Increasing Efficiency of Administrative Assistant Processes in Ambulatory Care Nursing

Final Report

Submitted to: Candia Laughlin, MS RN BC Director of Nursing Ambulatory Care Services

Kevin DeHority Lean Coach, Michigan Quality System University of Michigan Health System

Rama Mwenesi Lean Healthcare Engineering Fellow University of Michigan Health System, Program & Operations Analysis

Dr. Mark Van Oyen Professor of Industrial and Operations Engineering College of Engineering, University of Michigan

Submitted by: IOE 481 Project Team #9 Kyle Apsey Julie Dunn Ryan Gabler Joshua Singer

Date Submitted: April 22nd, 2014 TABLE OF CONTENTS

List of Figures i

Executive Summary 1

Introduction 4

Background 4

Goals and Objectives 5

Key Issues 5

Project Scope 5

Methods 6

Findings and Conclusions 7

Recommendations 12

Expected Impact 18

Appendix A: Initial Interview Questions 19

Appendix B: Process Flow Maps 20

Appendix C: Administrative Assistant Survey Questions 27

Appendix D: Nurse Manager Survey Questions 29

Works Cited 30 LIST OF FIGURES

Figure 1: AA Qualtrics Survey: Daily Emails Received 10

Figure 2: AA Qualtrics survey: Email Interruptions 10

Figure 3: AA Qualtrics survey: Frequency of Sharing Processes 11

Figure 4: AA Qualtrics survey: Comfortability Sharing Processes 11

3 Executive Summary

Ambulatory Care at the University of Michigan Health System utilizes a variety of medical, surgical, and emergency care services to provide patients with comprehensive and specialized consultations, treatments, and interventions. Ambulatory Care utilizes nurses across multiple departments and clinics throughout the Health System, who are managed by seven Nurse Managers (NM) and supported by seven Administrative Assistants (AA). To assist the nurses in Ambulatory Care, the AAs are responsible for managing nurse payroll, float calendars, personnel paperwork, evaluations, and much more. According to the Director of Nursing, the current AA work processes and roles within Ambulatory Care Nursing Administrative Assistants are not divided effectively to best utilize the AA’s skills and time, causing uneven and inefficient workloads. In addition, there are no established best practices in place for the daily functions AAs perform, nor standard training for new hires.

The Director of Nursing and the AAs have reported that the current processes for completing tasks are inefficient and lack standardization. The purpose of this project was to suggest improvements to increase the efficiency of six AA work processes and tasks that have the greatest capacity for improvement. A secondary goal was to provide recommendations to improve communication amongst the Ambulatory Care Nursing staff. In addition to the inefficiency of the processes, differing manager expectations with no established best practice produces problems with completing tasks efficiently and in an organized manner. These inefficiencies have also resulted in AAs reporting feelings of being overworked, frustrated, and under-appreciated. This contributes to a lack of communication amongst AAs, as reported by the Director of Nursing. Issues or problems that arise for the AAs can be further exacerbated by the current lack of standardized processes and expectations, which causes problem-solving to be more difficult and time consuming. Recent rapid growth and turnover of the Ambulatory Care Nursing AAs has revealed more clearly the need for process improvement, as well as the need for a standard training process and material.

The Director of Nursing asked the Industrial and Operations Engineering (IOE) 481 team to suggest improvements to increase the efficiency of AA work processes, as well as analyze and provide recommendations to where communication improvements apply. The IOE 481 team has collected and analyzed data to provide recommendations to improve the efficiency of the six most critical work processes and to improve communication in Ambulatory Care Nursing.

Data Collection Methods

The team collected and analyzed data using two methods: AA interviews and AA and NM surveys. The team later created process flow maps from these two methods.

4 AA Interviews

To understand the AA work processes and determine the most critical tasks, the team conducted one-on-one interviews with the four most experienced AAs and created process flow maps from these interviews of six current AA process steps.

In the first of the weekly interviews, the team used a set of eleven questions to obtain a basic understanding of the AAs work processes. The answers from these questions, coupled with information received during future client and AA meetings, enabled the team to identify the six critical processes. Critical processes were determined by those that are the most time consuming, those that vary the greatest in the way they are performed by each AA, and those in which the most errors occur or need to be corrected due to errors causing rework. The identification of the six critical processes allowed the team to refine the scope from the original project proposal and focus on recommendations with the most impact.

AA and NM Surveys

The team developed two job specific Qualtrics surveys that were distributed to 6 AAs and 7 NMs. The surveys were created to obtain information regarding inefficiencies in communication, training, best practices, errors and rework. The survey questions utilized four question types: multiple choice, checklist, Liker rating scale, and open ended questions. The surveys produced feedback that was both qualitative and quantitative, providing the team with a directional set of data to identify areas for improvement.

Findings and Conclusions

The data collected and analyzed from the AA interviews, and the AA and NM surveys, allowed the team to identify the areas for opportunity within the six critical AA processes, communication and training. From these findings, the team developed conclusions that were later used in the formation of recommendations to improve process efficiency, communication, and satisfaction.

AA Interviews

The six processes identified as most critical are: payroll, attendance monitoring, FMLA tracking, OA/OT individual limits, workload reports, and float calendars. Information from AA interviews and AA and NM surveys used to the create process flow maps revealed that there were variations among the AAs in how they completed the processes. Interviews also lead to understanding that many tasks take differing amounts of time for each AA to complete. Sometimes this was due to the variation in process steps, interruptions, or differing workload expectations.

AA and NM Surveys

Data stratified and analyzed from the two survey results revealed that many AAs and NMs believe that improvements are needed for both communication and training in Ambulatory Care Nursing. Both AAs and NMs feel that effective communication is lacking, and that the current training process lacks standardization and is large responsibility for AAs faced with the task. Many of the AAs and NMs suggested the development of a standard training manual and process for new AAs.

