and quality of service administered in the Cancer Center:• Focus more on patient satisfaction with visit.• Understand role responsibilities.• Understand need for being proactive. Learn to assist team with clinic coordination

without being asked to by RN.• Meet periodically with MAs from other teams to maximize best practices.• Handle more phone calls during busy periods to free up more RN time.• Develop more skills by cross-training with RNs. This will enable them to play a greater

role during busy periods and increase their job satisfaction by having a more dynamicresponsibility.

• Accept clerical responsibilities that occur within the staff room.

43

APPENDIX A

Team 2 & 3: Registered Nurses Worked FTE’s

Team 2 Worked Minutes!% of Total FI’E’s Patient

Team 3 Worked Minutes/% of Total FTEs Patient

Direct Patient CareDraw Blood / Nursing Procedures 3% 0.05 0.9 7% 0.15 2.5Assisting Exams (Chaperoning) 4% 0.08 1.4 0% - -

Post Exam Education 11% 0.20 3.4 5% 0.09 1.5

[ New Patient Education 1% 0.02 0.3 5% 0.11 1.8Pre-Surgery Consultation 0% - - 0% - -

Patient CoordinationSymptom Management CallsOther CallsContacting PatientsSchedule Next VisitProcedure Prep

I Patient History - computerReview Lab Results

19% 0.35 6.0 17% 0.35 5.8

9% 0.17 2.9 19% 0.38 6.410% 0.18 3.1 11% 0.22 3.70% - - 0% - -

4% 0.08 1.4 3% 0.05 0.92% 0.03 0.6 4% 0.07 1.27% 0.13 2.3 7% 0.15 2.513% 0.25 4.3 8% 0.16 2.80% - - 1% 0.02 0.30% 0%

Chart ReviewConsulting PhysicianPrepare and send orders

Clinic CoordinationLiaisonOrganization and Patient FlowMedical Records

L Making Phone ListsTeaching StaffDirecting and Coordinating StaffCollecting SuppliesOffice Clean-up

Other

10% 0.18 3.155% 1.04 17.7

4% 0.08 1.46% 0.12 2.06% 0.12 2.00% - -

0% - -

0% - -

0% - -

2% 0.03 0.619% 0.35 6.0

12% 0.24 4.065% 1.29 21.8

2% 0.04 0.69% 0.18 3.10% - -

0% - -

0% - -

0% - -

1% 0.02 0.33% 0.05 0.915% 0.29 4.9

Downtime 8% 0.15 2.6 4% 0.07 1.2

TOTAL 100% 1.90 32.2 100% 2.00 33.7

A-i

Team 5 & Avg: Registered Nurses Worked FTE’s

Organization and Patient Flow

F Medical RecordsL Making Phone Lists

Teaching StaffDirecting and Coordinating Staff

I Collecting SuppliesOffice Clean-up

6% 0.12 2.415% 0.31 6.13% 0.06 1.14% 0.09 1.71% 0.02 0.4

11% 0.22 4.30% - -

8% 0.17 3.247% 0.98 19.3

4% 0.09 1.611% 0.22 3.93% 0.06 1.02% 0.04 0.70% 0.01 0.25% 0.10 1.70% 0.00 0.15% 0.10 1.731% 0.62 11.0

Team 5 Worked Minutes!% of Total FTE’s Patient

Average Worked Minutes!% of Total FTE’s Patient

Direct Patient CareDraw Blood I Nursing ProceduresAssisting Exams (Chaperoning)Post Exam EducationNew Patient EducationPre-Surgery Consultation

Patient CoordinationSymptom Management CallsOther CallsContacting PatientsSchedule Next VisitProcedure PrepPatient History - computerReview Lab ResultsChart ReviewConsulting PhysicianPrepare and send orders

Clinic CoordinationLiaison

4% 0.08 1.5 4% 0.09 1.61% 0.01 0.2 1% 0.03 0.54% 0.09 1.7 6% 0.12 2.26% 0.13 2.6 5% 0.09 1.714% 0.30 5.8 5% 0.09 1.729% 0.61 11.9 21% 0.43 7.6

0% - - 8% 0.15 2.70% - - 6% 0.11 2.011% 0.22 4.3 5% 0.10 1.71% 0.01 0.2 2% 0.04 0.80% - - 1% 0.03 0.51% 0.02 0.4 4% 0.09 1.62% 0.04 0.9 7% 0.14 2.40% - - 0% 0.00 0.12% 0.03 0.6 1% 0.01 0.30% - - 6% 0.12 2.116% 0.33 6.5 40% 0.80 14.3

OtherDowntime 8% 0.18 3.5 7% 0.14 2.5

TOTAL 100% 2.10 41.1 100% 2.00 35.4

A-2

Team 2 &3: Medical Assistants Worked FTE’s

Team 2 Worked Minutes/% of Total FTE’s Patient

Team 3 Worked Minutes!% of Total FTE’s Patient

Direct Patient CareHeight, Weight, & Vitals“Nursing” ProceduresChaperoningPatient TestsRoute PatientsPatient PreparationCollecting Patient Information

