SWAT Patient Flow and Personnel Workload at the University of Michigan Hospital

Final Report

Submitted to:

Ms. Donna RobinsonClinical Nurse Supervisor, University of Michigan Hospital

1500 E. Medical Center DriveAnn Arbor, MI 48109 - 5307

Ms. Mary Shafer

Clinical Nurse Supervisor SWAT, University of Michigan Hospital1500 E. Medical Center DriveAnn Arbor, MI 48109 - 5307

Dr. Mark Van Oyen

Professor, University of Michigan Industrial and Operations Engineering1205 Beal Avenue #2853

Ann Arbor, MI 48109 - 2117

Submitted by:IOE 481 Group #10

Nicole BarteckiJack JasperRishi Shah

Emily Sweet

Date Submitted: December 13, 2016

TABLE OF CONTENTS

Executive Summary 4

Introduction and Background 4

Methods 4

Findings and Conclusions 5

Recommendations 5

Expected Impact 6

Introduction 7

Background 7

Scheduling Workforce 7

Transportation Workforce 8

Key Metric: Turf Rate 8

Policy Change 8

Current Transportation Process 8

Key Issues 9

Goals and Objectives 9

Project Scope 10

Methods 10

On-Site Observations 10

Time Studies 10

Value Stream Mapping 10

Data Analysis and Current State Value Stream Map (CSM) 11

Future State Value Stream Map (FSM) 11

Literature Search 11

Standardizing Processes Helps to Account for Variability in Hospital Settings 11

Previous IOE 481 Groups Discover Need for Additional SWAT Scheduler 11

Fire Department Staffing Procedures Give Insight into Needed SWAT Staffing Levels 12

Findings and Conclusions 12

Historical Data Gives Insight into Turf Rate and Employee Workload 12

On-Site Observations Reveal Inefficiencies with Scheduling Tool 12

Time Studies Provide Reliable Estimates of Procedure Times for Schedulers 13

Value Stream Mapping Gives Insight into Scheduling Process 15

Develop Scheduling Tool 15

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Recommendations 20

Utilize the New Scheduling Tool to Provide Greater Visibility and Decrease Turf Rate 20

Streamline Scheduling Process to Decrease Time Spent Scheduling 20

Utilize Standard Operating Procedures to Eliminate Additional Calls 21

Utilize MiChart Printing Feature to Eliminate Handwritten Paperwork 21

Add Personnel to Achieve Desired Turf Rate 21

Expected Impact 22

References 23

Appendix 24

Appendix A: Transport Timesheet 24

Appendix B: Scheduling Timesheet 25

Appendix C: Current State Value Stream Map for Scheduling Process 26

Appendix D: Future State Value Stream Map for Scheduling Process 27

Appendix E: Improved Scheduling Tool 28

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EXECUTIVE SUMMARY

Introduction and BackgroundThe Specialized Workforce for Acute Transport (SWAT) team at the University of Michigan Hospital has been responsible for the monitored transport of high risk patients in the hospital. In June of 2016, the hospital introduced a new intra-hospital transport policy that changed the requirements for patient monitoring, requiring SWAT to transport moderate risk patients in addition to high risk patients. Since the introduction of this transport policy, SWAT has received a significant increase in transport requests. The key metric that SWAT uses to measure performance is the turf rate, which is the percentage of calls that SWAT schedules and then has to cancel because it doesn’t have the personnel to complete the request. SWAT’s historical turf rate - as well as the turf rate that the hospital administration deems acceptable - has been 6-8%; however since the introduction of the new transport policy, the turf rate has increased to 17.88%. Although the SWAT team has obtained additional employees to assist with the increased workload, its current procedures and workforce have been insufficient in meeting increased demand.

MethodsThe team performed four tasks to improve the efficiency of the SWAT scheduling process for high and moderate-risk patient transports.

● Examined on-site observations of the current SWAT scheduling process. The team shadowed SWAT schedulers over a 5 week period. Observations predominantly took place between 0700 - 1700, as historical data shows that this is when approximately 70% of the workload takes place.