The Qualtrics tools were used to analyze the Liker rating scale responses, and the qualitative responses were analyzed by the team. The data from the analysis demonstrated the areas in which the AAs and NMs believed improvement was crucial, as well as general opinions and perceptions of the Ambulatory Care Nursing work environment. It was concluded that interruptions was a source of wasted time, and that many AAs and NMs agreed that a system for sharing best practices and collaboration is needed to improve overall efficiency and communication in the workplace.

Recommendations

Process Recommendations ● Decide and use one payroll validation method ● Utilize standard documents, such as updated timesheets and singular data tracking forms ● Implement a system for AAs to share best practices ● Create Excel macros to eliminate manual data entry for reports

Communication Recommendations ● Implement a task management system that would allow AAs to collaborate ● Flag emails requiring immediate action as urgent ● Schedule weekly meetings between AAs and NMs to create action plan for the week ● Encourage NMs to stress the importance for nurses to fill out paperwork properly

Training Recommendations ● Establish standard training materials and processes

6 Introduction

Ambulatory Care is a personal health care consultation, treatment, or intervention using advanced medical technology or procedures delivered on an outpatient basis. Within the Ambulatory Care Nursing Unit there are seven Administrative Assistants (AAs) who support seven Nurse Managers (NMs). Primary responsibilities of the AAs include managing nurse payroll, float calendars, personnel paperwork, and employee evaluations. According to the Director of Nursing, the current AA work processes and roles within Ambulatory Care Services are not divided effectively to best utilize their skills and time, causing uneven and inefficient workloads. It has also been reported that better communication and collaboration are needed among the AAs. The Director of Nursing has asked an Industrial and Operations Engineering 481 student team from the University of Michigan to suggest improvements to increase efficiency of AA work processes, and to identify areas for communication improvements. This report will provide more information on the projects background, data collection methods, findings and conclusions from the data collection, and recommendations to achieve the project goal.

Background

Ambulatory Care Services at the University of Michigan Hospital (UMHS) consists of seven AAs that directly support seven Nurse Managers (NMs) and the entire nursing staff across the University of Michigan Health Ambulatory Care Services. Currently, the AAs are responsible for tasks such as managing the nursing staff payroll, managing NM calendars, processing new hires, completing official reports, and scheduling float staff. Ambulatory Care Services is expected to transition to a new timekeeping software to be used for payroll starting in the Fall of 2014. Human Resources expects the rollout to occur over the following 24 months. The AAs are currently divided across two locations: Green Road and the Terrace. The AAs face differing expectations depending on the NM they support.

Differing manager expectations with no established best practice produces problems with completing tasks efficiently and in an organized manner. These inefficiencies have also resulted in AAs reporting feelings of being overworked, frustrated, and under-appreciated. This contributes to a lack of communication amongst AAs, as reported by the Director of Nursing. To address these concerns, the Director of Nursing asked the team to conduct studies to determine optimal methods for AA’s work that will improve efficiency and communication among the AAs.

An initial literature search was conducted of previous IOE 481 projects. One report, “Analysis of Clerical Workload in Central Staffing Resource Department,” suggested methods for workload distribution and FTE calculations for clerical staff. This study also noted that further studies on specific sectors of the hospital, such as Ambulatory Care Services, should be conducted [1]. Due

7 to a modification in goals and project scope the team found that the data presented by the report was no longer relevant, and was omitted from the data analysis and formation of recommendations.

Goal and Objectives

The primary project goal was to identify opportunities to improve efficiency within the six critical processes performed by AAs to support Ambulatory Care Nursing. A secondary goal was to identify opportunities for communication improvement. To accomplish these goals the team: ● Interviewed staff to understand workload and responsibilities ● Conducted interviews to outline critical tasks ● Analyzed workflow and division of roles ● Created process flow maps to show process variations and improvement opportunities

The team used this information to create recommendations to: ● Determine the most efficient work processes ● Better allocate responsibilities and overall workload ● Decrease variability between responsibilities ● Increase employee communication, productivity, and satisfaction ● Eliminate waste where possible ● Create uniformity and transparency across similar processes

Key Issues

The following key issues that drove the need for this project: ● Expectations for AAs differ from each NM ● Tasks do not vary much between AAs, but the way the AAs perform them does ● AAs report that they are overworked and underappreciated ● Lack of communication exist amongst AAs ● Unsure of optimal number of AAs required to complete responsibilities

Project Scope

This project included: ● Evaluating six critical processes of seven AAs across two locations: Green Road and the Terrace ● Understanding the needs and expectations of the seven NMs for their AAs ● Understanding the communication relationship among AAs

This project did not include: ● Individuals outside of the seven NMs, seven AAs, and Ambulatory Care Nursing

8 ● Reporting relationships between NMs and AAs ● Modification of the locations where employees are staffed ● Financial implications of recommendation ● Major changes in technology, including the transition to new timekeeping software for payroll beginning in Fall 2014

Methods

The primary project goal was to identify opportunities to improve efficiency within critical processes performed by AAs to support Ambulatory Care Nursing. The secondary goal was to identify areas for communication improvement. Based on AA interviews, client meetings, and initial analyses the team condensed the scope to include the critical AA work processes: payroll, attendance monitoring, float calendars, FMLA tracking, OA/ OT individual limits, and workload reports. Critical processes were determined by those that are the most time consuming, those that vary the greatest in the way they are performed by each AA, and those in which the most errors occur or need to be corrected due to errors causing rework. For each of these tasks, the team developed recommendations to determine the most efficient work processes, decrease variability between the responsibilities, reduce errors, and eliminate waste where possible. Communication recommendations were integrated into the best practices outlined by the team. The project methods are described below.

