Marilyn Chow, RN, DNSc, FAAN Vice President, National Patient Care Services Kaiser Permanente

1. How Nurses Spend Their Time: Effects on Quality & Safety in HospitalsAssociation for the Advancement ofMedical InstrumentationJune 2, 2008 Marilyn Chow, RN, DNSc, FAAN Vice President, National Patient Care Services Kaiser Permanente

3. Big Picture…A View From the Bridge • Facility Design and Construction • Workforce and Practice Models • Patient Safety • “Failure to Rescue” • Pay for Performance • Value-Based Purchasing • 27 Never Events • Physician Alignment • Patient Experience/Competition • Operating Margins • Vendor code and standardization

4. Problem—Nursing Shortage • Increased demand • Decreased supply • Shortage estimates range from 400,000 to 1 Million RN’s in the United States by 2020 • % of RN’s in hospitals has dropped from 65 to 56.2

5. Adding to Nursing Supply • Efforts at recruitment have resulted in turning away more than 145,000 qualified applicants last year (NLN 2007) • Shortages in faculty, classrooms, and clinical placements are slowing preparation of new nurses • Inadequate number of nurses prepared to become faculty • Supply cannot keep up with demand

6. Retention of Current Workforce • Nurses demand improvements in the hospital work environment • Safety • Efficient systems • Automation • Improved communication • Technological products and processes have not incorporated nurses’ viewpoints • Multiple studies nationally and internationally speak to the need to improve the practice environment as a key strategy to retaining nurses and improving patient care outcomes.

7. Three Studies Addressing the Work Environment • Data synthesis across three studies will build evidence-based case for new technologies to improve med-surg units

8. A Catalyst for Change Without bolder changes in the hospital work environment, the nursing shortage, coupled with the retiring nursing workforce and faculty shortages, will threaten the staffing sustainability of the American hospital as part of the care delivery system within the next 5-10 years.

9. Time & Motion Study: How Do Medical-Surgical Nurses Spend Their Time The purpose of this study is to identify specific environmental variables of the acute care nursing workplace that can be altered to positively impact nursing direct care activity and ultimately, patient safety. This study is designed to provide detailed information about: • The amount of time nurses spend in identified activity categories • Their movement throughout the nursing unit over the course of a typical nursing shift • The physical impact of nursing workload and stress

10. Study Partners Principal Investigators Grant Funding Statistics, Data Management and Economics Track A & B Technology Oversight Track C Study Coordination Track D

11. Participating Health Systems

12. Participating Hospitals • The participating health systems operate a total of 274 hospitals with more than 63,000 beds • The participating hospitals are geographically dispersed across fifteen states • Average length of stay for the study units ranges from 2.62 – 8.67 days, an average of 4.37 days • Unit size ranges from between 11-20 beds to 81-90 beds with a median size of 31-40 beds

13. Study Protocols Protocol A Baseline for EHR Implementation Protocol B How Do Nurses Spend Their Time Protocol C Nurse Location & Movement ! Data was collected for seven consecutive days, 24 hours a day on the randomly selected medical-surgical units. Protocol D Nurse Physiologic Response

14. Data Collection Overview Protocol C:Nurses carry locating RFID tags Protocol A:Documentation time Protocol D:BodyMedia armband Protocol B:Nurse work sampling Data download to laptop Wireless Receivers Secure data transfer to 24x7 Purdue Server Data:Checked for quality and loaded into Oracle DB Graphs & reports R objects generation R statistical software

15. 76% Participation Results On average, 76% of all eligible licensed nurses consented to participate during the seven day study period at 36 hospital sites 97% of those who consented completed the study while 3% voluntarily dropped out during the study period 97% No participants were removed from the study due to non-compliance!

16. Data Collection Results 763licensed nurses (RNs, LPNs/LVNs) completed the study Track A Track B Track C Track D 750 385 382 288 Participants Participants Participants Participants In total, study data has been collected on2,201 work shifts resulting in21,882hours of data

17. Key Research Findings Multiple publications pending - DO NOT reproduce or distribute without written permission from the authors 11

18. How do nurses spend their time? • 77.7% of the time devoted to nursing practice

19. Where do nurses spend their time? • 38.6% of time spent at the nurse station

20. Three Major Areas Accounted for Most of the Time • Documentation (electronic/paper) • Medication Administration • Care Coordination/communication with the patient care team, physicians and others

21. Time With Patients The amount of time a nurse spends with patients in patient rooms on daytime shifts varies from about 20% (120 minutes out of 10 daytime hours) to 38% (228 minutes out of 10 daytime hours) across the study units. The median is 171 minutes, or 30.8%. 30.8%

22. Time on Documentation The most time consuming nursing practice activity is documentation (includes all documentation categories, chart review, and computer data entry). The amount of time a nurse spends on documentation on daytime shifts varies from about 16% (96 minutes out of 10 daytime hours) to 34% (204 minutes out of 10 daytime hours). The median is 147.5 minutes.

23. Time on Medication Administration A time consuming activity is medication administration: obtaining, preparing, documenting, and giving medication. The amount of nursing practice time spent on medication administration averages 72 minutes, or 17.2% 17%

24. Distance Traveled During daytime shifts, study units averaged distance traveled rates between about 2.4 to 3.4 miles per 10-hours. The median is 3.0 miles. Individual nurses across all study units traveled from 1 mile to 5 miles per 10-hour daytime period.

