work study and measurement

Operations research, work study

and measurement

5

Section 2: Operations

research, work study and work

measurement

Operations research, work study and measurement

52

Contents

Introduction ...............................................................................................................53

Objectives ..................................................................................................................53

Operations research ...................................................................................................54

Work study.................................................................................................................56

Work methods and method study ..............................................................................57

Work measurement techniques .............................................................................58

Performance rating................................................................................................59

Allowances..........................................................................................................510

Measuring workload............................................................................................510

Use of work measurement data for workload monitoring systems.....................511

Workload validity................................................................................................512

Patient Assessment and Information System...........................................................513

Time study ...............................................................................................................514

Time study applied to nursing.............................................................................516

Predetermined time standards .............................................................................517

Work sampling ........................................................................................................519

Work sampling applied to nursing work.............................................................522

Self reporting ...........................................................................................................523

Time and work measurement ..................................................................................523

Principles of work study ..........................................................................................524

Use of self-recording to analyse work performed ...................................................525

Self-reporting studies applied to nursing.................................................................525

Professional judgements/estimates..........................................................................526

Skill mix ..................................................................................................................526

Summary..................................................................................................................527

References ...............................................................................................................527


53

Introduction Section 2 of this course concerns the input, output and processes of health care

services that define and determine quality and performance. Input refers to the actual

work performed as well as the material and labour resources required to deliver

health care services. Operations research, work study and work measurement are

techniques to measure and analyse input and work processes with the objective of

improving performance by increasing efficiency and productivity. Health services

products or output can be assessed and documented using standards, guidelines and

indicators. These are discussed in Chapters 5 through 7.

This first chapter of Section 2 introduces you to the disciplines of operations research

and work study. The concepts are complex, but the time invested to understand them

is worthwhile as the concepts used are very useful when analysing an organisation, its

operations and the work performed by individuals with a view to improve

productivity and performance.

Once a health service enterprise expands to the point where it can no longer be

managed by one person, it becomes necessary to organise all operations associated

with the services provided. This is often referred to as operations management. The

use of an operations manager was and continues to be prevalent in manufacturing

industry. More recently we have seen the introduction of such positions in the health

care industry particularly in the private sector. One of the main characteristics of such

positions is the need to determine the most efficient way to use available resources.

This is where operations research became popular, as this methodology aims to

identify the optimum use of all available resources. This discipline is closely related

to that of organisation and methods, also referred to as work study, and incorporates

both methods and time study. These disciplines were very popular in the 1960s and

1970s as is evident from the literature of that period. The concepts and principles of

these disciplines are now being applied in the health sector often under the guise of

new terminology such as business process reengineering as we will discuss in

Chapter 10. From an informatics perspective there is an increasing realisation that

systems must fit in with workflows and work practices to be successful. This in turn

requires a sound understanding of how people work and all associated organisational

operations and information flow. The concepts and principles covered in this chapter

provide a sound foundation for the conduct of such analysis. These methods are often

referred to in the current health informatics literature as sociotechnical approaches.

Objectives By the end of this chapter you should be able to:

understand the theories and practices of operations research and apply them to the

health services setting

demonstrate a reasonable understanding of work measurement and methods study

principles

understand the principles of methods study

identify meaningful units of work for various service areas

analyse how changes to work practices may impact on the outcomes (quality and

performance) of health service delivery.


54

Operations research Operations research (OR) is a quantitative method suitable for use in the health

services field. Many definitions for OR exist, each emphasising the different elements

according to its specific use. For our purpose, operations research can best be

described as the study of processes or systems and the application of quantitative

methods to the systems to design decision-making models. These decision models

provide the means to determine an optimum course of action within a complex

system with limited resources. It is important to remember that these models do not

provide a solution, but can only be solved to an optimum, that is, there will always be

trade-offs due to the constraints of the system. In the case of health services, these

constraints or trade-offs would include material and human resources, cost, and

quality issues.

OR models are quantitative representations of systems based on random events

occurring in a changing or uncertain future. An OR model to predict random events is

based upon probability theory. The OR model is than solved to its optimum solution

by changing the variables and generating the results. Manipulation of input to arrive

at the optimal results by starting with a wide range of scenarios and then refining the

model with each iteration is known as simulation and sensitivity analysis. The arrival

of an optimum solution through many iterations of a model is done with computers.

OR relies heavily upon the use of computers to generate solutions for many different

scenarios without having to experiment on the actual system that is being studied.

OR uses a systematic scientific approach to problem solving. The five steps of the

scientific method are used.

1. Observe the system or process.

2. Define the problem.

3. Develop alternative solutions (models).

4. Find optimal solutions to the model.

5. Implement the optimal solution.

These five steps do not represent the end of the scientific approach, they are a

continuing cycle. As the optimal solution is implemented, more problems needing

resolution are uncovered. Changes to the system occur and refinements are needed on

an ongoing basis. This cyclical process of continuous improvement is also the basis

for total quality management (TQM) and continuous quality improvement (CQI)

which will resurface again in Section 4. Simply stated, for problem-solving and

decision-making, four basic questions must be answered:

1. What is being done?

2. Why is it being done?

3. How is it being done?

4. How can we do it better?


55

Operations research is used as a problem-solving technique (White 1985, p. 22).

Examples are queuing, scheduling, distribution, inventory, maintenance, production,

supply versus demand and defective product type problems. Many of these types of

problems can be found in any health care setting. OR has three essential

characteristics:

1. systems orientation

2. use of interdisciplinary teams

3. adaptation of the scientific approach.

The two most common applications of OR to the hospital setting to date are queuing

theory and simulation models.

Queuing theory refers to the study of waiting lines. Waiting lines are generated by

random arrivals for the receipt of limited services and/or resources. The queuing

models purpose, combined with simulation, is to determine the optimal number of

people or services required to meet the needs of the waiting customers.

Simulation tests the model under different scenarios by changing the value of the

variables until an optimal solution is found. The various scenarios are tested by

running randomly generated numbers through the model to represent random arrival

times. If too many resources are made available, the waiting time is negligible

however the cost would be prohibitive. If too few resources are made available, the

cost is minimised but the waiting lines become unacceptable to the customers. There

will be cost associated with any system and in an environment of limited resources

there will be waiting lines. Operations research models provide a means to find

acceptable costs and risks to both the provider and the customer.

The practice of OR requires the construction and use of mathematical models

representing the problem. According to Ackoff and Rivett (1963, p. 24) all OR

models take the form of an equation in which a measure of the systems overall

performance (P) is equated to some relationship (f) between a set of controlled

aspects of the system (Ci) and a set of uncontrolled aspects (Uj). Thus expressed

symbolically, the basic form of all OR models is: P = f (CI Uj). In words this says that

performance depends upon significant controlled and uncontrolled aspects of the

system. Pidd (1977, p. 15) summarises the OR study as usually consisting of ten

stages, some of which may overlap and be undertaken concurrently.

1. Describe problem in its context

2. Collect preliminary information

3. Define problem explicitly

4. Set study objectives

5. Formulate the OR problems

6. Construct model

7. Collect detailed data

8. Test the model

9. Select solution from alternatives

10. Implement and monitor solution.


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Specific examples of operations research techniques as applied to health services

include, but are not limited to, optimal staffing, identifying the number of rooms and

equipment required for emergency rooms, cardiac care units, neonatal wards, meet

expected demand, ward layout for optimal efficiency, optimal placement of clinics,

optimal use of blood-mobiles, etc. More information on these specific uses are listed

in the references at the back of this chapter.