AA Interviews

The team conducted six sessions of one-on-one interviews of the four most experienced (more than six months full-time) AAs. Each member of the team interviewed one of the four selected AAs. For the first session, a set of eleven questions created by the team was used to obtain a basic understanding of the AA’s work processes. Refer to Appendix A for a list of the initial interview questions. Based on the information gathered from the interviews, along with the Director of Nursing and employee meetings, the team identified the following six processes as critical: payroll, attendance monitoring, float calendars, FMLA tracking, OA/ OT individual limits, workload reports. In successive interview sessions, the team gathered detailed information on each of the critical process’ subtasks, including time to completion, errors and rework. The team also worked with the AAs to create process flow maps for the six critical processes. Refer to Appendix B for the individual process maps.

AA and NM Surveys

The team developed two surveys in collaboration with a Lean Coach and Lean Healthcare Engineering Fellow within the University of Michigan Health Systems, Program & Operations Analysis. One was distributed to the AAs and the other was distributed to the NMs. The surveys contained multiple choice, checklist, Liker rating scale, and open ended questions. The surveys addressed processes with inefficiencies in the following areas: communication, training, best practices, errors, and rework. The two surveys were formatted in Qualtrics and were distributed electronically to one AA and one NM for feedback. Using the feedback, the team revised the surveys and subsequently distributed them electronically to 6 AAs and 7 NMs in scope. The client requested that one AA not receive the survey. Refer to Appendix C for the survey

9 questions posed to AAs, and refer to Appendix D for the survey questions posed to NMs.

Data Analysis

The AA interviews provided detailed process steps, subtask and process completion times, and waste and rework identification on each subtask of the critical processes. With the addition of times collected from self-observations, complete process flow maps were created. The process flow maps were used to reduce variability of the critical subtasks and create more efficient processes.

Upon receiving the completed surveys, the team used the data analysis features of Qualtrics and statistical analysis tools in Excel to identify trends in the following areas: communication, training, best practices, errors, and rework. Furthermore, the team looked for trends in AA perception of efficiency in the six critical processes.

Findings and Conclusions

During interviews with the four experienced AAs, the team developed process flow maps for the six critical processes, shown in Appendix B. Estimates of the completion times for each step within these critical processes can also be found on the maps. Survey results from both AAs and NMs were used in lieu of process flow maps. Findings and conclusions from the critical processes follow.

Large Time Variation in Processing Timesheets Processing a timesheet is the process by which the AA receives the timesheet from the nurse, and codes and enters it into OneStaff. Three factors contribute to the amount of time it takes to process a timesheet. First, timesheets are submitted either electronically or as a paper copy, depending on nurse preference. Timesheets submitted as paper copies often have written comments scattered throughout, which can create clutter and confusion. The AA may therefore have to spend additional time trying to make sense of everything written on the timesheet, and may even have to contact the nurse for clarification. Second, submitted timesheets may contain errors such that the nurse did not fill it out correctly. For example, errors may include incorrect coding or using the wrong timesheet with dates not corresponding to those of the current pay period. In such cases, the AA must again try to make sense of the errors before being able to make a fix, and possibly have to send the timesheet back to the nurse for clarification. Finally, if a timesheet is missing by the submission deadline, the AA must contact the nurse and obtain their timesheet.

Two Different Methods for Verifying Payroll Verifying payroll is the process of checking that what is entered on the submitted timesheet by the nurse matches what is actually entered into the system by the AA, which is what will eventually appear on the nurse's paycheck. Two methods for verifying payroll were found. In one method, the AA verifies payroll before OneStaff rolls over to, or interfaces with, Wolverine Access. This is done by printing out the time card and using this physical copy of the timesheet data to check that it matches what the AA has entered into OneStaff. In other words, the AA is

10 performing a “double check” of the data they entered into OneStaff. In the other method, the AA verifies payroll after OneStaff rolls over to Wolverine Access. In this case, the AA skips the OneStaff verification (printing off the time card and performing the double check), and instead runs a report, called the MTL_Payable_Time_Qty_Group Report, through Wolverine Access. This report catches any discrepancies between what is entered in OneStaff and what is entered in Wolverine Access. If discrepancies exist, the AA must go back and make changes in both software tools.

Differing NM Expectations for Attendance Monitoring AAs typically create one report for attendance monitoring that contains the unscheduled absences of their nurses, with an indication of whether or not each nurse has met the standard trigger of too many unscheduled absences. Sometimes, AAs are asked to create additional reports, such as an attendance monitoring grid that tracks the specific days of the week the nurse was absent. Additional reports cause a variation in the time and workload of the attendance monitoring process.

Coordinating PSMs is Inefficient If a nurse meets the trigger for unscheduled absences, they are required to have a problem solving meeting (PSM), which is coordinated by the AA. PSMs require the attendance of the nurse that needs the meeting, their NM, a Union rep, and an HR rep. It usually takes 7 to 8 emails for the AA to understand availability and find a meeting time that works for everyone. This is a disorganized and inefficient way of communicating availability.

Copying ACNRP Calendar to Other Staffing Calendars is Redundant When the ACNRP Calendar assignments are updated or changed, these updates are sent to the AAs personal calendars. From the personal calendars, some AAs are required to copy the ACNRP data to another staffing calendar, such as the CSS calendar. On Fridays, when the ACNRP Calendars are verified with the other staffing calendars, the color codes used are not uniform, requiring the AAs to decipher and understand which color codes are correlated. The updates that are sent from ACNRP to the personal calendars are unnecessary and the time spent copying this data to the other staffing calendars is a potential source of error.

