1. Where Does the Time Go? Results of Educator Time Studies Judith Goodwin, MBA Elaine Sullivan, MS, RN, CDE

2. Objectives  Describe benefits and methods of an educator time study  Define the educator role and best use of time  Analyze data from sample educator time studies to develop a CQI plan to improve efficiency

3. Where does the time go?  Do you feel like you run through your day?  At the end of the day do you feel like you didn’t get anything done?  Does your manager have to justify your productivity?  Do you feel pressured to do more, but don’t seem to know how?  Let’s see if we can figure out what gets in the way…

4. Educator Roles  Educator  Clinician  Coordinator  Consultant  Case Manager Mensing C & Mulcahy K. The Role of the Diabetes Educator in the Management of Diabetes Mellitus in Goldstein BJ & Muller-Wieland D, eds. Textbook of Type 2 Diabetes. London: Martin Dunitz; 2003: 39-50.

5. Key Tasks to Fulfill the Role  Teach patients self-management of diabetes  Help patients evaluate their self-management  Encourage & support patient behavior change  Update patients on new therapies/options  Identify community resources for patients  Educate PCPs & the community on the role of the educator

6. Purpose of an Educator Time Study  Identify how you are spending your time  Identify activities that impede your ability to see patients  Determine what activities can be eliminated or done by less expensive personnel  Acknowledge activities that support the organization even if they impede the key tasks  Discuss shifting cost of organization support to appropriate departments

7. Data Tool: Educator Daily Record Scheduled work hours 8 Actual worked hrs 8.25 Date: 6/12/07 Time1:1ClassChartingPhonesMtgsClericalInpatientMD support 8-930 9-1060 10-1160 11-1230 12-145 1-230 2-360 3-460 4-530 Total120 60 306045

8. Educator Time Study Summary Sheet Educ Total hrs worked 1:1 Hrs % Group Hrs % Direct Care Hrs % No show Hrs % Charts Hrs % Mtgs Hrs % Phones Hrs % Clerical Hrs % Inpt Hrs % Total

9. Process: Using the Data Tool  Get consensus on categories/definitions  Pick a typical time period when educators not on vacation or working on a major new project  Gather a week of data  Keep your Daily Record as you go through your day; don’t wait until the end of the day

10. Findings of 4 Educator Time Studies

11. Time Study Results - 2000  30 educators from 14 centers 1 week of data  Average 8.8 hours worked/day 40% of time in direct patient care 14% Charting time 7% Phone time 5% Meeting time 27% time in “other”

12. Time Study Results - 2005  10 educators in 1 center 2 weeks of data  Average 7.4 hours worked/day 30% of time in direct patient care 15% Charting time 7% Phone time 6% Meeting time 42% time in “other”

13. Time Study Results - 2006A  6 educators in 1 center 1 week  Average 8.5 hours worked/day 30% time in direct patient care 25% Charting time 6% Phone time % Meeting time 23% time in “other ”

14. Time Study Results – 2006B  7 educators in 1 center 2 weeks  Average 8.7 hours worked per day 36% time in direct patient care including inpatient 14% Charting time 8% Phone time 15% Meeting time (combined 5 specific “other”) 3% time in unidentified “other” because 9 categories of specific “other”

15. One Site’s Attempt to Improve Measurement of “Other”

16. Conclusions from 4 Time Studies

17.  Direct patient care 30 – 37%  Charting 14 – 25%  Phone time 6 - 8%  Meetings 5 – 15%  Other 3 – 42%  Wide individual variance

18. Our Programs Need to Be Financially as Well as Clinically Successful  As educators our most important role is to be in front of patients educating  Some activities support that role  Some activities get in the way  We need to identify and eliminate activities that get in the way of educating

19. If we only spend 30 – 37% of our time in direct/face to face/billable activities, we are not fulfilling our mission or assuring our financial viability!