Patient CoordinationChart LocationTest Results

[ Ancillary CoordinationGoing to AncillariesPrep Patient PaperworkRoom TurnoverComputer WorkPatient List I FlowLab Work

HClinic Coordination

Stocking RoomsUpdating RolodexLooking for referring DoctorsVoice MailOffice preparationAssisting Other Teams

Other

7% 0.14 2.5 4% 0.09 1.51% 0.03 0.5 1% 0.02 0.40% - - 4% 0.08 1.34% 0.09 1.5 5% 0.11 1.96% 0.13 2.1 9% 0.19 3.21% 0.02 0.3 13% 0.29 5.03% 0.06 1.0 2% 0.03 0.6

23% 0.46 7.9 38% 0.83 14.0

3% 0.07 1.1 4% 0.08 1.321% 0.42 7.0 8% 0.17 2.98% 0.16 2.8 13% 0.29 5.02% 0.04 0.7 4% 0.09 1.51% 0.02 0.3 8% 0.17 2.96% 0.12 2.0 9% 0.20 3.42% 0.05 0.8 0% - -

18% 0.36 6.1 5% 0.11 1.90% 0.01 0.2 7% 0.16 2.7

62% 1.24 21.0

4% 0.08 1.33% 0.07 1.11% 0.03 0.52% 0.04 0.70% - -

1% 0.03 0.512% 0.24 4.1

58% 1.28 21.6

2% 0.05 0.80% - -

0% - -

0% - -

0% - -

0% - -

2% 0.05 0.8

Downtime 3% 0.06 1.0 2% 0.05 0.8

TOTAL 100% 2.00 33.9 100% 2.20 37.1

A-3

Team 5 & Avg: Medical Assistants Worked Fib’s

Patient CoordinationChart LocationTest ResultsAncillary CoordinationGoing to AncillariesPrep Patient PaperworkRoom TurnoverComputer WorkPatient List / FlowLab Work

Clinic CoordinationStocking Rooms

[ Updating Rolodex

L Looking for referring DoctorsVoice MailOffice preparationAssisting Other Teams

Other

Direct Patient CareHeight, Weight, & Vitals“Nursing” ProceduresChaperoningPatient TestsRoute PatientsPatient PreparationCollecting Patient Information

Team 5 Worked Minutes! Average Worked Minutes!% of Total FTE’s Patient % of Total FTE’s Patient

17% 0.29 5.6 8% 0.16 2.93% 0.05 1.1 2% 0.03 0.610% 0.18 3.5 4% 0.07 1.33% 0.05 1.1 4% 0.09 1.510% 0.16 3.2 8% 0.16 2.83% 0.05 1.1 6% 0.12 2.110% 0.18 3.5 4% 0.08 1.557% 0.97 19.1 37% 0.72 12.7

8% 0.14 2.78% 0.14 2.71% 0.01 0.30% - -

2% 0.04 0.87% 0.12 2.40% - -

10% 0.16 3.20% - -

36% 0.62 12.1

0% - -

0% - -

0% - -

0% - -

0% - -

0% - -

0% - -

5% 0.09 1.613% 0.25 4.58% 0.16 2.92% 0.04 0.84% 0.07 1.37% 0.15 2.61% 0.02 0.3

11% 0.22 3.93% 0.06 1.0

54% 1.07 19.0

2% 0.04 0.81% 0.03 0.51% 0.01 0.21% 0.01 0.30% - -

1% 0.01 0.26% 0.11 1.9

Downtime 6% 0.11 2.1 3% 0.07 1.2

TOTAL 100% 1.70 33.3 100% 1.97 34.8

A-4

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B-4

APPENDIX C

LLL

Nursing Workload Data Collection

_________________

Time Begin:_

________________

Time End:Lunch Begin:_Lunch End:

Please collect this information for 1 week. When the beeper sounds, make a hash mark

under the frequency column corresponding to the activity you are currently performing.Thank you for your cooperation.

Activity I Before Noon I After NoonDirect Patient CareDraw BloodChaperonePost Exam EducationNew Patient Education

Patient CoordinationSymptom Management CallsOther CallsSchedule Next VisitProcedure PrepPatient History - computerReview Lab ResultsPrepare and send orders

Clinic CoordinationLiaisonOrganization and Patient FlowMedical RecordsOffice Clean-up

OtherDowntime1.2.3.4.5.

I

Name:.Date:

c-i

RN Random Beeper Time Study Definitions

Direct Patient Care:

Draw Blood/Wound Care - time spent drawing patients blood and caring for apatients wound.

Chaperone - exams or procedures.Post Exam Education - any time spent talking with patient following physician’s

visit.

New Patient Education - any time spent talking with new patient solely because it istheir first visit.

Pre-Surgery Consultation - time spent talking with patient about their upcomingsurgery.