Two Tracking Grids used for FMLA is Inefficient Currently AAs use two tracking grids. One tracking grid monitors each individuals FMLA, PTO, and OTB, all in one form, while the other only monitors FMLA. Using two different tracking grids contributes to inconsistencies in the way that each AA performs their tasks, and creates difficulty when training new employees due to the lack of standardized documents.

Converting and Re-formatting Reports from OneStaff is a Waste When a report is pulled from OneStaff, such as the OA/OT report, it is downloaded as a text file. The AA must then convert the text file to an Excel file. The result is an Excel file that is not professionally formatted, and one that cannot be sent directly to managers. The AA must delete information, add column or row headings, and create a presentable document before sending it out. These tedious steps are performed within the workload report and OA/OT individual limits processes. It is reported that converting and re-formatting a report can take up to an hour and a half. OneStaff does not produce user-friendly reports, and rework done by AAs to create presentable reports can be eliminated to increase efficiency.

11 Manual Data Entry and Color Coding is Unnecessary After the OA/OT individual limits report is converted to an Excel file and re-formatted, the AA must complete some additional steps. The AA must enter the OA/OT data for each nurse into an OA/OT bonus tracking grid. Then, the AA will search the grid and color code the cells of the Excel workbook to indicate if the nurse: has or has not qualified for bonus consideration that period, could qualify for a bonus payout next period, and qualifies that period for a bonus payout. Furthermore, the AA may include details on the nurse bonus payout, including date submitted into Wolverine Access for HR approval, HR approval, and period paid out to nurse. Color coding and details included on the OA/OT tracking grid differ between AAs, but all AAs track bonuses manually in an Excel document. Manual data entering and processing is a potential source of error, and OA/OT bonuses are contractual obligations. When OA/OT bonuses are not correctly and timely paid out to nurses, additional work is created for the AA. Also, it is reported that error or untimely payout of bonuses causes frustration between nurses and AAs. Not only is manual data entry and color coding tedious for AAs to complete, but errors have legal consequences. Elimination of manual data entry and color coding will increase AA efficiency in the OA/OT individual limits processes, and reduce the risk of error.

Copying Data to Clinic Checklist is Rework Four reports compose the workload reports process: non-productive, trigger, OA/OT, and clinic checklist report. The clinic checklist does not include any new information not included in the non-productive, trigger, or OA/OT reports. Therefore, an AA creates the first three reports from data pulled from OneStaff, and then copies the applicable data from each report into their clinic checklists. One checklist is produced for each clinic managed by the AA’s corresponding NM. The number of clinics per NM varies. The copying of data from one report to another is rework, and reportedly takes up to an hour to complete. This rework can be eliminated to improve the efficiency of the AA workload report process.

Differing Expectations on Critical Data and How Data is Reported Out It is reported that what AAs include in workload reports, specifically the clinic checklist, vary slightly; furthermore, it is reported that some data AAs report is underutilized or never utilized. OneStaff provides a great deal of data to the AAs, and any data reported should be utilized. The way the workload reports are sent to NMs and clinic managers also varies slightly among AAs depending on their NM expectations. Depending on how NMs meet with their clinic staff, an AA may send out one large Excel document with all workload data reports or multiple emails with workload data reports separated by clinic. These differing NM expectations create difficulty in training new employees on standard practice. Furthermore, if an AA supports a new, different, or multiple NMs, not having standard expectations could lead to lack of transparency and frustration between AAs and NMs. With each differing expectation, an AA is forced to remember and perform different process steps.

Data Pulled from Non-Productive Time Reports are Inaccurate It was reported by some AAs that approximately 95% of data pulled for the Non-Productive Time Reports are incorrect. Because the hours pulled from the report are not accurate, the AA must perform several steps to bypass the inaccuracies. It is estimated that this can take the AA an additional 30 to 60 minutes. This workload increase due to inaccurate data is not only increasing the workload of the AAs, but increasing frustration.

12 Determining the Urgency of Email is Non-Value Added Time Figure 1 indicates that AAs typically receive more than 50 emails on a given day. Figure 2 indicates that over 80% of AAs find these emails to sometimes interrupt their ability to compete the assigned task that they are currently working. The team has observed that the AAs spend a great deal of their time reading through and responding to emails. Some of these emails, however, are not urgent matters and do not require immediate action. Therefore, determining the urgency of each email is a non-value added time.

Figure 1: “How many emails do you receive in an average work day?” Source: AA Qualtrics Survey, Feb.-March 2014, sample size 5

Figure 2: “How much do email interruptions affect your ability to complete the current task you are working on?” Source: AA Qualtrics Survey, Feb.-March 2014, sample size 5

No Easy Way for AAs to Share Best Practices As seen below in Figure 3, 66% of AAs surveyed currently only share the way they perform a task with other AAs less than once per month. Figure 4 below indicates that all of the AAs surveyed are comfortable or very comfortable sharing the way they perform a task. In other words, the AAs are willing to share best practices with other AAs, but do not have an easy forum to do so.

13 Figure 3: “How often do you share the way you perform a process with other AAs?” Source: AA Qualtrics Survey, Feb.-March 2014, sample size 6

Figure 4: “How comfortable are you to share your methods of completing tasks with other AAs?” Source: AA Qualtrics Survey, Feb.-March 2014, sample size 5

Repeat Interruptions by Phone are Created when Nurses and NMs Call Throughout the Day Several AAs reported repeat interruptions by phone. These interruptions are created when nurses, NMs, or other employees call multiple times throughout the day with requests and questions, sometimes multiple times within an hour. In the AA Qualtrics Survey, one AA said that they would prefer one call with a list of requests and questions, as opposed to multiple calls with one request or question per call. This way task priority can be determined in advance and an action plan with a timeline can be developed and understood by each party.