In summary, OR can be considered both an art and a science as it attempts to apply

scientific methods to complex systems containing intangible elements including

random events, unpredictable human behaviour and subjective outcomes. Given these

considerations, operations research is highly applicable to health services

performance research in the ongoing quest to provide high quality service within the

constraints of limited resources.

Berg (1999 p. 89) notes that sociotechnical approaches emphasize that thorough

insight into work practices in which IT applications will be used should be the

starting point for design and implantation. This is seen as especially important in the

health industry where this concerns the work of health professionals. More

specifically their work activities coordinate many business processes or operations

such as scheduling, interactions among functional units, staff members, software

components, planning, reporting and more. The skills acquired by adopting the

various workstudy techniques detailed in this chapter are also very useful as the basis

for analysing workflow for the purpose of developing models or activity diagrams

using various modelling techniques such as the Unified Modelling Language (UML).

Work study Work study is a specific type of operations research used to measure work being

performed in order to increase efficiency and productivity. Said another way, the ILO

(1978, p. 29) (see Reading 51) defines the term work study as a generic term for

those techniques, particularly method study and work measurement, which are used

in the examination of human work in all its contexts, and which lead systematically

to the investigation of all factors which affect the efficiency and economy of the

situation being reviewed, in order to effect improvement.

Work study techniques may be employed to study processes or operations as well as

for the study of people at work. Work consists of the basic work content plus content

added as a result of:

defects in equipment

deficits in knowledge and/or skill

treatment/care regimes used

use of inefficient methods

organisational or management shortcomings, such as scheduling, resource

allocation, location of supplies

inefficient time management by the worker.

Similar to the methodology described previously for operations research, work study

examines work to identify the factors which contribute to the time required to

perform the work. Work study techniques are then used to review the objectives of


57

the work, the prevailing constraints, search and formulate possible solutions, evaluate

each alternative and to select the most efficient and effective way to perform the

work (the optimal solution).

Thus, work study is a systematic way to effect change and improve efficiency by

applying the following steps (compare to the five steps of the scientific method listed

previously):

1. Observe work being performed.

2. Identify factors contributing to performance time.

3. Review work objectives and work constraints.

4. Formulate solutions and evaluate alternatives.

5. Select most efficient method.

Once you have documented a process you are ready to examine it by challenging

every step of the process. The aim is to eliminate all unnecessary work, combine

operations, change the sequence of operations and simplify the necessary operations.

The latter may require an in-depth analysis of specific steps in the process.

Reading 51 below by the International Labour Office (ILO) is an overview of the

principles and basic procedures of work study. Reading 52 is taken from Currie,

1977 and discusses some of the human aspects of performing work study. These

principles have not changed.

Reading 51 ILO 1978

pp. 2935

Optional reading Currie 1977

Ch. 23, pp. 247257

Work methods and method study The study of methods and processes employed to perform work logically leads to

improved efficiency. Some methods are more efficient than others in terms of

resource usage and time and effort required. The preparation phase of work

measurement is an appropriate time to analyse the system as a whole and the methods

used to perform the work.

The purpose of method study is to facilitate the performance of work while meeting

pre-determined standards using the least amount of time, effort and resources. The

best way to conduct method study is in collaboration with the people actually

performing the work to be studied. The people doing the work usually have the best

insight into how methods may be analysed and improved.

Conducting a method study is as simple as questioning everything that is being done

and the manner in which it is being done and then ask why it is being done and is it

necessary? Although, as we have stated, the people performing the work may have

the best idea of how to streamline and improve the work being done, their reaction to

this questioning may be the initial response of but weve always done it this way.

Many activities represent habits or artefacts from the past that no longer serve a


58

useful purpose and may sometimes even hinder the achievement of stated objectives.

It is human nature to avoid change and frequently people are reluctant to let go of the

past at first.

By conducting method study, significant savings of resources, time and money can be

achieved by eliminating unnecessary activities. To complete method study

successfully, one needs to ask the following questions:

Why is it being done?

How else can it be done?

Is it being done by the appropriate person?

Is it being done at the appropriate time?

Is the minimal amount of effort being expended to achieve the desired results?

Any work process can be studied, applying the methods described above, in very

general terms or in minute detail. The challenge in methods study is to maintain focus

and degree of granularity (level of detail) on the subject matter being studied. To aid

in this objective, standard and reliable data collection methods and consistent

methods of recording and analysing work are paramount. The following reading from

Anderson is a discussion of how to record work through charts and lists of activities.

Reading 52 Anderson 1973

pp. 69106

Work measurement techniques The following optional reading taken from Currie, 1977 provides an introduction to

work measurement and work measurement techniques.

Optional reading Currie 1977

Ch. 12, pp. 136145

Techniques used to measure and quantify work vary in terms of degree of difficulty,

accuracy and cost. The type of work to be measured, the desired degree of accuracy

to be achieved and the resources available to conduct work measurement can

determine which work measurement techniques should be used. One needs to choose

the most appropriate work measurement technique for the work to be measured.

Work measurement techniques may be applied to measure any type of work, be it of a

repetitive or variable nature, efficient or inefficient in its use of human resources. The

measurement technique chosen needs to be appropriate to suit the objectives and the

purpose of the study.

There appear to be many misconceptions in the health-care industry regarding work

measurement techniques and their applications as judged by the applications

observed by this author. Many reported research (work measurement) studies

conducted by people not trained in work study reveal major deficiencies in the area of

work measurement and the quantification of workload when compared with industrial

engineering principles. The application of work study concepts and principles within

the healthcare industry is more complex than in the manufacturing industry. Work

may be quantified in a variety of ways ranging from very precise; that is, within


59

definable tolerance limits, to broadly based estimates. Work measurement implies a

degree of precision.

Principal work measurement techniques listed by the ILO (1978, p. 192) are; work

sampling, stop-watch time study, predetermined time standards (PTS) and standard

data. Currie (1977, p. 138) lists the following; time study, synthesis, predetermined

motion time system (PMTS), analytical estimating, comparative estimating,

estimating, activity sampling and rated activity sampling. Another method is the

modular arrangement of predetermined time standards (MODEPTS) developed in

Australia by Heyde (1966) and promoted by the Australian Association for

Predetermined Time Standards and Research.

Work measurement has traditionally been applied in industry as evidenced by work

study and industrial engineering texts which primarily use examples from the

manufacturing industry (Barnes 1980; Maynard 1971). Indeed the work of Taylor and

others early in the 1900s was encouraged by the American Society of Mechanical

Engineers (Hammond 1971). Work measurement is used to establish time standards

and to identify the amount of ineffective time used to perform the work being studied

to improve efficiency. This requires the work to be broken down into elements of

work, so that the work content may be examined in some detail. Work measurement

is either preceded or followed by method study to reveal shortcomings of design,

tools, procedures, work organisation, flow of production processes, holdups etc., and

to find ways of overcoming such inefficiencies. Following the introduction of

improved methods, work measurement is again applied, for the purpose of setting

standard times and to document the impact of new methods (Antis 1971). This

includes costing previous and new methods for comparative purposes.