Patient Coordination:

Symptom Management Calls - calls answering questions regarding patients health.Other Calls - concerning patient prescriptions, lab work, records, etc.Schedule Next Visit - time spent recording information on patients next visit.Procedure Prep - prepare patients for procedures either in exam rooms or forinfusion.

Patient History - Computer- time spent on computer related to patients history.Review Lab Results - from all labs both internal and external.Prepare and send orders - time spent preparing and sending orders for all types of

patient required activities.Contacting Patients - calls made to patients for any reason other than symptom

related issues.

Chart Review - time spent reviewing patient chart information.Consulting Physician - time spent talking with physicians regarding patient care.

Clinic Coordination:

Liaison - between team physicians and all other physicians or medical departmentsboth internal and external.

Organization and Patient Flow - daily team organization and patient flowthroughout visit.

Medical Records - any time spent locating a patient’s medical record.Office Clean-up - cleaning up the staff room or other staff work areas.

C-2

Medical Assistant Workload Data CollectionName:_________________________________ Time Begin:Date:__________________________________ Time End:________________

Lunch Begin:Lunch End:_____________

Please collect this information for I week. When the beeper sounds, make a hash markunder the frequency column corresponding to the activity you are currently performing.Thank you for your cooperation.

Activity I Before Noon I After NoonDirect Patient CareHeight, Weight, & VitalsBlood DrawsChaperoningPatient TestsRoute PatientsPatient PreparationCollecting Patient Information

Patient CoordinationChart LocationTest ResultsAncillary CoordinationGoing to AncillariesPrep Patient PaperworkRoom TurnoverPatient List / FlowLab Work

Clinic CoordinationStocking RoomsOffice preparationAssisting Other Teams

OtherDowntime1.2.3.4.5.

C-3

MA Random Beeper Time Study Definitions

Direct Patient Care:

Height, Weight & Vitals - time spent taking patients height, weight, and vitals.Chaperoning - exams or procedures

Patient Tests - EKG, Pulse OX, etc.Route Patients - walking patients to rooms.Prep Pt. for Med. Procedure - any time spent with patient in exam room preparing

patient for physician’s visit.“Nursing” Procedures - any time spend performing (blood draws, wound care, etc.)Collecting Patient Information - time spent asking patient health or history related

questions.

Patient Coordination:

Chart Location - time spent physically looking for records, time looking or printingPMR’s, and time spent calling for charts.Ancillary Coordination -pharmacy, lab, EKG, radiology(on phone or on computer)Going to Ancillaries - pharmacy, radiology,etc.Prep Patient Paperwork - any time spent working on patient paperwork.Room Turnover - tasks involved in preparing rooms for next patient’s use.Computer Work - time spent on computer for reasons not listed above.Patient List/Flow - pulling the patient lists in the morning(possibly during theday)/Coordinating patient flow by monitoring rooms occupied.Lab Work - time spent in the lab, i.e. urine spinning.

Test Results - calling or retrieving test results (internal or external)

Clinic Coordination:

Stocking Rooms - refurbishing rooms of any supplies needed.Updating Rolodex - time spent on rolodex organization.Looking for referring Doctors - any time associated with this activity, either calls,

traveling, etc.

Office preparation - making coffee, setting up or cleaning officeAssisting other teams

Voice Mail - time spent on voice mail.

C-4

PHONE TRACKING DATA COLLECTION

Please collect this information for one week starting March 11th. It is essential for reviewing workloaddistribution.Fill in time for any call greater than 3 minutes, otherwise just check.

Route - I=IncomingO=Outgoing

?- Was call routedappropriately?-YIN

Codes: I - Intake InformationS -SchedulingTR - Test ResultsY - Symptom RelatedDC - Doctor CallP - PharmacyR - RecordsF - Film I Radiology0-Other

Date:

___________________Day

of week:Team:

______________________

Position: RN CC MA

Time of Day Time of Call Route Who Call Follow up Call Type I Note(# of mm) WO) (PatientJStafl Needed (x)

Notes:

C-5

Phone Study Code Definitions

Intake information - Contacting new patients to collect information for upcoming visits

Scheduling - All calls related to paient’s appointments

Test Results - Calls dealingwith patient test results inside and outside the hospital

Symptom Related - All conversations with patients related to sympotom management

Doctor Call - Calls to physicians

Pharmacy - All calls to and from pharmacy concerning patient prescriptions

Records - All calls concerning patient records

Film / Radiology - All calls concerning patient films / radiology

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CCC CLINIC SUPPORT POSITIONSKEY AREAS OF RESPONSIBILITY

- Patient Coordination

RN - - Symptom Management

- Clinic Support Staff Lead

- Schedule Management

CLINIC COORDINATOR - - Continuum of Care Coordination

- Clerical Lead

Draft4/23/98

P&OA

- Clinic FlowMA -

- Clinician Assistance

- Schedule PlanningCLERICAL -

- Patient Clinic Processing

L F-2

APPENDIX F