Large Imbalance of Workload and No System to Reach Out to AAs to Request Help The team found that one or two individuals are solely in charge of training new staff, and it is difficult for them to complete their own work with this additional responsibility. Moreover, AAs do not feel that they are compensated for the additional workload of training. This creates frustration and stress for AAs. Also, AAs with additional workload do not have a way to reach out to other AAs to request assistance with tasks. One AA cited constant interruptions and

14 workload increased due to the training of new staff is too much for one person. It should be noted that, as mentioned previously, all of the AAs surveyed are comfortable or very comfortable sharing the way they perform a task as seen in Figure 4.

Recommendations

Below are three types of recommendations formed from the team’s findings and conclusions: quick fixes, long term fixes, and future investigations. All recommendations will either increase AA process efficiency, better allocate workload, increase communication, or help determine best practices.

Quick Fixes

Listed below are quick fixes that can be implemented at any time to increase AA process efficiency, communication, and satisfaction.

Provide Additional Support Resources for Nurses Much of the time variation in processing timesheets is due to the nurses not filling them out correctly. AAs originally orient nurses on how to fill out all paperwork within their first week of work. This can be very overwhelming and difficult for the nurse to remember everything. Therefore, many of the nurse errors that appear on submitted timesheets are a result of the nurses not remembering exactly how to fill out the timesheet correctly. Many of these errors could be eliminated if nurses received a constant reminder on how to correctly fill out paperwork, or if nurses had access to additional support resources with instructions on filling out paperwork. Such an instructional resource could be put on a shared drive to which all nurses have access.

Require NM Follow Up for Incorrect Timesheets Submitted Repeatedly Timesheet errors, due to nurses not filling out the paperwork correctly, is creating a large variation in the time it takes for AAs to process timesheets before being able to input time into OneStaff. There is currently no consequence or motivation for nurses to fill out timesheets correctly. Having to make sense of and fix nurse errors becomes another task for the AAs. Since nurses may disregard AAs request to fill out paperwork correctly, NMs should emphasize the importance of filling out timesheets correctly to the nurses who are repeatedly making mistakes.

Create a Collaborative Form for PSM Availability To coordinate a PSM, AAs currently send 7 to 8 emails to understand the availability of all people required to attend the meeting, and to schedule a meeting time that works for everyone. This inefficient and tedious process could be eliminated with a shared availability form that all the meeting attendees have access to. The AA would thus notify all attendees that the form is available, the attendees would go into the form and enter the times they can meet, and then the AA would simply have to go into the form and find a meeting time that works for everyone. One example of a collaborative form is Doodle.

Request that ACNRP Send Calendar Updates Directly to Staffing Calendars Currently, some AAs receive ACNRP calendar updates to their personal calendars, and then are

15 required to copy that data over to the CSS or other staffing calendars. To eliminate the tedious rework of copying redundant data from one calendar to another, the team recommends that the AAs request for ACNRP to send the calendar updates directly to the CSS or other staffing calendar in use.

Uniform Color Codes for ACNRP and Staffing Calendars Different color codes are currently used between the ACNRP calendars and the other staffing calendars. This creates confusion for the AAs when they have to copy data over from ACNRP. They must decipher the color codes and reformat the color to represent the same information. This lack of uniformity is a cause of unnecessary rework and a waste of time. The team recommends that a uniform color code be established for all staffing and ACNRP calendars. It will be easiest to change the AA staffing calendars to match the color codes of the ACNRP calendar.

Implement One Tracking Grid for FMLA, PTO, OTB AAs currently use two tracking grids. One tracking grid contains FMLA, PTO, and OTB, while the other is FMLA-specific. This causes variations in how processes are done and creates difficulties and variations in the training of new AAs. Implementing the use of only the tracking grid that monitors FMLA, PTO, and OTB for nurses would eliminate the variations and increase process efficiency. Balance requests would be improved because all of the necessary data requested for an individual would be located in one document, eliminating the need to search through multiple documents for information. Nurse transitions and clinic acquisitions would be more effective and less confusing for the respective AAs because all of the data that they may need pertaining to the recently acquired nurses or clinics would be available in one standard document.

Improve the Accuracy of the Data Pulled from Non-Productive Time Reports The data currently being pulled from the Non-Productive Time reports in OneStaff is reported to be inaccurate and should be improved by HR or technology as soon as possible. If this is not possible, other reports pulled from OneStaff should be considered to obtain the necessary data that do not require non-value added time by exporting the report to Excel, modifying rows in the spreadsheet, and using Excel functions to autosum the total hours. A new report format could also be adopted to resolve data inaccuracy.

Request that Emails Requiring Immediate Action be Flagged as Urgent To reduce the amount of time AAs spend reading through emails and responding to messages that are not urgent, the team recommends that emails requiring immediate action be flagged as URGENT in the subject line. This would allow the AA to quickly glance through their emails and determine if an email is important and requires their immediate attention. The amount of daily interruptions and distractions would be reduced, and the ease of prioritizing tasks and responsibilities increased.

Develop an Established Meeting Amongst AAs to Collaborate The team found it difficult to quantifiably determine the best practice of performing the multiple processes that each AA performs. Through interviews, observations, and reported expected times the team was able to establish recommended best practices for the identified critical processes. However, due to time constraints, the team was unable to collect adequate data and non-objective

16 measures to make definitive recommendations as to what procedure is the is the most efficient with the least amount of errors. Therefore, the team recommends that the current AAs establish a recurring meeting time in which they discuss the best practice and why they perform specific tasks. The AAs could meet at the same time each month and go through one or two specific processes. This would greatly improve the communication amongst AAs, as well as establish a standardized best practice that all AAs agree upon.