20. Good medicine is good business!

21. Joslin’s Goals and Assumptions for Financial Viability  60% of an educators day is spent face to face in billable encounters with patients  Groups are an effective and efficient way to increase financial viability  Decreasing “no shows” and cancellations is essential to clinical and financial success  Getting new patients in the door and bringing existing patients back is essential to clinical and financial success

22. Explaining the Gap Between Expectation and Reality  Educators tend to respond to everyone’s needs generously  We are used to giving away our expertise on the phone  In centers that include medical management we are frequently pulled to be physician extenders  Some PCPs give us their diabetes patients because of our expertise and we take on medical management of insulin by phone

23. Effective: Are we doing the right thing? Efficient: Are we doing it the right way?

24. We need to nurture patient independence!

25. Tasks that May Support or Impede Role Depending on Time Spent  Charting/ documentation  Phone calls  Meetings  Preparation for classes  Orienting new hospital staff  Email processing

26. Tasks that May Support or Impede Role Depending on Time Spent  Driving to classes held in off-site locations  Prescription refill support/clarification  Professional development  Marketing related activities  PCP support  Inpatient support  Glucose log & CGM analysis

27. Tasks that could be done by less skilled staff  Clerical functions - finding charts, filing, making copies, ordering booklets/supplies  Scheduling appointments  Calling/faxing referral sources for labs, signatures, etc  Tracking diabetes patient education outcomes  Looking for missing medical records

28. Tasks that could be done by less skilled staff  Setting up room for classes  Insurance verification  Greeting and trouble-shooting “walk-in” visitors  Phone triage  Organizing diabetes walk (or other events)  BG screening / meter downloading

29. Can we narrow our scope?  Are we willing to let go of anything?  Can documentation be streamlined?  Are we practicing medicine without a license?  Should we consider hiring clerical help rather than another educator?  Do we limit/discourage patient access to us by phone?

30. Can we narrow our scope?  Are we billing for all our services?  Should inpatient responsibilities be in another department’s budget?  Are we getting more out of students than we give?  Are we successfully recruiting and using volunteers?

31. Tabulate & Calculate: Educator Time Study Summary Sheet Educ Total hrs worked 1:1 Hrs % Group Hrs % Direct Care Hrs % No show Hrs % Charts Hrs % Mtgs Hrs % Phones Hrs % Clerical Hrs % Inpt Hrs % RN 14313 (30)3 (7)16 (37%) 4 (9)10 (23)4 (9)6 (14)7 (16) RN 2244 (17)4 (17%)1 (4)2 (8) 13 (54) RD 33620 (55)3 (8)23 (64%) 2 (5)4 (11)2 (5)4 (11)3 (8) Total10337(36)6 (6)43 (42%) 6 (6)15 (14)8 (8%)12 (12) 13 (13)

32. Analyzing the Time Study: Individual Educators  Does your own scheduling template have 60% of your time available to see patients?  Is your personal schedule full?  Are your DSMT visits in 30 minute increments?  Are the other educators on your team more available to see patients? What can you learn from them?  If you are one of the most productive on your team, what time management techniques can you teach the others?  If you have administrative responsibilities, consider what percent of your time is spent in those activities.

33. Analyzing the Time Study: The Team  If your team average is close to or over the goal, does individual productivity matter?  Is there a difference between part time and full time educators?  Do formal and informal team meetings and special projects take up too much time?  Is time spent marketing increasing your patient base?

34. Analyzing the Time Study: The Team  Is there a difference in how time is spent if the data is sorted by RN vs. RD?  Is your “no show”/cancellation rate acceptable?  How would the results look if all “not typical” days were removed?  What can you learn from the range between individuals in some of the categories?

35. Developing a CQI Plan  Identify the problem  Collect data, tabulate, calculate and analyze  Plan - discuss possible solutions  Select something to try  Act - implement change  Evaluate the results  Revise the plan

36. A Time study is only a tool in the CQI Process not the whole process!  Analysis and discussion are critical to using the data to improve your program  Select typical days/ weeks to do the study  Decide together on definitions to avoid lots of “other”  Set individual and team targets to increase direct patient time and decrease “other”  Collaborate with team and administration to develop strategies to reach targets  Set follow up time frame to repeat the time study

37. Another Example  4 educators in 1 center for 1 week  Average 7.7 hrs/day worked 32% Time in direct patient care 6% Charting time 31% Phone time 7% Meeting time “Other” defined by team 10% Clerical 6% Chart search 2% Sales reps

38. Next Steps in CQI Process  Phone time is a problem!!!  Who is precipitating calls? Patients/Families, Educators, Physicians  Are calls substituting for visits?  What percent of calls are to cover for endocrinologists in the practice?  What percent of calls are necessary vs. nice?

39. Next steps in CQI Process  Define necessary calls  Educate patients, physicians and each other about necessary vs. nice calls  Set goals to decrease phone time by a specific percent for individuals and the team  Re-measure and ???

40. Remember the time study is just the beginning of the CQI process! Send us your results - elaine.sullivan@joslin.harvard.edu elaine.sullivan@joslin.harvard.edu