25. Distance Traveled (continued) On night shifts, study units averaged distance traveled rates between about 1.3 to 3.3 miles per 10-hours. The median is about 2.2 miles, a reduction of 0.8 miles per 10-hours from day time shifts. During the day time, while off shift, distance traveled varied from 1.2 miles to 3.5 miles. The median is 2.1 miles, a reduction of 0.9 miles per 10-hours from day time work shifts.

26. Other Results • No consistent, statistically significant relationship was found between various unit architecture types and nursing time spent with patients • Distances traveled and time spent on activities varied considerably between shifts. Of interest, variability between individual nurses on the same unit was often greater than the variance across different hospital units.

27. 7% of a nurse’s time is spent on patient assessment 17% of a day shift nurse’s time (median) is spenton medication administration 35% of a nurse’s time is spent on documentation Day shift nurses spend about 30.8% of their time in patient rooms with all of their patients During a typical 10-hour day, a nurse travels 1-5 miles

28. Technology Drill Down (TD2) Study • Technology Targets Study funded by Robert Wood Johnson Foundation (RWJF) • Aims of the study • Create an improved process for identifying technology solutions to medical/surgical unit workflow inefficiencies. • Capture the attention of and prompt industry to develop technology that improve workflow processes.

29. TD2 Process • Two day process of brainstorming and visioning • 20 – 30 multidisciplinary representatives • Primary Purpose • Map gaps between current workflow & idealized workflow • Identify potential technological applications that could close the gaps

30. Preliminary Findings from TD2 SitesDocumentation • Computerized Order Entry included in electronic record • Touch screen/Voice activated • Global Documentation System • Multidisciplinary • Real time • Universal – physician, hospital, home care • Flash Drive/Smart Card

31. Preliminary Findings from TD2 SitesPatient Care • Smart Monitoring Devices – interfaced with EHR • Portable devices to quickly add information and updates to patient charts • ID Bracelet or Tracking Chip System -Use with a handheld scanner. Linked to chart. Interfaces with screen at bedside. • Smart Bed

32. Preliminary Findings from TD2 SitesCommunications • Computerized, centralized patient scheduling system for all departments • Wireless voice communication device/Hands free communication device. • RFID for caregivers. • Universal Translator/Automatic language interpretation device.

33. Preliminary Findings from TD2 SitesMedications • Robotic delivery • Medication Barcode/Chip System (same system for labs, blood products) • Smart IV/Blood Pump • Simplify systems and eliminate redundancies

34. Preliminary Findings from TD2 SitesSupplies & Equipment • RFID tag - item scanned when used Inventory to central computer Include linens, supplies & equipment • Robot to restock and deliver supplies & equipment • Ensure availability at the point of care

35. What We BelieveA Working Proclamation: Recommendation Prototype…

36. Proclamation For Change • Key study findings presented in January 2007 to more than 200 health care executives and frontline staff • Leaders developed a set of national recommendations for the idealized unit design to maximize efficiency and reduce work stress, in order to improve the quality and safety of patient care • Resulting “Proclamation for Change” presents four principles to guide decisions about hospital design and technology While they sound simple in theory, implementing the principles requires that the silos that America’s hospital staff operate in – technology, nursing, facilities, etc. – be removed.

37. In order to transform the hospital-patient care environment and improve the delivery of safe, high-quality, patient-centered care, we believe in the need for: • Patient-centered design.Hospital and technology design should be organized around patient needs – helping patients and their families feel engaged in the caregiving process rather than removed from it – and be tailored to address unique factors and diverse patient populations. • System-wide, integrated technology. Architects and technology vendors should work closely with nurses, physicians and other caregiving departments (i.e., pharmacy, lab, housekeeping, admitting) in all aspects of designing workspace and technologies in order to ensure a system-wide approach to meeting patient needs.

38. In order to transform the hospital-patient care environment and improve the delivery of safe, high-quality, patient-centered care, we believe in the need for: • Seamless workplace environments. To consistently provide the highest quality care to patients, the physical design of medical-surgical units should be completely integrated with caregiver work processes and the technologies they use, so caregivers always have the right medication, materials and information, in the right place, at the right time. • Vendor partnerships. The design and operation of technology devices should be intuitive, error-free, and part of interoperable systems – so that health care providers can access information in hospital or outpatient settings – and not waste time serving as human bridges that link multiple technology devices in different locations.

39. We believe… Our work processes can’t be dictated by technology and space. It must be the other way around. • Nurses need to be innovators of their own work systems • Vendors and architects must include us in the co-design of our work systems

40. We believe… Our space and tools must support collaboration (among providers, patients, and family) • Design environments that allow people to remain connected throughout their work-time and across disciplines • The renovation and/or new construction design process must include the input of those who will use it

41. We believe… We will only buy technology solutions that work well together (and with us!) • Technology providers need to align around a common platform for interoperability of different types of equipment • The user experience must be intuitive, and not require the nurse to be the bridge between different devices and systems • A nurse is not an interface

42. If these principles are followed, then: • Documentation will be a byproduct of care • Needed patient supplies and medical equipment will be available on demand • Medication will be administered as part of a seamless system that provides accurate and timely information about the patient • Communication systems will link healthcare providers as appropriate, fostering efficient, effective communications across and between disciplines • Patients and families will experience nurses and other care providers who spend more time in direct patient care

43. How Can You Help Nurses? • Understand the work environment • Be alert to how you can simplify the environment • Listen to the concerns of nurses • Be astute observers of how nurses interact with biomedical and clinical IT devices • Be translators of technology “gobblygook” • Think about how to integrate new clinical technology seamlessly into the work environment.