Request that NMs Provide Prioritize List of Needs It is reported that AAs are constantly interrupted, specifically phone calls. Being called multiple times per hour is more than an interruption to AAs, it causes the constant evaluation of the priority of tasks and replanning of task completion order. To reduce the amount of daily interruption requests that each AA receives, the team recommends that NMs prioritize a list of needs that they need their AA to complete each day. This would greatly reduce the reported phone call interruptions AAs receive from their NM to complete less-urgent tasks throughout the day.

Establish a Weekly One-on-One NM-AA Meeting To further reduce the amount of daily interruptions and to improve the communication between AAs and NMs, the team recommends the NMs establish a weekly, or bi-weekly, one-on-one meeting time with their respective AA. In these meetings the AAs could discuss any challenges or frustrations that they have been having. The team recommends ensuring these meetings are honest and open, and that the NM listen to any concerns or recommendations that the AA might have. The NM could also create a weekly action plan of prioritized tasks to be accomplished throughout the week and discuss these and any concerns with their AA. This would greatly improve the communication amongst NMs and AAs, ensure that the tasks each AA is working on is the top priority, increase understanding of AA and NM workload, and reduce the reported number of daily interruptions.

Long-Term Fixes

Listed below are long term fixes that will provide the most impact on AA process efficiency, communication, and satisfaction.

Reformat Timesheet: auto-total, additional row(s), and additional space for comments AAs spend time manually calculating timesheet totals for code and week hours, which is a waste. Reformatting the timesheet to allow for the implementation of Excel summation functions would allow these totals to be calculated automatically and eliminate the need for the AA to calculate them manually. Furthermore, the current timesheet contains only one row for exception hours; however, a nurse may have more than one exception for one day. In such situations, multiple exception codes are written in the timesheet and create clutter and confusion. Additionally, nurses may need more space to write comments than what is provided on the timesheet. With only a small space for reasons/comments on exception and OT hours, nurses often try to fit too much information in the space, or write all over the timesheet. Once again, this creates clutter and confusion, and causes the AA to have to spend additional time trying to make sense of the timesheet and contacting the nurse for clarification. The timesheet should therefore be reformatted with an additional row for exception hours, as well as additional space for

17 comments. One suggestion includes a separate reason/comment sheet that is attached to, and submitted with, the timesheet. Timesheets should also be requested to be submitted electronically. Only electronic timesheets would allow for the auto-totaling function in Excel, and would force nurses to fill out the timesheet correctly.

Standardize the Payroll Verification Process As stated previously, two different methods for verifying payroll are used. At this time, the team has not gathered enough data to conclude which, if either, method is best; however, it is recommended that the methods be compared and analyzed to further understand the times and benefits of each. Since both methods are essentially accomplishing the same goal, ideally one method should be chosen. Having one method used consistently amongst the AAs will increase the ease of training and transparency of expectations among AAs. The decision of which method to use, as well as method implications, should be discussed among those involved in the process such as AAs, NMs, and clinic managers.

Utilize the ACNRP Calendar Solely for Unique Nurse Scheduling Information Currently, some AAs who use the CSS calendar, as well as other staffing calendars, receive ACNRP calendar updates through their personal calendars, and then are required to copy that data over to the CSS or other staffing calendars. Because the AA staffing calendars and the ACNRP calendar feature different information, the team suggests that the two calendars remain separate. Within Outlook, one can view two calendars at one time. Removing the copying of the ACNRP calendar removes continuous rework time by AAs and reduces the risk of incorrect information, be that from copying or a missed updated of the ACNRP calendar. This would improve the efficiency of the float calendar process and provide a standard process for the float calendar process.

Use a Macro to Convert Text Files into Usable Reports To address time wasted converting and formatting reports, the team recommends creating and using an Excel macro to complete data mining from OneStaff text files to Excel files. A macro will increase efficiency of AAs because a macro can be created to retrieve only necessary information from OneStaff text files, and only this data into a standard professionally formatted Excel document. The AA would download the text file from OneStaff, run the macro, which would result in an estimated hour and a half time savings biweekly by eliminating the converting and re-formatting workload report process steps.

Develop a Standard Excel Form, or Macro, that Compiles Data for the Clinic Checklist Because the clinic checklists are a compilation of the other three workload reports, creating the clinic checklists are rework and manual data input for AAs. To remove this efficiency a standard Excel form or macro should be utilized. An Excel form would be created to automatically input data into the clinic checklist once the other three workload reports were completed. Alternatively, an Excel macro could be created to accomplish the same goal, the difference being that the macro would need to be executed by the AA after the other three reports are completed to successfully fill out the clinic checklist. Either option will produce an estimated time savings of an hour biweekly.

Use a Macro to Check Nurse Eligibility for OA/OT Bonus Similar to the aforementioned recommendations, an Excel macro can be utilized to transfer

18 OA/OT data from the OneStaff report into the OA/OT bonus tracking grid, and determine if a nurse qualifies for a bonus payout. This eliminates the need for an AA to manually transfer data, and determining if a nurse qualifies for a bonus payout. The only process steps an AA would need to complete would be downloading the OneStaff data report, and entering bonus details into Wolverine Access for HR to approve and payout. Not only does this increase the efficiency of the AA work process, but it reduces the risk of incorrect and untimely payouts due to tedious manual process steps.