● Conducted time studies to get an accurate estimate on process point times for determining standard transport process times and creating the current value stream map. The team conducted time studies on the SWAT transport and scheduling process. A total of 183 transport timesheets were collected over a period of 13 days, and a total of 79 scheduling timesheets were collected over a period of 16 days.

● Created current and future state value stream maps of scheduling process. Using the data collected from the time studies, a current state value stream map (CSM) was developed that details the patient scheduling process. Taking from the current state value stream map, a future state value stream map (FSM) was created to highlight the potential areas for improvement.

● Conducted literature searches for alternative scheduling processes and staffing levels. The team researched methods concerning how to best handle variability within a hospital setting and the need for additional staffing.

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Findings and ConclusionsThe team analyzed historical data in order to find the number of turfed calls per month and how many transports each full-time employee (FTE) goes on per month. Each FTE goes on 43 transports/month. Then, the team calculated the number of FTE’s that would need to be hired to reduce the turf rate to the acceptable rate of 8%. The team found that for each additional FTE hired, the turf rate would decrease by 3.07%.

On-site observations of the SWAT Department helped the team gain a better understanding of the SWAT transport and scheduling processes, and revealed two important pieces of information. Firstly, the team noticed that a majority of the scheduling workload takes place from 0730-0930. Additionally, the team found that current the scheduling tool used by the department is inefficient, leading to increased employee workload and an increased number of turfed calls.

In order to analyze the results of the transportation time studies, the team stratified the data by variables such as “Procedure Type” and “Risk Level” to determine which variables were most indicative of how long a transport would take. The team found that stratifying the data by “Procedure Type” produced the smallest standard deviations, thus indicating that this variable was most indicative of how long a transport would take. The results of the scheduling time studies were used to create a current state and future state value stream maps of the scheduling process.

The current state value stream map (CSM) includes each step in the scheduling process, as well as a timeline that reflects how long each of these steps currently takes based on scheduling time sheets. Once the CSM was completed, the team created a future state value stream map (FSM). In creating the FSM the team found that several process steps can be eliminated to make the scheduling process simpler and shorter.

RecommendationsThe team has developed a new, improved scheduling tool (as seen in Appendix E) that will provide greater visibility to the scheduler and standardize the scheduling process. This new scheduling tool will decrease the workload on the schedulers because it explicitly shows which transporters will be available at which times throughout the day, thus eliminating any confusion as to the times when transporters are available. The team found that with the transportation time estimates and the increased visibility that the scheduling tool offers, the SWAT department would have been able to accommodate an additional 40 transports that month. This is equivalent to 0.93 FTE’s, which would reduce the turf rate by 2.85%.

Additionally, the team recommends utilizing a Standard Operating Procedure (SOP) to eliminate additional calls as seen in the CSM. An SOP is a set of step-by-step instructions compiled to help workers carry out routine operations. The SOP used by the SWAT department would serve as a checklist for the schedulers to follow when scheduling a patient.

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To further streamline the scheduling process, the team recommends automating patient information paperwork using MiChart. The team has already been in contact with a MiChart Credentialed Trainer who has submitted a request to create an automated form for the SWAT team. Implementing this technology would eliminate the need for the schedulers to manually fill out patient paperwork, thus reducing the scheduling process time by 28.62%.

After implementing the above recommendations, the team estimates that the new scheduling process will take 60.13% less time than the current process. For this reason, the team recommends that SWAT no longer use two schedulers throughout the entire day. From 0730 to 0930, two schedulers should still be used because this is the busiest scheduling time of the day, however after 0930 one of the schedulers should join the rest of the SWAT team in assisting on transports. This new transporter will reduce the turf rate by 2.3%.

In implementing all of the above recommendations, the turf rate is expected to decrease by 5.15% which would make the turf rate 12.73%. In order to reach the acceptable level of 8%, the SWAT team will need to hire 1.5 additional full-time employees.

Expected ImpactThe team’s recommendations are expected to decrease the current turf rate of 17.88% to 8.13%. In making these recommendations, the team met each of the goals outlined at the start of the project. The proposed changes to the scheduling process both streamline the scheduling process and reduce the workload on the schedulers; the new scheduling tool increases visibility in scheduling and further simplifies the scheduling process; and optimal staffing levels were proposed in order to achieve a turf rate that meets the hospital administration’s standards.

