Professional Documents
Culture Documents
Work Study and Measurement
Work Study and Measurement
Work Study and Measurement
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
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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
analyse how changes to work practices may impact on the outcomes (quality and
performance) of health service delivery.
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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?
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55
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
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
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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
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:
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
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
58
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
59
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
510
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.
Technical accuracy of the analysis of the data upon which the staffing formula is
based.
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.
511
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
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
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
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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.
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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:
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.
514
515
X =
where
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
516
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:
The universe of nursingdo the sum of the activities equal the universe of
nursing services?
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
518
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).
519
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:
Standard time=
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
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(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
521
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.
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.
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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.
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<.001). These results did lead to the implementation of some
improvements into the major study. Notwithstanding these results are probably better
than the actual accuracy due to a Hawthorn effect created by continuous
observations, i.e. the act of observing tends to positively influence the results. Also of
concern in this study was the amount of missing data resulting from non-compliance.
This meant that data for individual patients throughout their length of stay was rarely
complete. However the researchers argue that as these are random occurrences the
remaining data are representative (personal communication with Abernethy 1987).
Professional judgements/estimates
Reaching agreement regarding notional times or relative values between defined units
of work is referred to as using professional judgement. Professional judgements may
also be used to estimate the frequency of occurrence of certain work activities. It is
not a work-measurement technique.
An example where these methods were used to quantify nursing work is the
development of the Resident Classification Instrument (RCI) (Commonwealth/State
Working Party report 1988). It also plays a major part in the development of
departmental service weights (relative value units), which express relative resource
usage or costliness of defined work units, used in conjunction with both clinical
costing and cost modelling systems. Service weights are explained elsewhere.
Skill mix
So far only the quantity of human resources, in terms of total hours required to
perform the work, has been examined. Another factor to be considered is the quality
of the human resources, which is usually referred to as skill mix. There are many
different types of healthcare workers. Even within each category of worker there are
various levels based on formal qualifications plus years and type of experience.
Providing the right number of staff hours for the work to be performed, does not
necessarily mean that the desired outcomes are achieved. One may achieve
performance efficiency but not performance effectiveness.
526
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 notes, Footscray Technical College, Industry Service
Department, Victoria.
Antis, W. 1971, Stopwatch time study, in Industrial Engineering Handbook,
3rd edn, W.B. Maynard, McGraw-Hill, New York.
Aydelotte, M. 1973, Nurse Staffing Methodology: A Review and Critique of Selected
Literature, USDHEW pub. no. (NIH) 73433, Washington DC Government Printing
Office.
527
Bardossy, A., Bogardi, I. & Duckstein, L. 1993, Fuzzy nonlinear regression analysis
of dose-response relationships, European Journal of Operational Research, vol. 66,
no. 1, pp. 3651.
Barnard, C. & Esmond, T. 1981, DRG based reimbursement: The use of concurrent
and retrospective clinical data, Medical Care, vol. 19, no. 11, pp. 10711082.
Barnes, R.M. 1980, Motion and Time Study Design and Measurement of Work,
7th edn, John Wiley and Sons, NY.
Bendigo Home & Hospital for the Aged 1981, Patient-nurse Dependency, Report of
study undertaken, Bendigo, Victoria.
Berg, M. 1999, Patient care information systems and health care work: a
sociotechnical approach, International Journal of Medical Informatics, vol. 55,
no. 2, pp. 87101.
Boyd, J. 1982, Prediction of staff to acuity: A confirmation of nursing judgement, in
Nurse Staffing Based on Patient Classification, AHA, Chicago.
Brennan, J.E., Golden, B.L. & Rappoport, H.K. 1992, Go with the flow: Improving
Red Cross bloodmobiles using simulation analysis, Interfaces, vol. 22, no. 5,
pp. 113.
Brisley, C.L. 1971, Work sampling, in Industrial Engineering Handbook, 3rd edn,
H.B. Maynard, McGrawHill, New York.
Butler, T.W. 1995, Management science/operations research projects in health care:
The administrators perspective, Health Care Management Review, vol. 20, no. 1,
p. 19.
Butler, T.W., Kawan, K.R., Sweigart, J.R. & Reeves, G.R. 1992, An integrative
model-based approach to hospital layout, IEE Transactions, vol. 24, no. 2,
pp. 144152.
Clark, E.L. & Diggs, W.W. 1971, Quantifying patient needs, Hospitals JAHA,
vol. 45, pp. 96100.