Decide How Workload Reports Should be Dispersed When each NM has different expectations on how workload reports should be dispersed to clinic managers and workload chairs, such as expecting one large Excel file with all NM clinics included versus each of the NM clinics having separate Excel files and emails out, it causes lack of uniformity and standardization. One method should be used to disperse workload reports to increase ease of training and transparency of expectations among AAs. The decision of which method to use, as well as method implications, should be discussed amongst those involved in the process such as AAs, NMs, clinic managers, and workload managers.

Utilize OneStaff Webinars and Online Help Forums On the McKesson ANSOS OneStaff website, there are support tools such as webinars and seminars that AAs can attend to better utilize and understand the OneStaff software. Also, online there are help forums that talk about OneStaff issues and shortcuts that others who use the software utilize. AAs can use the webinars and online help forums for free to explore other options within OneStaff to increase efficiency and decrease frustrations of software functionalities. Although this support is not all inclusive, say for training new employees, it could provide more quick and long term fixes for AA processes.

Develop Way for AAs to Share Best Practices It was determined that AAs are very comfortable sharing and discussing the way that they perform a task with other AAs. Unfortunately, there is currently no system in place for AAs to do so. Therefore, the team recommends a central folder to be created on a shared drive in which each AA is responsible for updating specific processes with best practices and support tools. This shared drive could also be used as a quick reference guide for new AAs during initial training period.

Develop a Way for AAs to Request Help from Other AAs The team believes the AAs would benefit greatly from a having a shared task management system amongst AAs to better balance the workload. Reported frustrations with workload and lack of communication led the team to this recommendation. One possibility would be for each AA to input the extra or unique tasks that they are required to complete each day or week into a shared Excel file or management system. The system would allow for NMs and AAs to view the anticipated increased workload for each AA. This increased transparency would allow both AAs and NMs to see which AA has capacity to handle additional tasks and lead to a more balanced workload. Furthermore, developing a way to request help from other AAs will be critical to alleviate stress and frustration during times of increased workload, such as training of new hires or annual responsibilities.

Create Standard AA Training Process and Materials

19 Training a new hire requires a great deal of time and dedication from other AAs in the Ambulatory Care Nursing Unit. Currently, it is the responsibility of one or two AAs to train all new AAs on all AA specific work processes. This can lead to stress, frustration, and uneven workload among AAs. The training process should be balanced across multiple AAs with the ultimate goal of creating a standard training process and materials for the future. The team recommends the following training options: ● Create an online training program, similar to ACES, or incorporate training into ACES ● Create a reference guide handbook, for questions frequently asked and easily answered ● Post and update best practice diagrams and support material to a shared drive for all AAs ● Delegate each process training to a specific AA, to level workload and allow all AAs to take part in new hire training and general relationship building

The above options, as well as other training methods, should be considered in developing a standard training process and materials. Employee input should be considered for those involved and affected by the process, including AAs, NMs, current external UMHS training staff, and upper level management.

Future Investigations

Listed below are future investigations that may provide additional benefits to Ambulatory Care Nursing AAs and staff, including and beyond the project goals of increased AA process efficiency, communication, and satisfaction.

Determine Whether Additional Reports are Necessary NMs sometimes request additional reports for attendance monitoring. Additional reports cause a variation in the time and workload of the attendance monitoring process. Further investigation is needed to determine whether such reports are necessary, and to align NM expectations. Reducing the variation in the way AAs handle attendance monitoring will increase the ease of training and the ease at which AAs can share their work with, as well as cover the work of, other AAs.

Investigate Utilizing a Different Staff Management Software OneStaff As discussed earlier, OneStaff does not create user-friendly reports and leads to rework and frustration on the AAs workload. If the above recommendations to improve the reporting processes does not create the desired impact, an alternate staff management software should be considered. The team investigated API’s Healthcare RES-Q Labor Resource Management software. This is only one option among many software tools that Ambulatory Care Nursing can investigate as a replacement for OneStaff. Functionality and support tools, as well as financial implications, should be considered before changing technologies.

Investigate Details of Workload Report Data Utilization Data reported in Workload Reports to NM and workload chairs is reported to be underutilized, or sometimes not utilized at all. An investigation should be completed to understand what is contractually or legally necessary to report out, what data used provides the most and least impact, and what data AAs have access to that would be more impactful to report. AAs spend at least three hours creating and compiling data for workload reports. An analysis of this time and its impact in Ambulatory Care Nursing should be completed to understand time costs and

20 efficiency savings.

Weigh Benefits of AA and NM Locations Currently, AAs are located in two separate physical locations. It is reported that having two separate locations creates a disjoined community that leads to communication issues. It is also reported that the two locations receive different treatment by management. The benefit of co- locating all AAs includes, but is not limited to, increased ease of: communication, sharing best practice, leveling workload by delegating extra tasks, and training new staff. In addition, AAs are currently not co-located with their corresponding NM. An investigation should be completed to understand the implications of co-locating, be that AAs with all AAs, AAs with their corresponding NM, or all AAs and NMs together.

Compare Ambulatory Care Nursing AA’s Workload to Other AA UMHS Units Throughout the UMHS there are many AA units. Many AA units perform similar tasks. In order to further share best practices, understand efficient workloads, and find opportunities to improve communication, a comparison of Ambulatory Care Nursing AAs and other UMHS AA units should be completed. Furthermore, open lines of communication among AAs may lead to an overall more efficient UMHS AA process.

Determine Workload and Financial Implications of Restructuring the AA to NM Ratio Currently, there is a one-to-one ratio of AAs to NMs. It was reported that when additional clinics are added to the AA workload there is a learning curve to overcome, but managing additional clinics is feasible and manageable. The learning curve was report to include learning the clinics staff and OneStaff reports codes. It was reported that AAs may be able to support up to two NM given financial compensation. Restructuring the AA to NM ratio will lead to altered workload levels, and therefore financial compensation, but may produce a more efficient Ambulatory Care Nursing Unit.