INTRODUCTION

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The University of Michigan Hospital services more than 47,000 patient stays a year. Each year, for the past two years, an average of more than 8,000 of these 47,000 patients have been high-risk patients needing monitored transportation to different areas in the hospital. The Specialized Workforce for Acute Transport (SWAT) has been responsible for the monitored transportation of high-risk patients at the University of Michigan Hospital. In June of 2016, the hospital introduced an intra-hospital transportation policy that changed the requirements for patient monitoring, requiring SWAT to transport certain moderate-risk patients in addition to high-risk patients. Since the policy change, SWAT has received significantly more transportation requests than it has in previous months. Although SWAT has received additional employees to assist with its increased workload, its current procedures and workforce have been insufficient to meet the increased demands. SWAT requested the Industrial and Operations Engineering (IOE) 481 Project Team recommend changes to the SWAT scheduling process that could be implemented to reduce SWAT workload and meet the performance criteria as determined by the hospital administration.

The IOE 481 Project Team examined the current SWAT patient transport and scheduling processes and collected data on site. The team analyzed the data, developed conclusions, and provided recommendations to streamline the patient scheduling process and decrease the workload on the SWAT personnel. This report outlines the steps taken throughout the project, including goals and objectives, methods in detail, findings and conclusions, recommendations, and supporting documentation.

BACKGROUND

The following information regarding the SWAT team was presented to the team by its clients. The clients included the SWAT workforce details, key metrics, and current process details. The SWAT team is divided functionally into two workforces: the scheduling workforce and the transportation workforce.

Scheduling WorkforceThe scheduling workforce, composed of two nurses or paramedics, coordinates the transportation workforce to meet as many patient requests as possible. SWAT receives 70% of its calls between 0700 - 1700; during this time it takes one nurse or paramedic off of the transportation workforce to assist in scheduling. The rest of the time, SWAT has only one scheduler. The scheduling process consists of a unit's charge nurse calling or paging the schedulers to request a time for a SWAT team to transport the patient to a given destination or procedure. Only calls concerning the transportation of high or moderate risk patients are scheduled. These calls are scheduled on a first-come, first-served basis. All other calls are redirected to the appropriate department.

Transportation Workforce

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The transportation workforce is responsible for transporting patients according to the schedule created by the schedulers and is composed of specially trained SWAT nurses, paramedics, and transporters. The transportation workforce may also use bedside nurses to assist in certain transports. Requests for SWAT transportation vary in monitoring requirements, so the SWAT team may respond to calls with different teams of nurses, paramedics, or transporters to appropriately match the level of attention necessary. Because SWAT transports may occur in any part of the hospital system, the SWAT team requires additional time to arrive at the patient’s bedside.

Key Metric: Turf RateThe turf rate is a measure used by SWAT to reflect the percentage of calls that are scheduled but are not responded to, usually due to insufficient resources from SWAT. Historically, the turf rate has been 6-8%, with 8% being the acceptable turf rate as determined by the administrative staff.

Policy ChangeIn June of 2016, the University of Michigan Hospital introduced a new policy that requires specially trained nurses to transport certain moderate-risk patients in addition to its existing workload. Since the policy change, SWAT’s non-ICU requests have doubled, while ICU requests have remained stable. Due to the policy change implemented in June 2016, the turf rate has increased to approximately 17.88%, based on historical data, versus the acceptable 8% turf rate. When SWAT is unavailable to transport its patients, bedside nurses without the appropriate skillset must take high-risk patients to their destinations.

Current Transportation ProcessSWAT defines its current patient transportation process in six steps:

1. TriageThe SWAT scheduler receives a request for transportation and helps the requesting location decide if the transport team is needed based on SWAT guidelines. If the transport team is needed, the scheduler books an available time, instructs the patient’s bedside nurse on the preparation work that needs to be done before the SWAT transport team arrives, and briefs the patient’s bedside nurse on the transportation procedure.