Performance rating In addition to basic work measurement, the work study practitioner needs to be able

to assess whether the person performing the work is working at an effective speed

relative to standard rating. Barnes (1980, p. 292) noted from his observations and

experience that there are wide differences in the capacities and abilities of

individuals. In fact he found that the fastest worker produced up to twice as much as

the slowest worker. Also people tend not to work consistently throughout the day or

from day to day. Hence the convention in work study to determine the rating factor

used to adjust measured time values to standard time values. Various methods have

been developed for this purpose (Barnes 1980). Anderson (1971) describes

performance rating as including all procedures which have as their purpose the

adjustment of observed time values to correspond more closely to the time which is

deemed to be reasonable and fair for doing the work in question. It is important that

the time standard ultimately arrived at is appropriate for the average worker. As an

average worker does not exist, one aims to include a sufficiently large sample of

workers so that they approximate a normal distribution curve.

Standard performance is defined by the ILO (1978, p. 240) as: the rate of output

which qualified workers will naturally achieve without over-exertion as an average

over the working day or shift, provided that they know and adhere to the specified

method and provided that they are motivated to apply themselves to their work.

This rate is generally accepted as being equivalent to the speed of motion of the

limbs of a man of average physique walking without a load in a straight line on level

ground at a speed of four miles (6.4 km) an hour (ILO 1978, p. 240). This may be


510

slightly less for women. Performance ratings are used to adjust times arrived at by

means of time study.

Allowances Another issue relevant to work measurement is that of allowances. It is recognised

that no worker can be expected to work consistently without taking time out to meet

personal needs for rest and other interruptions beyond the workers control. Standard

time values need to be realistic and be applicable to the total job, thus specific

allowances are added to the basic time as measured in accordance with the specific

demands for the work studied. These may include allowances for physical strain,

stress, posture, restrictive clothing, highly repetitive work, noise etc. Some special

allowances may be included in each workers industrial award.

Measuring workload The measurement and monitoring of workload provides very valuable information

about production processes which can then be related to organisational inputs,

outputs and outcomes for improved understanding and decision making. It is a

prerequisite to cost accounting which in turn forms the basis for the measurement of

performance regarding departmental and organisational efficiency. Thus it is an

important component in being able to control costs. Furthermore, workload statistics

assist in projecting future departmental costs and budgets. Costs are expenses

classified by a standard chart of account. Costs are then allocated directly or

distributed according to a uniform method of apportionment and transformed into

unit costs by dividing the total costs by consistently defined and generally accepted

units of service or work units. The sum of these units is referred to as departmental

workload which may be equated directly with labour resources. For example in

nursing the departmental (ward) workload may be expressed in terms of the number

of patients serviced by patient dependency category (unit of service), where each

category has an associated nursing hours per shift.

Once the workload in various departments is quantifiable one needs to decide how

these data are to be used. Usage will determine data collection frequency and the

timing for data analysis. Workload monitoring systems should permit comparisons to

be made between resource usage performance standards and actual resources used

per defined work unit (output measure). As a result of rostering practices, rounding to

the nearest full-time staff member, unexpected staff absences or movement between

departments or unexpected major changes in workload, the workload actually

generated and the corresponding standard staff hours required to perform that work,

rarely matches with the actual staff hours made available. Thus a distinction needs to

be made between the standard values and actual resource usage. Standard values, if

arrived at by means of valid work measurement techniques, should reflect a

performance standard (benchmark) which is defined by Herzog (1985, p. 356) as:

... a measure of how much time it should normally take for one individual to do a

particular job under the particular working conditions in effect. A performance

standard does not set the fastest nor the slowest time in which an operation may be

performedit represents the desirable time required. The conditions under which

work is performed affect the resulting standard.

Such a standard provides a baseline measure against which actual resource usage may

be measured. As a result of computerisation, the details underpinning many workload


511

monitoring systems are hidden from the user who tends to concentrate on the user

interface and reporting capabilities. Prior to the selection of such systems the

purchaser must be satisfied that the formulae and algorithms used, to convert data

entered into the system into workload information, are valid.

Contrary to some statements (Picone et al. 1993, p. 46), it is not necessary to replicate

work measurement studies in individual hospitals, departments or healthcare

facilities. One needs to be satisfied that the time values used by the workload

monitoring system represent valid standards or benchmarks against which individual

performance may be measured. Furthermore the standard time values must be

applicable to the type of work being monitored. It is also necessary to monitor the

systems usage in terms of data collection reliability.

Use of work measurement data for workload

monitoring systems Clinical practice has been quantified in the past primarily for the purpose of arriving

at the number of staff required to care for a stated patient group. When evaluating the

various techniques used to quantify clinical practice through the use of a workload

monitoring system, a distinction needs to be made between the work measurement

techniques themselves and the methods employed in applying these techniques to

represent workload. Invariably methods of application have become extraordinarily

complex making it difficult, if not impossible, to evaluate validity. One of the main

difficulties encountered is the conversion of work measurement data into a staffing

formula relative to identifiable groups of patients. Frequently the use of professional

judgements cloud the use of empirical data. The method of data collection ultimately

determines the degree of accuracy of the source data. Hence it is as important to

examine this as it is to examine the work measurement technique itself. Only from a

close examination of the application of the method adopted is meaning provided to

the results stated.

Gault (1982, p. 62) found this when critically examining the derivation of the

Aberdeen Formula, a product of Scottish Home and Health Department studies

conducted during the 1960s and which aimed to determine nursing establishments.

On the basis of his findings one needs to examine any clinical workload measurement

system regarding the following:

Identification of the patient dependency criteria (work units) used, is it subjective,

objective, reliable?

Technical accuracy of the analysis of the data upon which the staffing formula is

based.

Suitability and validity of the methodology used to quantify the work.

The philosophical basis and purpose of the study which underpins the workload

measurement system.

The formula used to convert work measurement data to represent workload data.


512

Many of the reported nursing studies were limited to one hospital only. This then

limits the applicability of results obtained to other hospitals as these may not be

representative of the norm. Available resources during any study constitute a very

significant variable influencing the final time value per work unit. Given that it is

well known that currently resources in Australia are inequitably distributed between

hospitals, the use of data obtained from one hospital only, is a valid concern.

Another limitation is the difficulty in defining the boundaries of the domain of any

type of clinical work due to the variations known to exist between health services.

Yet when evaluating if a workload measurement method adequately reflects human

resource usage and costs, one needs to be able to establish if the universe of the type

of work measured is accounted for. That is, does it include all the work performed by

a given staff category or only components thereof.

For example some nursing workload measurement systems use time values which

reflect patient/nurse interaction (direct care) only. As this component of hospital

nursing work takes up less than 50% of all nursing time (Hovenga 1990, 1995, 1996)

one needs to ask how the remainder of nursing work is quantified. One needs to

establish whether the identified nursing resource usage reflects the nursing services

needed and whether the predicted nursing service requirements, on which actual

nursing resource usage is commonly based, were services actually provided. Finally

in terms of costs one needs to establish whether the costs identified reflect standard

costs, that is standard time values multiplied by an hourly rate, or actual costs where

total costs were distributed on a relative basis. This continues to be a topical issue.