Community Systems Foundation (Australasia) 1975, Hospital Work Measurement.
Crowther, L. & Help, A. 1986, Report Royal Park Hospital - PAIS psychiatric model,
unpublished report.
Currie, R.M. 1977, Work Study, 4th edn, Pitman, London.
Datta, S. & Bandyopadhyay, R. 1993, An application of O.R. in micro-level
planning in India, Computers & Operations Research, vol. 20, no. 2.
Davies, R. 1994, Simulation for planning services for patients with coronary artery
disease, European Journal of Operational Research, vol. 72, no. 2, pp. 323332.
DesOrmeaux, S.P. 1977, Implementation of the CASH patient classification system
for staffing determination, Supervisor Nurse, April.
de Zwart, J. 1991, Nurse Staffing Methodology, Health Department of Western
Australia, Perth.
Duffield C, Roche M, Merrick E.T 2006 Methods of measuring nursing workload in
Australia. Collegian Vol.13 No. 1 pp16-22
Dunphy, D.C. 1981, Organizational Change by Choice, McGraw-Hill Book Co.,
Sydney.
528
Jacobs, S.E., Patchin, N. & Anderson, G.L. 1968, Nursing Activity Study Project
Report, American Hospital Association, Chicago, Illinois.
Jelinek, R.C. & Dennis, L.C. 1976, A Review and Evaluation of Nursing Productivity,
DHEW pub. no. (HRA) 7715
Kramer, R.N. & Douglas, J.V. 1999, Planning for performance, in: Performance
Improvement Through Information Management, M.J. Ball & J.V. Douglas (eds),
Springer-Verlag, New York.
Kuhn, B.G. 1980a, Prediction of nursing requirements from patient characteristics
part 1, International Journal of Nursing Studies, vol. 17.
Kuhn, B.G. 1980b, Prediction of nursing requirements from patient characteristics
part 1, International Journal of Nursing Studies, vol. 17.
Lapsley, H.M. 1981, Hospital efficency, Australian Health Review, vol. 4, no. 3.
Laufer, A.C. 1984, Production and Operations Management, 3rd edn, South-Western
Publishing Co., Cincinnati.
Lindsay, J.N., Gillman, R.D. & Melrose, A.M. 1985, The Development of a Nursing
Dependency System Using Computerised Standard Data, The Resource Management
Services Unit, Canterbury Hospital Board.
Lindsay, N., Gillman, R., Melrose, A. & Kurta, G. 1987, Nursing dependency system
using computerised standard data, New Zealand Health Review, vol. 7, no. 2.
Maynard, H.B. (ed.) 1971, Industrial Engineering Handbook, 3rd edn, McGraw-Hill,
New York.
McHugh, M.L. & Dwyer, V.L. 1992, Measurement issues in patient acuity
classification for prediction of hours in nursing care, Nursing Administration
Quarterly, vol. 16, no. 4.
Meyer, D. 1978, GRASP - A Patient Information and Workload Management System,
MCS, Morganton, NC.
Murphy, L.N., Williams, M.A. & McAtchie, M. 1976, Development of Methods for
Determining Use and Effectiveness of Nursing Service Personnel, San Joaquin
General Hospital PHS Contract No. 1 NU 34048.
Murphy, L.N., Dunlap, M.S., Williams, M.A. & McaAtchie, M. 1978, Methods for
Studying Nurse Staffing in a Patient Unit, DHEW pub. no. HRA 783.
Nascimento, E.M. & Beasley, J.E. 1993, Locating benefit posts in Brazil, Journal of
the Operational Research Society, vol. 44, no. 11, pp. 10631066.
National Association of Childrens Hospitals and Related Institutions, Inc. 1978,
Study to Quantify the Uniqueness of Childrens Hospitals, Wilmington, Delaware.
Norby, R.B., Freund, L.E. & Wagner, B. 1977, A nurse staffing system based upon
assignment difficulty, Journal of Nursing Administration, Nov.
Overfelt, F.C. & Ballash, D.W. 1982, A broad perspective on patient condition
related staffing, in Nurse Staffing Based on Patient Classification, AHA, Chicago.
Pallin, A. & Kittell, R.P. 1992, Mercy hospital: Simulation techniques for ER
processes, Industrial Engineering, vol. 24, no. 2, pp. 3537.
Pidd M. 1977, The operational research method, in Operational Research for
Managers, S.C. Littlechild (ed.), Philip Allan, Oxford.
530
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