2. Preparation timeThe transport team records basic patient health information, including past transportations. Depending on this information, SWAT may need to re-assess the patient needs with the bedside nurse.

3. SWAT to bedsideThe SWAT transport team leaves the office or its last location and travels to the patient’s bedside.

4. Equipment and bedside preparation

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The SWAT transport team obtains the necessary equipment and prepares for the transportation procedure. Then, the SWAT transport team informs any patient family members about the procedure.

5. Travel or procedureIf a patient is being dropped off to a new location, SWAT transports the patient from his or her original location to the destination and ensures the patient is properly situated. The transport team may need to wait at the destination if the destination is not ready for the patient. If the patient is being transported to and from a procedure, SWAT transports the patient to the procedure, waits with the patient until the procedure is completed, and then transports the patient back to his or her original location.

6. Post transportation or procedureThe SWAT transport team completes documentation on the transportation, cleans used equipment, and returns back to the office or to the next call. If a SWAT transport is taking longer than the expected time and a SWAT team member has another transport scheduled, these steps may be given to the bedside nurses. Additionally, if a bedside nurse is assigned only one patient, he or she will always complete the documentation.

KEY ISSUES

The following key issues drove the need for this project.

● Increased turf rate since the policy change● Increased number of patient transportation and procedure requests● Inefficient scheduling process● Perceived shortage in SWAT personnel

GOALS AND OBJECTIVES

To increase the efficiency of the SWAT team and address SWAT employee workload, the team set the following objectives:

● Decrease turf rate ● Streamline scheduling process to reduce workload on schedulers● Increase visibility in scheduling to simplify the scheduling process● Determine optimal SWAT staffing levels in order to achieve an acceptable turf rate, a

maximum of 8%

PROJECT SCOPE

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The scope of this project included examining each of the steps in the SWAT patient transport process from the time a transportation request is received to the time the SWAT personnel are available for the next request (see the Current Transportation Process section for more detail). It also included any procedures performed by the SWAT personnel such as patient preparation and documentation.

The scope of this project did not include procedures outside the jurisdiction of SWAT such as medical operations and surgical procedures.

METHODS

To determine where improvements could be made to the University of Michigan Hospital’s SWAT patient transport process and SWAT employee workload, the team collected and analyzed data through on-site observations, time studies, value stream mapping, and literature searches.

On-Site ObservationsThe team first conducted preliminary observations of the SWAT scheduling process. In order to gain a better understanding of the scheduling process and workload, the team shadowed SWAT schedulers in the office predominantly between 0700 - 1700, as historical data shows that this is when approximately 70% of the workload takes place. These observations were conducted over a period of 5 weeks during which the team collectively spent 10 hours per week shadowing the SWAT personnel. These observation helped the team gain a better understanding of the current processes and workload.

Time Studies Based on the observations, the team created two data collection sheets: the Transport Timesheet (Appendix A) and the Scheduling Timesheet (Appendix B), used to conduct time studies on the transportation and the scheduling processes, respectively. A total of 183 transport timesheets were collected over a period of 13 days, and a total of 79 scheduling timesheets were collected over a period of 16 days. The transport timesheets were crucial in determining standard processing times for the SWAT transport process. The scheduling timesheets were created to form the current state and future state value stream maps of the SWAT scheduling process. Additionally, the team used statistical software such as Tableau and Excel to analyze the results of the data collection and identify the areas of the scheduling process that need improvements.

Value Stream MappingThe following subsection details the value stream maps the team created in order to clearly show how the scheduling process works and identify where changes can be implemented. Data Analysis and Current State Value Stream Map (CSM)

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After data collection, the team developed a current state value stream map (Appendix C) of the scheduling process to provide a baseline for improvement and serve as a tool to explain the current system flow. The map includes each step in the scheduling process as well as a timeline that reflects how long each of these steps currently takes to complete.

Future State Value Stream Map (FSM)Using the current state value stream map and the results of the scheduling data, the team worked alongside the Nurse Manager to create a future state value stream map (Appendix D) to reflect the ideal state of the scheduling process as well as a plan to achieve it.

Literature SearchThe team conducted literature searches to broaden the team’s understanding of relevant solutions to intra-hospital transport and staffing.