Expected Impact

The team provided recommendations to improve the overall efficiency of the AAs’ processes. Specifically, the recommendations will result in: ● Determination of best practice for AA responsibilities ● Better allocated AA workload ● Elimination of rework and waste in AA processes ● Improved communication amongst the AAs and NMs ● Increase satisfaction of AAs with workload

21 APPENDIX A: INITIAL INTERVIEW QUESTIONS

1. What does your typical day consist of? 2. Which tasks during a typical day are most time consuming, and what do you estimate the percentage of time you spend on these tasks are? 3. Which tasks are the most frustrating (regardless of time)? 4. Which tasks do you enjoy? 5. If there were any changes you could make to your work/ working environment, what would they be? 6. How often are you pressed for time, or have trouble completing tasks on time? 7. What software do you use, and how proficient are you with that software? 8. Can you complete all your tasks independently/ independently solve problems that arise, or do you ever need to request help? ‘ 9. How was the learning curve for the work you do? 10. Were you adequately trained? 11. Who do you feel comfortable going to with problems that arise? 12. How often do you have to work overtime/ extended hours? 13. How would you rate your work/ individual tasks on difficulty? What other things (outside of your designated tasks) take up your time throughout the day?

22 APPENDIX B: PROCESS FLOW MAPS

The process flow maps are the team’s interpretations of the process steps of the six critical processes. They were developed from weekly interviews with AAs and client meetings. Many of the process steps are denoted in shorthand and may not reflect more than a general overview of the critical process.

Process Flow Map Key

The Kaizen Bursts found in the process flow maps indicate areas where opportunities for improvement were found and recommendations provided.

The boxes denoted with the red lettered circles indicate a presence of variation for how that specific step is performed among the AAs, or the addition of an extra step in the process.

Note: Process steps that were marked with approximate time values were based on the team’s interviews with the AAs and their best estimations for the individual steps.

23 1. Payroll

24 2. Attendance Monitoring

25 3. FMLA Tracking

26 4. Float Calendars

27 5. OA/OT Individual Limits

28 6. Workload Reports

29 APPENDIX C: ADMINISTRATIVE ASSISTANT SURVEY QUESTIONS

1. How much experience do you have in your current Administrative Assistant position? 2. Do you feel communication needs to be improved among Admin. Assistants? 3. Do you feel communication with Nurse Managers needs to be improved? 4. When a problem occurs, how comfortable are you reaching out to your Nurse Manager? 5. When a problem occurs, how comfortable are you reaching out to other Admin. Assistants? 6. How well do you feel your Nurse Manager understands your responsibilities? 7. How well do you feel your Nurse Manager understands the quantity of your workload? 8. Do you have any suggestions for how the communication between you and your Nurse Manager could be improved? 9. How often do you share the way you perform a process with other Admin. Assistants? 10. How often do you share the way you perform a process with Nurse Managers? 11. Do you use the same processes for completing tasks that you were taught during training? 12. How comfortable are you to share your methods of completing tasks with other Admin. Assistants? 13. Do you have any suggestions for how the best practices can be more easily shared? 14. How often are tasks completed the first time with no errors? 15. How much time do you spend redoing tasks or fixing mistakes throughout a typical work week? 16. Please rank the following processes in order of the amount of time spent redoing or correcting tasks (1 being the greatest amount). 17. What are the most common causes of having to redo a task? (interruptions, unclear task instructions, insufficient training, lack of resources needed to complete the task, etc.) 18. How often are you interrupted while performing a task? 19. Do you consider emails interruptions? 20. How many emails do you get in an average work day? 21. On average, how long does it take you to respond to an email? (Including completing tasks requested in the email and messaging back) 22. How much do email interruptions affect your ability to complete the current task you are working on? 23. How much do other interruptions affect your ability to complete the current task you are working

30 on? 24. How difficult is it for you to begin working on a task again after you have been interrupted? 25. Do you have any suggestions for how to minimize the amount of interruptions? 26. What are the most common interruptions or distractions that occur? 27. Please rank the following procedures in order of the ones you feel most comfortable performing (1 being most comfortable). 28. Please rank the following procedures in order of the ones you feel require the greatest amount of time to complete (1 being the most). 29. Please rank the following procedures in order of the ones you feel have the greatest opportunity for improvement (1 being the most). 30. Please rank the following procedures in order of the ones you feel require additional training during the initial Admin. Assistant training period (1 being the most). 31. Please rank the following procedures in order of the ones you feel require additional training during the initial Admin. Assistant training period (1 being the most).

31 APPENDIX D: NURSE MANAGER SURVEY QUESTIONS

1. How well do you feel you and your Admin. Assistant communicate? 2. How well do you feel you understand the responsibilities of your Admin. Assistant? 3. How well do you feel you understand the workload of your Admin Assistant? 4. How reasonable do you feel the Admin. Assistant workload is? 5. How comfortable do you feel asking your Admin. Assistant to do more, when necessary? 6. How comfortable do you feel asking your Admin. Assistant to do less, when necessary? For example, completing or help to complete a task you may have given them. 7. How often do you have to remind your Admin. Assistant to complete a task? 8. How often do you communicate with your Admin. Assistant per week? 9. How many times per day do you contact your Admin. Assistant? (Including phone calls, emails, faxes, etc.) 10. Do you have any suggestions to help improve the communication between you and your Administrative Assistant?

32 WORKS CITED

[1] D. Gilmore, H. Ho, and M. Williams, “Analysis of Clerical Workload in Central Staffing Resource Department,” University of Michigan, Ann Arbor, MI, IOE 481 Students, Project 10, Dec. 2009.