Duffield Roche and Merrick (2006) have recently undertaken a critical review of the

methods applied to measure Australian nursing wotkloads. They explored the

strengths and limitations of each approach in terms of their reliability and utility.

There is a strong relationship between nurse staffing levels and safety outcomes.

Workload validity To a large extent, the selection and application of work measurement techniques

determine the validity of any workload monitoring system. Validity of any workload

monitoring system is as much a function of the system itself as its usage or

application. The validity of using either activity based workload measures or patient

classification models to reflect degree of patient dependency and human resource

usage is dependent upon the following:

accuracy of work measurement and time values used, i.e. source data

the ability for the model or system to represent all work

consistency of data collection in accordance with the model or system

requirements

categories of staff included in the time values used by the model or system are

identical to the actual staff hours with which workload comparisons are made

ability of the classification model to consistently discriminate between the

categories on the basis of resource usage (validity)

the ability of the model to represent the norm and thus be used as a valid proxy of

actual resource usage.

The key question when evaluating individual studies or workload monitoring systems

is whether the underlying work measurement technique chosen was the most


513

appropriate for the purpose. Standard time values are either applied to individual

activities, to defined units of work or to output measures. Secondly validity, in terms

of how well do the resultant time values reflect actual human resource usage, must be

demonstrable. The degree of accuracy achieved must be acceptable to the purpose for

which the resultant information is used. Estimates and self reported source data lack

the precision achievable when the most appropriate work measurement techniques is

used are qualified work study officers. The measurement of work refers to the process

adopted to translate reality into numbers.

According to Knapp (1985, p.189) any measurement involves three concepts, the

construct C; the true score on the variable, T (work); and the obtained score on that

variable, X. Validity issues arise when the fit between the construct and the true score

is studied. Reliability issues arise when the fit between the true score and the

obtained score is studied.

For example:

C = time required by a qualified worker to perform the work

(the standard = validity),

T = actual time used to perform the work, mean of a representative sample

(reliability),

X = measured time, a measure of time used in one setting over a specified period.

Although most studies aim to quantify or measure actual human resource usage (T),

this value is commonly expressed as the staff time required (C). Thus it is assumed

that the actual time measured was appropriate and adequate to meet the objectives of

the provision of services measured and that these values have a predictive quality.

When these time values are later used as a basis for costing services, it is further

assumed that patients/clients did actually receive the services identified as required to

produce the desired outcomes.

Patient Assessment and Information System The Patient Assessment and Information System (PAIS) was first developed in 1981

and continues to be used extensively throughout Australia. PAIS consists of two

components; work measurement and patient classification methodology. Work

measurement techniques were used to develop and test the patient classification

model and to assign time values to the dependency categories. The patient

classification model was developed using work-sampling methodology.

The PAIS model was tested using different patient populations. The use of work

measurement methodology permitted detailed comparisons to be made between

patient populations. The original medical/surgical data were compared to data

collected from studies involving obstetrics/gynaecology, midwifery, and paediatrics.

The research design for the development of PAIS consisted of collecting random

samples of naturally occurring nursing work events. The study was designed to

provide information on nursing resource usage including nursing work, patient

characteristics and ward staffing levels.

The following reading by Hovenga is an overview of the development of PAIS.


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Reading 53 Hovenga 1994

Four preliminary pages plus pp. 144

Time study Various timing devices may be used depending on the nature of the job being studied

and the precision required. These include various types of stopwatches, electronic

timers and cameras. Time study may be conducted by reading the stopwatch

intermittently, referred to as the snapback method, or continuously. Either way

predetermined elements of work are identified and related to time. Such elements

usually require only a minute or less to perform. The time study method is most

suited to those jobs which are repetitive in nature and which are required to be

performed according to a clearly definable method. Time study is task-oriented and

should only be conducted by people trained in work study. The time study and

predetermined time standards methods may effectively be applied to those elements

of work for which procedures and methods of performance are clearly defined. These

methods are appropriate when individual procedures are being evaluated in

conjunction with method study for the purpose of improving efficiency and the

establishment of time standards. It is most suited to production line type of activities

such as in the central sterilising department, or other work which has clearly defined

procedures such as cleaning, and which may be broken down into small components

of work.

Time study was originally applied to direct work where the work was performed in

one location. It was used in an era when jobs were narrowly specialised and

repetitious. During the 1930s, the emphasis was on maximising throughput per time

unit and the use of available resources. Each workers job generally consisted of one

particular task and was most suited to a less educated workforce. Todays nursing

practice does not relate to such a description of work. It is probably more in line with

other industries where since the 1960s and 1970s the emphasis has been on designing

jobs which have greater variety. In particular the aim has been:

to improve employee job satisfaction and work involvement

to raise productivity and improve quality

to improve efficiency by reducing costs associated with symptoms of

dissatisfaction, such as high levels of turnover, waste, delays and accidents

to use new technology as a means of increasing rather than decreasing work

satisfaction (Dunphy 1981, p. 162).

Time study may be used for non-repetitive work. In such instances the work needs to

be carefully analysed noting in particular the variable components of the work.

Non-repetitive work also has longer cycles.

The work of any health professional can be described this way. When time study is

applied to this type of work, problems arise regarding the attainment of a

representative distribution of the procedures studied, documenting the precise method

used, estimating the degree of accuracy, relating the time values to output and in

arriving at a representative sample of the work components studied.


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Individual clinical activities vary considerably in terms of the time required to

perform them. For example, wound care activities can range from one minute to

several hours. This broad range is true for most commonly performed clinical

activities. The time required to perform individual activities is influenced by the

reason for hospitalisation, the severity of illness of, and total degree of dependency on

nursing services by the patient, as well as the skill and performance of the clinician

and the time available.

Hodson (1971) notes that because of the variable sequence of the work elements

which make up any one activity or cycle of work, and the variables that may exist

within a given work element, it is essential to rely heavily on the standard data and

the building block concept of work measurement to time non-repetitive work. Either

time study or predetermined motion times can be used for this purpose. The only

nursing study found by the author to adopt this approach when using time study as the

work measurement technique was de Zwart (1991) who was commissioned by the

Health Department of Western Australia to conduct a nurse staffing study in that

State.

The definition of work measurement requires that only qualified workers are studied

and that the work is performed according to a specified method. This implies that

time study is not suitable to measure work where the methods employed are likely to

vary according to the situation within which the work takes place, unless only basic

work elements are studied as opposed to a total procedure. Recognised work study

texts stress that any one time should refer to one specified method (ILO 1978;

Maynard 1971; Barnes 1980; Currie 1977). A method of performing work or

elements of work, may be defined in infinite detail as seemingly minor differences

may impinge on the effort required to perform the work.

The timing device chosen for the job needs to match the purpose of the study, the

nature of the work being studied and the degree of accuracy desired. Short and/or

highly repetitive cycles of work requires either a decimal hour stopwatch or a camera.

These instruments are also required when it is necessary to time many short elements

of work making up a particular task. Each work element consists of a sequence of

basic human motions.

Cameras are more accurate as timing devices, as a permanent record is created,

permitting the observer to stop the action at required intervals in order to document

what is being observed. Direct observation using a stopwatch, together with rating,

can lead to inconsistencies and non-acceptance by workers of the standard times thus

developed.