Standardizing Processes Helps to Account for Variability in Hospital SettingsThe team read research on intra-hospital transport. The most applicable paper, Bringing Robustness to Patient Flow Management Through Optimized Patient Transports in Hospitals by T. Honne et al. [1], indicated that common objectives in intra-hospital transport include minimizing lateness, decreasing earliness, maximizing nurse utilization, and maximizing patient satisfaction. The research also helped identify the key areas of uncertainty in patient transport, specifically that transport requests are not known in advance, and that the requirements of scheduled requests may change. Most importantly, the research provided a variety of rules for schedulers to follow. These rules augment schedulers’ intuition and expertise with standard processes to scheduling. For this reason, the team considered standardizing scheduling processes for SWAT scheduling.

Previous IOE 481 Groups Discover Need for Additional SWAT SchedulerIn order to gain a better understanding of previous projects associated with the SWAT team, the team researched previous IOE 481 project recommendations. The most applicable project is titled Nursing SWAT Patient Transport Analysis Regarding Workload and Tasks [2]. In this report, the authors point out that the SWAT team is understaffed and as a result many employees were dissatisfied. The relevant recommendation found in this report is to add an additional scheduling nurse during the busiest times of the day in order to decrease the workload on the current SWAT staff [2]. This recommendation was made in 2006. While the specific recommendation made in this report may no longer be relevant, the team feels that additional staffing during exceptionally busy hours could be a useful recommendation to keep in mind throughout the project.

Fire Department Staffing Procedures Give Insight into Needed SWAT Staffing Levels

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The team read research on how fire departments in the United States efficiently staff their firefighters. The article, Fire Department Staffing: A Need, Not a Want by K. Wilson [3], indicated the minimal recommended staffing levels as set forth by the National Fire Prevention Association (NFPA) through various studies. The NFPA has minimal staffing levels based on the location of the fire departments. The research helped provide insight into the differing levels of staff based on the frequency and type of calls the department is responding to. From this article and the data collected, the team will make recommendations on the number of staff (nurses, paramedics, and transporters) needed per shift. These recommendations will stem from the frequency of varying types of calls that have been observed during the observational period.

FINDINGS AND CONCLUSIONS

After completing SWAT transport and scheduling observations, along with analyzing the historical data, data from the time studies, CSM, and literature searches, the team was able to draw conclusions that led to an understanding of the need for an improved scheduling process.

Historical Data Gives Insight into Turf Rate and Employee WorkloadThe team used an A3 report completed in December 2015, as well as historical data on SWAT transports in its analysis of employee workload and the turf rate. The A3 report, Resources to Support Changes to Intrahospital Transport by Calarco and Desmond [4] provided data on the number of transports completed per full-time employee (FTE) per month. Each FTE goes on 43 transports/month. The historical data on SWAT transports provided the number of completed transport requests and the number of turfed calls for each month since June 2015. Using these data sources, the team calculated the number of FTE’s that would need to be hired to reduce the turf rate to the acceptable rate. The team found that for each additional FTE hired, the turf rate would decrease by 3.07%.

On-Site Observations Reveal Inefficiencies with Scheduling ToolWhile conducting on-site observations of the scheduling process, the team observed that the busiest time period for the schedulers was from 0730-0930, as this is the time during which the majority of requests to schedule transports are made. For this reason, the team conducted observations of the scheduling process during these hours.

The team found that the scheduling tool used by the SWAT team does not allow the scheduler to properly visualize the availability of the SWAT team. For example, the scheduler must use his or her intuition to estimate how long each staff member will be gone on a transport, and use these estimates to schedule or turf future transport requests. Additionally, when trying to estimate the time when a staff member will be finished with a certain transport, the scheduler has to scroll up and down to check each transporter on staff that day. Issues with this method arise when the scheduler assumes that a transport request must be turfed due to unavailable personnel, but in reality the request could have been completed by personnel who would have been available at

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the requested time. This leads to an increased turf rate. An example of the current scheduling tool used by the department is shown in Figure 1 below.

Figure 1: Current Scheduling Tool

As seen in the image above, the only information that the current scheduling tool provides concerning transporter availability is the time at which a transporter is scheduled to go on a transport. For this reason, the team determined that the SWAT department would benefit from a new, more user-friendly scheduling tool. Additionally, both schedulers cannot simultaneously update the schedule due to inefficient scheduling software.

Time Studies Provide Reliable Estimates of Procedure Times for SchedulersThe team collected 183 transport time sheets over 13 days to get a reasonable representation of SWAT transports. The team stratified data by different variables to determine which of these variables were most indicative of how long a transport will take. First, the team stratified the data by procedure type and measured the mean and standard deviations of each procedure. The results of this analysis can be seen in Table 1 on the following page.

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Table 1: Transportation Times by Procedure Type

Procedure Type Mean Transportation Time (min)

Std. Dev. of Transportation Time

(min)

Bedside Sedation 96.67 16.82

CT 47.65 12.57

CPU Return 32.83 6.08

Echo 78.80 19.35

PET Scan 141.80 15.20

MRI 119.00 34.30

Radiology 47.23 16.80

For the purposes of this analysis, the team chose the most common procedures seen in the time studies. The average transport times varied from 47.23 minutes (Radiology) to 119.00 minutes (MRI), and the standard deviation varied from 6.08 (Bedside sedation) to 34.30 (Radiology). At the Nurse Manager’s request, the team also stratified the data by patient risk level, shown in Table 2 below.

Table 2: Unreliable Transportation Times Based on Patient Risk Level

Patient Risk Level

Mean Transportation Time

Std. Dev. of Transportation Time

Moderate 63.56 112.85

High 71.41 87.97

As seen in Table 2, the standard deviations are extremely high. This indicates that transportation times are not dependent on patient risk level, therefore this variable is not helpful in predicting the length of a transport. Therefore, the team used “Procedure Type” to predict the length of patient transports.

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Value Stream Mapping Gives Insight into Scheduling ProcessAfter collecting the results of the scheduling time study (seen in Table 3), the team created a current state value stream map of the SWAT scheduling process. This current state value stream map includes each step in the scheduling process, as well as a timeline that reflects how long each of these steps currently takes based on the scheduling time sheets. This timeline was approved by the Clinical Nurse Supervisor as well as two SWAT schedulers.

Table 3: Results from scheduling time study show opportunity for improvement

Scheduling Process Step Time (min.)

Receive call or page 1.71

Schedule patient 0.50

Call charge nurse 1.71

Additional call #1 3.97

Additional call #2 2.67

Update Excel spreadsheet 0.50

Paperwork 6.53

Confirmation call 3.48

After the CSM was approved, the team created a future state value stream map (FSM). In creating the FSM the team found that several process steps can be eliminated to make the scheduling process simpler and shorter. Specifically, “Additional Call #1”, “Additional Call #2”, and “Paperwork”, as called out in Table 3 above, can be eliminated by implementing standard work and automating paperwork.

DEVELOP SCHEDULING TOOL

The team developed a scheduling tool using Microsoft Excel Visual Basic Application. This scheduling tool has all of the information provided on the original scheduling sheet, but is reformatted to allow for greater visibility into transporters’ availability. To use this tool, SWAT schedulers will find the time of the transport along the left side and the transporter going on the call on the top of the Excel sheet. Then the scheduler will select the cell that corresponds to the proper time and transporter. For example, Figure 2 (on the following page) shows the proper cell to select to schedule a transport for 0900 for Transporter #3. For a look at the full screen, see Appendix E.

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Figure 2: Scheduling Tool - Selecting the Correct Cell

Next, the scheduler will click the button on the top that corresponds to the type of procedure to which the patient is being transported. The buttons were the most common types of transports, and comprise 71.10% of all transport requests (Figure 3 below): Bedside Sedation, CT, CPU Return, Echo, PET Scan, MRI, and Radiology along with an Other button for types of transport types that are not included in the list.

Figure 3: The seven most common transport requests comprise 71.10% of all requests

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When a specific transport button is clicked, a form will pop-up that allows the scheduler to put in relevant information such as Patient Name, Type of Procedure, Location, SED, VENT, ISO, REG #, NARC #, and Comments. An example of a filled out version of this form can be seen in Figure 4.