It is necessary to conduct many individual time studies of the same task performed by

a large variety of qualified workers in order to ensure that the study is representative

of normal conditions and that a normal distribution of occurrence was in fact

measured. There are many variables which influence the number of observations

required. They include the length of the work cycle, number of repetitive elements in

each work cycle, skill of the worker, variations in method and the number of

interruptions. Barnes (1980, p. 273) provides the mathematical methods of

determining the number of observations required to determine time values at a

desired level of confidence. These are based on the following formula:


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XN

=

where X = standard deviation of the distribution of averages

= standard deviation of the universe for a given element

N = actual number of observations of the element.

Time study applied to nursing None of the nursing work research studies reported in the literature referred to the use

of any mathematical formula to calculate the number of time study observations

required to achieve the desired degree of accuracy relative to the work under study.

In 1928 Rottman, Director, Nursing Service, Bellevue and Alfred Hospitals (USA)

reported that the best study undertaken was that by Margaret Tracey who has been

able to present a chart outlining the average time required per treatment in minutes,

for 21 procedures common to surgical patients (cited by Aydelotte 1973, p. 8),

others followed; Edgecombe (1965); DesOrmeaux (1977); CSF Australasia (1975,

1986, 1990); Clark and Diggs (1971); Meyer (1978); Bendigo Home and Hospital for

the Aged (1981); Anderson (1983); Sherrod (1984); Overfelt and Ballash (1982);

Sawyer et al. (1986). In respect to time study, Aydelotte (1973, p. 29) concluded that:

an individual must be very attentive as he (she) reads reports since the operational

definitions used for categorising activities differ from one study to another. The

differences in category descriptions make comparisons either impossible or highly

questionable.

The use of standard times and their applicability to individual institutions and

individual units were questioned by Murphy et al. (1986, p. 86) as even within the

same hospital there may be considerable variance in the manner and thus the time in

which the same activity is performed in different units. Furthermore Kuhn (1980,

p. 6) asserts that standard times for procedures are not appropriate since the amount

of nursing fluctuates according to patient differences. In other words the use of time

study was not considered appropriate for nursing due to the variable nature of nursing

work. This issue has been addressed by the Trendcare system where users are

required to verify times used by the system. It is achieved through the use of patient

types and the measurement of activities via a stop watch relative to those patients.

It is considered difficult if not impossible to document and consistently use precisely

the point where each nursing activity begins and where it ends for time study

purposes. Methods used to perform individual nursing activities are rarely identical.

This work measurement method requires activities to be broken down into definite

and measurable elements and (to) describe each of these separately (Barnes 1980,

p. 269). McHugh and Dwyer (1992, p. 24) noted that this is a time consuming and

expensive method. They went on to say that original standard time measures should

be validated when these standard time values are used by another hospital. The

reasons given were the use of different types of equipment, methods and experience

levels of nurse which may alter the values of standard task performance times.

The continuous time study observation method goes some way towards overcoming

some of the difficulties identified previously. This method permits the measurement

of all nursing work performed by at least one nurse and records the sequence in

which elements of work take place. To measure all the work generated by all patients


517

in a ward would require continuous observation of all staff performing the work. This

method was also rejected for the empirical work reported in this thesis as it was

perceived to be too costly, intrusive, unpopular with staff and likely to influence the

results through a Hawthorn effect. The total cost is a function of the purpose of the

study and the subsequent sample size required. Abernethy et al. (1988) used

continuous observations to test the degree of accuracy of self-reported data. This is

discussed in Section 3.2.

In summary, the difficulties associated with using time study or continuous

observations to measure nursing services include:

Issues of definitionat what point does an activity start or finish?

Representativenessdo the number of activities included in the measured sample

represent the norm? Were they randomly selected? Are there differences between

patient populations?

The universe of nursingdo the sum of the activities equal the universe of

nursing services?

Issues of numerositywhich activities or parts thereof, should be measured? For

example bedmaking consists of many individual activities and combinations

thereof; similarly wound care or activities associated with hygiene, mobility etc.

To what detail should nursing practice be analysed and measured?

Estimating the degree of accuracy.

Relating the time values to output.

Predetermined time standards As a result of breaking down jobs into elements of work for the purpose of time

study, it became apparent that many seemingly different jobs contained common

elements of work at the lowest level of analysis. Clinical work is no exception. Once

those elements had been studied many times over, standard time values were readily

available for those work elements. Therefore once a job was analysed and broken

down into work elements these standard time values could be applied, avoiding the

necessity of further time studies. Various predetermined time systems are now in use.

They vary in the level and scope of application of data, motion classification and in

time units used. A predetermined time standard is defined as a work measurement

technique whereby times established for basic human motions (classified according

to the nature of the motion and the conditions under which it is made) are used to

build up the time for a job at a defined level of performance (ILO 1978, p. 313). The

method has been used to measure some nursing work (CSF 1986).

The application of predetermined time standards requires detailed job analysis. This

documents individual basic motions used to perform human work, such as move an

object or walk from A to B or grasp an item, and includes noting the conditions

surrounding the movement of a limb or limbs. Variables noted are such things as the

distance moved, the weight moved, the control required and whether the motion

begins and ends with the hand at rest. Once a job is analysed and broken down into

the work elements corresponding with the system to be used, the appropriate standard

time values may be applied. This avoids the need for further time studies.

The use of predetermined time standards has the advantage of consistency as the time

standards are well researched and represent the norm in terms of time required by a


518

qualified worker to perform these basic elements of work. It may be applied during

the job design stage permitting changes to layout and design of the workplace to

achieve optimum production with minimum worker effort. Their use also makes it

possible to estimate costs when evaluating alternative methods of work. It is often

less time consuming and hence less costly to apply when compared with other work

measurement techniques. The use of predetermined time standards does involve a

considerable amount of calculation. The use of computer technology reduces the time

required to use this method of work measurement.

Historically, Gilbreths ideas on the basic human motions, he called Therbligs,

sowed the seeds for a predetermined time standards system. Segur, around 1927,

realised that all human work is made up of Therbligs and put forward the idea that

the time required for a qualified worker to perform these basic human motions would

be constant (Currie 1977, p. 192). Since then various systems were developed

including the methods-time measurement system (MTM). Maynard et al. (1971),

the originators of MTM during the 1940s, noted that the main cause for wide

variations in work performance, was the method employed. As various methods were

employed to perform the same or similar tasks, they set out to time common elements

of work. A special synchronous cine-camera was used to perform the extensive time

studies relative to basic motions of work, from which the MTM system was

developed. The classification of work elements used by MTM and associated with a

TMU value, consisted of 300 separate values and a further 200 or so could be

determined by interpolation.

Later generations of MTM reduced this number considerably. A simplified version

derived by Imperial Chemical Industries has 97 time values (Currie 1977). The Serge

Birn Company developed the master standard data (MSD) system by averaging,

eliminating, and combining MTM elements which resulted in 49 categories

(Anonymous 1980). Other systems such as the modular arrangement of

predetermined time standards (MODAPTS) do not require as much detail (Heyde

1966). MODAPTS has only 21 elements, although different combinations of

activities enable an enormous variety of tasks to be documented. This system has

incorporated the results of extensive research into valid physiological recovery time

required when the work is physically heavy. Notwithstanding the loss of detail,

MODAPTS is applicable for widespread general use and has modules for special

applications such as office and transit modapts. The latter was first published in

1974 and is suitable for studying work performed in warehouses and other places

where physical distribution occurs. It is possible to develop a nursing modapts

module.