Figure 4: Patient Information Form

When the scheduler clicks Okay, the Excel sheet will automatically fill in the amount of time needed for that specific call along with the patient information from the form as seen on the following page in Figure 5.

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Figure 5: Scheduling Tool Automatically Fills in Data

When the scheduler clicks the Other button instead of a specific procedure type, a form will pop-up prompting to the scheduler to enter the necessary amount of time that would need to be scheduled, ranging from 20 to 200 minutes, as seen in Figure 6 below.

Figure 6: Other Button Time Entry Form

Once this time is entered and the scheduler clicks Okay, a second form will pop-up. This form is the same form that appears for a specific transport (Figure 4).

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If at any time a scheduler tries to schedule a transport that overlaps a previously scheduled one, a warning message will appear and the scheduler will not be able to schedule it. This message can be seen in Figure 7.

Figure 7: Warning Message about Overlapping Transports

The data used to estimate the time needed for each transport is based on the transport time sheets. These estimates will capture at least 75% of all transports, as seen in Table 4 on the following page.

Table 4: Actual Transport Time Estimates Used in Scheduling Tool

Procedure Estimated Time (min.) Percentage Captured

Radiology 50 75

CT 50 75.68

Echo 90 80

MRI 125 80

Bedside Sedation 110 100

CPU Return 35 100

Pet Scan 155 75

The team decided to capture at least 75% of all transports in its estimates of transport times rather than using the means found earlier (Table 1), because using the means would not capture a significant percentage of the transports. It was more effective to capture at least 75% of the transports to ensure that the tool would estimate all but extreme cases of transports.

Additionally, the times used to estimate the duration of each transport includes the walking time to the patient’s bedside and back to the SWAT office or to the next patient. When scheduling a

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transport, the scheduler needs to keep this fact in mind. Therefore, when scheduling patient transports using the new scheduling tool, the scheduler should mark on the Excel sheet the time the transporter will be out of the office, not necessarily the time the patient is scheduled. For example, if a patient needs to be at CT at 0900, the scheduler might want to select the cell that corresponds to a time of 0850 instead of 0900, to accurately capture the time the transporter will be out of the office.

RECOMMENDATIONS

The final recommendations are based on the following key conclusions:

● The scheduling tool needs to be updated to assist schedulers in optimally scheduling transports.

● The paperwork portion of the scheduling process can and should be automated to increase efficiency.

● The scheduling process should be streamlined to increase efficiency.

Based on these main conclusions, the team has generated the following recommendations.

Utilize the New Scheduling Tool to Provide Greater Visibility and Decrease Turf Rate To decrease the turf rate and decrease the schedulers’ workload, the team has developed a new scheduling tool that will provide greater visibility to the scheduler and standardize the scheduling process (as recommended by T. Honne et al. [1]). Notice that all of the information from the past scheduling tool is still listed in the improved tool, but it has been reformatted to provide greater visibility of available transport personnel to the schedulers. This new scheduling tool will decrease the workload on the schedulers because it explicitly shows which transporters will be available at which times throughout the day, thus eliminating any confusion as to the times when transporters are available.

In order to determine how the new scheduling tool would affect the turf rate, the team tested it for the month of November. The team first obtained SWAT’s transportation schedule for each day in November and used the new tool to schedule each of the calls. The team found that with the transportation time estimates and the increased visibility that the scheduling tool offers, the SWAT department would have been able to accommodate an additional 40 transports that month. This is equivalent to 0.93 FTE’s, which would reduce the turf rate by 2.85%.

Streamline Scheduling Process to Decrease Time Spent SchedulingThe following subsection explains two recommendations that were developed as the team created the FSM of the scheduling process. These recommendations aim to decrease the amount of time spent scheduling SWAT transports.

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Utilize Standard Operating Procedures to Eliminate Additional CallsThe team recommends utilizing a Standard Operating Procedure (SOP) to eliminate additional calls as seen in the CSM. An SOP is a set of step-by-step instructions compiled to help workers carry out routine operations. The SOP used by the SWAT department would serve as a checklist for the schedulers to follow when scheduling a patient. This checklist will remind the schedulers of all necessary information to exchange with the bedside nurses in the initial request, thus eliminating the need for additional calls. The elimination of “Additional Call 1” and “Additional Call 2” will streamline the scheduling process, reduce the workload on the schedulers, and reduce the scheduling process time by 31.51%.

Utilize MiChart Printing Feature to Eliminate Handwritten PaperworkTo further streamline the scheduling process, the team recommends automating patient paperwork by using MiChart. MiChart is an electronic health records system used by UMHS that has the capability of printing out custom designed patient information forms. The team has already contacted a MiChart Credentialed Trainer to submit a request to create an automated form for the SWAT team, and suggests that the Nurse Manager follow up with the MiChart contact to ensure implementation. Implementing this technology would eliminate the need for the schedulers to manually fill out patient paperwork, thus reducing the scheduling process time by 28.62%.

Add Personnel to Achieve Desired Turf RateAfter implementing the above recommendations, the team estimates that the new scheduling process will take 60.13% less time than the current process. For this reason, the team recommends that SWAT no longer use two schedulers throughout the entire day. From 0730 to 0930, two schedulers should still be used because this is the busiest scheduling time of the day based on observations and the need for additional schedulers during this time period (according to M. Blasco et al. [2]). However, after 0930 one of the schedulers should join the rest of the SWAT team in assisting on transports, effectively adding an additional transporter to the team at no additional cost to the hospital. This new transporter will reduce the turf rate by 2.3%.

In implementing all of the above recommendations, the turf rate is expected to decrease by 5.15% which would make the turf rate 12.73%. While this turf rate is lower than the current turf rate, it is not at the acceptable level of 8%. In order to reach this acceptable level, the SWAT team will need to hire 1.5 additional full-time employees. This increase in staffing levels to accommodate demand is corroborated by Fire Department Staffing: A Need, Not a Want (K. Wilson [3]).

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EXPECTED IMPACT

The team’s recommendations are expected to decrease the current turf rate of 17.88% to 8.13%. The decrease in turf rate due to each recommendation is outlined below in Table 5. This decrease in turf rate addresses the key issues of the rising turf rate and increased number of patient transportation and procedure requests due to the policy change.

Table 5: Expected Impact on Turf Rate per each Recommendation

Recommendation Decrease in Turf Rate

Cumulative Decrease in Turf Rate

Turf Rate

Utilize Scheduling Tool 2.85% 2.85% 15.03%

Move Scheduler to Transporter

2.30% 5.15% 12.73%

Add 1.5 Full-Time Employees

4.60% 9.75% 8.13%

In making these recommendations, the team met each of the goals outlined at the start of the project. The proposed changes to the scheduling process both streamline the scheduling process and reduce the workload on the schedulers; the new scheduling tool increases visibility in scheduling and further simplifies the scheduling process; and optimal staffing levels were proposed in order to achieve a turf rate that meets the hospital administration’s standards.

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REFERENCES

[1] T. Hanne, T, Melo, S. Nickel, (2009) Bringing Robustness to Patient Flow Management Through Optimized Patient Transports in Hospitals. Interfaces 39(3):241-255. http://dx.doi.org/10.1287/inte.1080.0379

[2] M. Blasco, M. Brennan, and L. Soderstrom, (2006) Nursing SWAT Patient Transport Analysis Regarding Workload and Tasks. Ann Arbor, MI: University of Michigan, Industrial and Operations Engineering Department

[3] K. Wilson, (2009) Fire Department Staffing: A Need, Not a Want. Fire Engineering. http://www.fireengineering.com/articles/print/volume-162/issue-8/features/fire-department-staffing-a-need-not-a-want.html

[4] L. Shever (2015), Resources to Support Changes to Intrahospital Transport, (A3).

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APPENDIX

Appendix A: Transport Timesheet

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Appendix B: Scheduling Timesheet

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Appendix C: Current State Value Stream Map for Scheduling Process

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Appendix D: Future State Value Stream Map for Scheduling Process

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Appendix E: Improved Scheduling Tool

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