To appreciate the level of precision used by each system one needs to consider that

MTM uses TMUs as its time measurement unit where each TMU is equivalent to

.036 second (Barnes 1980, p. 376). MODAPTS uses MODs where one MOD is

equivalent to .129 second for normal time and .143 second for allowed time. The

latter includes an allowance of 10.75% for physiological recovery (Heyde 1966). As

the number of categories with associated time values decreases, degrees of precision

are lost. It now has software to support its use. You can learn more about MODAPTs

by visiting their website at http://www.modapts.com/

The use of predetermined time standards has the advantage of consistency as the time

standards are well researched and represent the normal distribution of time required

by a qualified worker to perform elements of work. It may be applied during the job

design stage permitting changes to layout and design of the workplace to achieve

optimum production with minimum worker effort. Their use also makes it possible to


519

estimate costs when evaluating alternative methods of work and for budgeting or

tendering purposes. It is often less time consuming and hence less costly to apply

when compared with other work measurement techniques.

Work sampling Work sampling is a work measurement technique usually applied to groups of people

or machines. It was first used by Tippett in the British textile industry in 1934 and has

increasingly been applied to areas not previously measured (Barnes 1980). Work

sampling, also referred to as work measurement sampling, requires an observer to

record the actual work being done at the moment of observation. Work sampling

consists of a large number of observations (N) taken at fixed or random intervals.

Prior to taking these observations the work situation is noted and the purpose of the

study identified. Then, predefined categories of activity pertinent to the work

situation and purpose of the study are incorporated into a classification system unique

for each study. This permits observations to be made relative to these predefined

activities which collectively make up the universe of work performed in the area

under study. Work observations may be recorded relative to any number of variables

depending on the purpose of the study, and the questions to be answered. For

example, defined nursing activities may be recorded relative to the patient for whom

they are performed or relative to the category of staff performing each activity.

From the proportions of observations (p) made regarding each activity, inferences are

drawn concerning the total work under study. These proportions are referred to as

percentages of occurrence and are derived by expressing the number of observations

(n) made per activity measured, as a percentage (p) of the total number of

observations (N) made during the study.

The frequency of observation rounds depends upon local circumstances. The number

of observations to be made will depend upon the purpose of the analysis and the

degree of accuracy required for the activity being studied (Brisley 1971). When

measuring ward work, observations may be made of all nursing and other staff

allocated to that ward on every round, or by observing a randomly selected staff

member every two minutes (or at some other time interval) or by observing patients

for direct patient/nurse interaction for any chosen period of time.

According to Brisley (1971, pp. 347) work sampling works because a smaller

number of chance occurrences tends to follow the same distribution pattern that a

larger number produces. This sampling technique does not assume that the

momentary observation is continued throughout the intervening observation interval.

It is based on the fact that the number of times an activity is observed being

performed is closely correlated with the total time spent on its performance (Manual

of the USDHEW 1964 cited by Kuhn 1980, p. 13). For example if an activity is

observed 10 times out of a total of 100 observations then it is assumed that the

activity consumed 10% of the total time made available during that observation

period. The 10% denotes the percentage of occurrence (p) of all observations (N)

made. A sample taken at random, such as nursing work relative to a defined patient

population, tends to have the same pattern of distribution as the total patient

population. If the sample is large enough, the characteristics of the sample will differ

little from the characteristics of the group. (Barnes 1980, p. 406).


520

Brisley (1971, pp. 365) referred to one of the first work sampling studies in a

hospital conducted by Marion Wright in 1950 at the Harper Hospital in Detroit,

Michigan. He used it to illustrate some of the shortcomings inherent in the design of

this study. As a result of the Wright study the American Hospital Association became

interested in this methodology. The purpose of the 1950 study was to analyse the

activities of the various categories of staff working in a ward. The staff participated in

analysing the data and used the results to make improvements in their jobs. The result

was that many tasks being handled by higher skilled people were passed on to lower

skilled personnel.

Many of the studies reported in the literature as using self-reporting, continuous

observation or time-study have also used the work sampling method (Overfelt &

Ballash 1982; Bendigo H & H 1981; Edgecombe 1965; Medicus Corp. cited in

Jelinek & Dennis 1976; CSF 1986) mainly to establish distribution and/or frequency

of specific nursing activity occurrence; for example, proportion of direct versus

indirect or as a rough measure to check validity. As most studies do not indicate the

total number of observations or the percentage of occurrence of the activity being

measured, the accuracy of the results cannot be ascertained.

The advantage of using work sampling as a work measurement technique is its ability

to state statistically the degree of accuracy of the results obtained. It is noteworthy,

however, that none of the studies referred to previously noted this fact. Another

advantage of work sampling is its applicability to answer a variety of research

questions regarding the distribution of work relative to what, where, why and by

whom, the work is performed. Intermittent observation is non-intrusive, and sampling

observations may be made by people with no previous work study experience.

Observer bias was found to be negligible by Murphy et al. (1978) who also noted that

observations made at regular fixed intervals achieved the same results as observations

made at random. The latter is due to the variable nature of nursing.

Using work sampling for purposes of work measurement requires that the work

sampling study is related to a defined observation period within which the total actual

hours and the number of units produced are noted. The personnel being sampled are

usually performance rated. The formula for arriving at a standard time value is as

follows:

actual hours % of occurance (p) average performance rating

Standard time=number of units produced

Brisley (1971) notes that in some instances it is difficult to determine what the work

count should be and suggests that this may require some innovative approaches. In

nursing studies the work unit may be a defined as a patient-day. Allowances are

then added as per time values arrived at by the use of time study.

The underlying theory of work sampling is, that the percentage of observations (p) for

any activity provides an estimate of the percentage of time actually spent on that

activity, to a known degree of accuracy. Statistically this theory is based on the laws

of probability and uses Bernoullis theorem, random variable and distribution laws

and the law of large numbers (Barnes 1980; Brisley 1971; von Mises 1981;

Gnedenko and Khinchin 1962; Walpole 1982).

The laws of large numbers require mutually independent random variables. In work

sampling these variables are the observations made per activity under study. Every

activity is mutually exclusive from another. The sum of these mutually independent

random variables divided by the total number is as close to unity as we please


521

(Gnedenko & Khinchin 1962, p. 96). It needs to be understood that each observation

within a data set of observations has the same value, whereas an individual

observation viewed as a proportion of the data set, frequently takes on a value far

removed from its mean. The arithmetic mean of a large number of observations,

viewed as a proportion of the data set expressed as a percentage of occurrence,

behaves differently to the mean of a very small number of observations within the

same data set. The larger percentage of occurrence is a far more accurate estimate of

the actual mean than the small percentage of occurrence.

To make effective use of these random variables there is a need to identify as

precisely as possible their laws of distribution. For example if we want to know the

range of time taken for wound care we would assume that some average range exists.

The difference between the actual and average range may be referred to as the error,

whose magnitude will vary from one action to another. This will depend on a number

of other variables which act independently of one another. The final error represents

the total effect on the time taken to provide wound care. All such errors are

approximately distributed according to normal laws. This law was discovered in the

middle of the last century by Chebyshev, a Russian mathematician.

This knowledge enables the calculation of the number of observations (N) required to

obtain work sampling percent occurrences (p) for a desired relative accuracy to yield

a confidence interval of 95 percent. As both p and S are unknown, the number of

observations (N) required for any study is calculated by using an estimate of the

percentage of occurrence (p) for the event of interest and the desired relative accuracy

(usually 0.05). Values required for the calculation of the standard error of each

activity or event measured, are the corresponding percentage of occurrence (p) and

the total number of observations (N) made. The relationship between these three

variables is such that the smaller the desired standard error and the percentage of

occurrence (p) the greater the number of observations (N) required in the total study.

To ensure that the results obtained can be represented by the 95% confidence interval

it is important that unusual circumstances are avoided during the study period. A

daily control chart may be used for this purpose (Brisley 1971; Barnes 1980). A

formula is used to ascertain the daily limits of error relative to the percentages of

occurrence of interest. It needs to be emphasised that the percentage of error reduces

as the number of observations increase.

An estimate of the number of observations which may be made on any one day

together with the total number of observations required determines the duration and

cost of a work sampling study. The daily number of observations possible is

dependent upon the number of staff to be included in the study and the duration and

frequency of each observation round. In addition the study period should be at least

as long as the longest period of any cyclical behaviour or characteristic being studied.

In the case of nursing this means for all days of the week and at least all day shifts,

desirably every full 24-hour period for seven days. The sampled population (staff and

patients), from which inferences will be drawn, must be similar to and representative

of the population to which the results will be applied (Brisley 1971; Barnes 1980).

Work sampling is very suitable to measuring work with many variable characteristics.

It is therefore an appropriate method to measure all aspects of nursing work. It has

the advantage of permitting the calculation of the degree of accuracy of the results

and of being more cost-effective in terms of study period and sample size required,

from which inferences may be made with a degree of confidence, relative to the

population studied. It is a very useful method to identify possible inefficiencies from


522

which individual aspects of nursing work may be evaluated. Work sampling may be

used in conjunction with normal supervisory duties. Studies may be designed to

answer any number of research questions. Work sampling lends itself more readily to

be related to an output measure as all work is easily included in the measurement.

Work sampling applied to nursing work A number of researchers have used this work-measurement technique exclusively.

(Abdellah & Levine 1954; Hovenga 1983; Scott 1982; Jacobs et al. 1968; Lindsay et

al. 1985; Crowther & Heip 1986; Giovannetti 1983). Howarth (1976) used work

sampling to identify what was being done and by whom, in response to a 1968

standing Nursing Advisory Committee report which had stated that nurses continue to

carry out a wide range of duties that do not require nursing skill. More recently

Hendrickson et al. (1990) used work sampling to determine how nurses distribute

their time. This was also measured as a by-product in the empirical work reported in

Hovengas thesis (1995). The latest work sampling study known to have been

undertaken in Australia was in 1995 for Queensland Health (HOvenga and

Hindmarsh 1996)

Contrary to popular belief, the work-sampling methodology does in fact include the

measurement of sophisticated cognitive processes used by nurses during the course of

their working day. It does this by accounting for all time spent by nurses caring for

patients. As such cognitive processes are not usually readily observable as a separate

activity, they are not listed in the work measurement taxonomy used for the PAIS

studies. These cognitive processes tend to occur concurrently with observable

activities although the latter then usually take longer to perform than when these

same activities are performed in the absence of such cognitive processes. The only

time both observable and cognitive activities are truly concurrent is when the

observable activity is a routine one performed by an expert, such as bedmaking.

Other researchers who have used work sampling in hospitals were Boyd (1982);

National Association of Childrens Hospitals & REI Institute (1978); Norby et al.

(1977); Lindsay et al. (1985); Giovannetti (1973); Kuhn (1980). Kuhn (1980) used

activity sampling, measuring both direct and indirect nursing activity concurrently at

15-minute intervals for eight hours per day only. Both direct and indirect activity

observations were assigned to the patient for whom they were performed. Indirect

activities which could not be assigned to a specific patient were assumed to relate

equally to all patients. These latter nursing activities consumed between 46% and

51% of all nursing time. The original PAIS study (refer Chapter 7) reported that all

nursing time was distributed between direct (with patients) 34.2%, indirect 45.3%

and non-productive (including meal breaks) 20.4%. A more recent US

work-sampling study (Hendrickson et al. 1990) reported that nurses spent an average

of 31% of their time with patients. It is this direct interactive time which is

distributed between all patients on the basis of need (nurse dependency).

Although most of the work-sampling studies cited did identify the proportion of

nursing time used for direct, indirect and non-patient related activities, few studies

concurrently related the sampling observations of direct care activities to individual

patients as was done in this study (Hovenga 1983). A choice needs to be made

between observations attributing to individual activities and staff category or

individual patients. It is possible, although difficult, to capture all three. During the

trial for the original data collection for PAIS, different colours were used to denote

each staff category to create a three dimensional data collection method. It was found


523

that, practically, this proved to be fraught with inaccuracies due to the resultant

complex nature of data collection.

Lindsay et al. (1985) chose the work-sampling/work-measurement technique as it

was considered by far the best technique to collect the required information for the

following reasons:

1. All staff and patients could be observed together with the minimum disruption to

their daily routine.

2. That the intensity of the activity sample planned would make the data collected

as accurate as that collected using any other technique.

3. Not only would the information collected using activity sampling give a good

overview of the daily routines in the wards, but could also be analysed in such a

way as to create a base of standard data, on which it would be possible to build

the proposed dependency system.

4. No other technique would allow for a comprehensive survey to be completed

with only one weeks observations in each ward.

Self reporting Another method popular in health service organisations is the self recording or

logging method. This requires each worker to record how much time is actually spent

on various activities. Much debate continues regarding the accuracy of this type of

data. It is favoured because it is thought to be a low cost method and is said to be

accepted by the workers themselves due to their participation. However it is open to

manipulation, distortions, omissions and gross inaccuracy. Much depends on the

commitment by the staff involved in the study and the controls that are in place

during data collection. It is not a recognised work-measurement technique as it lacks

precision in measurement terms, but may be useful for some purposes.

Time and work measurement Quantifying workload, which involves the measurement of human resource usage, is

a prerequisite to cost accounting. This in turn forms the basis for the measurement of

performance regarding departmental efficiency. Thus it is an important component in

being able to control costs.

To a large extent, the purpose for which the workload is to be measured determines

what is to be measured. Defining what is to be measured is also associated with how

the organisation has divided the work and responsibilities. Quantifying the workload

should assist individual departmental managers in allocating their human resources.

The aim is to match resource availability with workload generated. Where the

number of staff exceed the number required to perform the work, then there is an

unnecessary cost to the organisation. On the other hand if there is insufficient staff

then there is a cost to individual employees and the service may be compromised.

That is the quality of the work may not conform to standard practice. Staffing levels

need to be such that individual staff members are able to perform the work, in

accordance with quality requirements, within the specified time.


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Work measurement implies the ability to express human work quantitatively, in terms

of a common unit which assumes that a quality standard is consistently achieved. The

common unit used is that of time expressed as day, hour, minute or second. This is

achieved by defining work relative to fixed units of time. Various techniques may be

employed to define work this way as were discussed in the previous chapter. It

requires the work content of any job to be related to its most suitable characteristic or

unit of work. In healthcare these are the services provided to produce the desired

outcome per patient/client per day.

Work measurement is defined by the British Standards Institution as; The

application of techniques designed to establish the time for a qualified worker to

carry out a specified job at a defined level of performance (ILO 1979). Work

performed by health professionals includes creativity and decision making. These

activities are not directly observable, hence do not lend themselves to being

measured. Yet sufficient time needs to be allocated to allow for these activities.

The objectives of work measurement are to improve overall efficiency and

effectiveness of the workforce. Work measurement data provide a reliable reference

for use in calculating staff requirements for current and projected workload and for

scheduling and controlling work and staff. These data are also widely used in

standard cost accounting systems and for budget formulation. It contributes to the

organisations statistics regarding human resource usage and utilisation relative to

overall performance and utilisation of services.

Principles of work study Work measurement evolved as a consequence of applying the basic questioning

approach of what, how, where and when to any human work. The purpose was

usually to find a better way of performing the work to either increase production

within a given time span or, to reduce the effort required in the performance of the

work or, to improve the quality or utility of the work. The use of work measurement

in conjunction with productivity has been recorded throughout the ages by such

notables as Leonardo Da Vinci, Babbage, Boulton, Watt and Sons to name a few

(Currie 1977). Adam Smith (1776 in Hicks 1977) was the first to use the concept of

designing a work process to efficiently use the available workforce by introducing

specialisation of labour. The improved productivity was expressed in terms of how

many pins could be produced by one worker per day. Taylor (Hicks 1977) is better

known than Smith for his contribution to the science of work study, encompassing

both work design or methods study and work measurement. Other contributors to the

science of work study were the Gilbreths who first applied motion study to find the

best way of doing a job (Currie 1977). Thus from the industrial engineering

perspective, work measurement should not be viewed in isolation. It is intricately

linked with all facets of resource usage influencing productivity. Contemporary Work

Study as a science draws on numerous concepts within disciplines such as economics,

engineering, ergonomics, behavioural sciences, computer science, statistics and

management science.

Work measurement has traditionally been applied in industry to identify the amount

of ineffective time used to perform the work being studied in order to improve

efficiency. This requires the work to be broken down into elements of work, so that

the work content may be examined in some detail. Work measurement is either

preceded by, or followed by, method study to reveal shortcomings of design, tools,


525

procedures, work organisation, flow of production processes or delays, and to find

ways of overcoming such inefficiencies, most of which are outside the control of

individual workers. These need to be considered when individual performance is

being evaluated. Following the introduction of improved methods, work

measurement is again applied, this time for the purpose of setting standard times and

to document the impact of new methods. This includes costing previous and new

methods for comparative purposes.

The effectiveness of the time values arrived at is dependent upon whether the right

technique was used for the type of work measured and the purpose or desired use of

the data. Analysing work is a valuable exercise in determining areas for productivity

improvement, such as deficiencies in the system, equipment or work methods. Most

activities are measurable, although for some the cost may be too high compared with

the potential benefits. One needs to select work which is highly labour intensive and

of a large enough volume to make work measurement profitable. One could use the

overall cost or percentage of the total cost as a criteria for deciding which activities

should be measured and which are better estimated. For example if a service

consumes less than 1% of the allocated resources then improved precision in work

measurement is unlikely to provide significantly greater benefits compared with a

more pragmatic approach.

Generally speaking work which requires a high degree of creativity and decision

making is very difficult to measure. In health services one must also consider the

stand-by component. That is, resources allocated may be there for reasons other than

the services needed as measured by volume. For example for safety or security

purposes.

Use of self-recording to analyse work

performed The self-recording method is not a work measurement technique. It is essentially a

method used for job or position analysis and requires workers to record, either

continuously or intermittently, how they spend their time. This may include self

timing of individual activities. Alternatively it may require the listing of activities

performed during any one time period and the documentation of the frequency of

occurrence of such activities. When recorded intermittently, the data are the result of

a self-recorded sample as distinct from a continuous log. There are a variety of

methods by which self reported data pertaining to work may be captured. Each is

specific to the purpose of the study.

Self-reporting studies applied to nursing In the development of methods for determining use and effectiveness of nursing

service personnel, the San Joaquin General Hospital study teams major thrust was

the testing out of data collection tools and procedures for use in a nurse staffing

methodology (Murphy, Williams & McAthie 1976, p. 40). Self recording was

compared with observer recording of nursing activities. The observer recording

method resulted in 31% more activities being recorded during the same study period.

It was concluded that unless there was exceptional personnel commitment to

accurate data collection, self-recording as a method should be seriously questioned.


526

Because of the error rate in self-recording, the results obtained through the use of the

method were considered as suggestive only. Other reports in the literature, about the

inaccuracy of, or problems associated with this method also exist (Williams 1977;

Grimaldi & Michelleti 1982). Sovie et al. (1984) set out to overcome the reporting

problems by requiring each nurse to total all time recorded in each category to reach

a grand total time in minutes for each shift. This was compared against the actual

minutes worked. Sovies method only demonstrated that all nursing time was

accounted for and did not test the reliability or validity of what was actually recorded.

Abernethy et al. (1988) in an Australian nurse costing study, decided to capture data

for two mutually exclusive categories only, to overcome definitional problems. These

were patient-related nursing activities and non-patient-related activities. The time

was estimated by nurses themselves on a relative basis once per shift. Degree of

accuracy of the data thus captured was tested by continuously observing one nurse

per shift for 40 shifts. There was a strong correlation between nurse and observer

time (r = .83, p


527

Summary This chapter included a detailed description of the processes involved in work study,

work measurement and work sampling. The most important point to take away from

this chapter is the value and importance of operations research, including work study

in performance measurement in health care and as a method to undertake extensive

and in depth studies of work practices, work and information flows. Such studies are

required to analyse and document system requirements which in turn may be used to

evaluate the applicability of proposed information systems implementation. The next

chapter will provide more information on the applications of work measurement

including patient assessment, staffing and costing, and individual performance

evaluation.

Activity 51

Describe how you would design an operations research or work study experiment in

your organisation or individual department with the aim of improving performance.

Include the rationale and methodology (using the five step method) listing what data

elements you would include and how you might record the data.

References Abdellah, F.G. & Levine, E. 1954, Work sampling applied to the study of nursing

personnel, Nursing Research, vol. 3, no. 1, pp. 916.

Abernethy, M.A. & Stoelwinder, J.U. 1987, Development of a model for costing

nursing wards in public hospitals, Internal progress report on pilot study, Monash

Medical Centre.

Ackoff, R.L. & Rivett, P. 1963, A Managers Guide to Operations Research, John

Wiley & Sons, New York.

Anderson, C.A. 1971, Performance rating, in Industrial Engineering Handbook,

3rd edn, W.B. Maynard, McGrawHill, New York.

Anderson, J. 1983, Design and evaluation of a patient dependency tool at the Royal

Melbourne Hospital, unpublished paper.

Anderson, R.G. 1973, Organization and Methods, Macdonald & Evans, London.

Anonymous 1980, Lecture no

work study and measurement

Documents

nursing work

work sampling

principles of work study

work methods

work measurement data

work measurement techniques

time study

method study