THE APPLICATION OF THE
PRINCIPLES OF INDUSTRIAL
ENGINEERING TO A
HOSPITAL SWUATION

“MI: for the Dogma of M. S.
MICHIGAN STATE COLLEGE
Geraid E. Clark
1953

This is to certify that the

thesis entitled

"Industrial Engineering Techniques Applied to a.
Hospital Situation“

presented by

Gerald D. Clark

has been accepted towards fulfillment
of the requirements for

 

 

M's. degree in M.I.

ajor professor

Date MAE——

 

 

I

-._-.p —.—.-

-.-u-a'-av-¢n.. -.... .. I - .

L

THE APPLICATION OF THE PRINCIPLES OF
INDUSTRIAL ENGINEERING TO A HOSPITAL SITUATION“

By

Gerald E. Clark

A THESIS

Submitted to the School of Graduate Studies of Michigan
State College of Agriculture and Applied Science
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

Department of Mechanical Engineering \‘

1955

TH ESIS

 

6/?31/SL5

ACKNOWLEDGMENT

The author wishes to eXpress his sincere thanks
to Professor James Apple, whose constant encourage-
ment and help has made this project come to a success-
ful conclusion.

He is also greatly indebted to Miss Marion
Wright, Associate Director of Harper Hospital, Detroit,
Michigan, and to all of the many individuals at the
hospital whose c00peration and help made this project
possible.

To Mr. Owen Goodrich, Chairman of the Society
for the Advancement of Management Improvement of
Patient Care Committee, and to all of the other mem-
bers of the committee, who unselfishly gave of their
time and skill to bring to this study a wealth of ex-
perience which is not often possible, goes a special
thanks and a hope that they have been at least
partially compensated by the satisfaction of a job

well done.

(7,"; -" 2 {VI
(in) ‘IL .1. J I)

TABLE OF CONTENTS

CHAPTER PAGE

I INTRODUCTION . . . . . . . . . . . . . . . l
A. The Necessity for This Type of

Work . . . . . . . . . . . . . . . .

B. The Approach to the Problem. . . . .

C. The Over-all Aim . . . . . . . . . .

.p (n on re

D. The Purpose of This Report . . . . .
II THE SCOPE OF THE INDUSTRIAL ENGINEERING
APPLICATION AT HARPER HOSPITAL . . . . . . 6
A. The Industrial Engineering Approach
to the Problem . . . . . . . . . . . 6
B. Definition of the Scope of the
Industrial Engineering Program . . . 7
C. The Necessity for a Continuing
Program . . . . . . . . . . . . . . 9
III REVIEW OF THE INDUSTRIAL ENGINEERING
APPROACH WHICH WAS USED AT HARPER
HOSPITAL . . . . . . . . . . . . . . . . . 14
A. The General Approach . . . . . . . . 14
B. Definition of the Problem. . . . . . 16
C. Collection of the Facts . . . . . . 19
D. Analysis of the Facts. . . . . . . . 22

E. Formation of a New Plan. . . . . . . 27

CHAPTER

IV

V

F.

Implementation of the Plan

THE INDUSTRIAL ENGINEERING PROJECTS.

A.
B.

Method of Presentation . .

The werk Simplification Training

Program. . . . . . . . . .

The Work Simplification Organization

The Pharmacy Delivery Service. .

The Central Messenger Service.

Linen Cart Exchange Service

The WOrk Sampling Study. .

CONCLUSIONS. 0 O O O O O O O O O

A.
B.

C.
D.
E.
F.

Restatement of Problems. .
Utilization of Professional

Personnel. . . . . . . . .

Reduction in Operating Cost.

Employee Morale. . . . . .
Better Care for Patients .

Areas for Future Study . .

BIBLIOGMIH O O O I O O O O O 0

PAGE

33
58
58

58
48
55
58
61
74
91

LIST OF FIGURES
FIGURE PAGE

1 The Industrial Engineering Approach to a
Problem.................15
Proposal for Improvement Form . . . . . . 50

3 Flow Diagram of Procedure of Submitting
a Proposal for Improvement . . . . . . . 53

4 Prepackaged Drugs in Pharmacy Awaiting
DeliverytotheUnits . . . . . . . . . . 59

5 Flow Process Chart of Present Method of
Supplying Clean Linen to Patient's Room . 64

6 Flow Process Chart of Proposed Method
of Supplying Clean Linen to Patient's
Room .................. 68

7 Laundry Cart Being Loaded Directly from
theMangle ............... 7O

8 Housekeeping Maid Selecting Linen from
a Linen Cart Which is Moved from Roan
toRoomasisneeded . . . . . . . . . . 7O

9 Cost Analysis of Use of Linen Cart
System ................. 72

10 A Tally Sheet Used in the Work
Sampling Study 0 O O O O O O O O O O 0 O 81

FIGURE
11

12

13

PAGE
Example of an Accumulation Sheet Used
in the Work Sampling Study . . . . . . . . 82
Determination of Length of Study-
Activities of Registered Nurse . . . . . . 83
Questionable Activities of Professional .
Staff . . . . . . . . . . . . . . . . . . . 88

CHAPTER I
INTRODUCTION
A. The Necessity for This Type of Work

In 1950 the entire country was in a period of
increased spending. The cost of living as indicated
by the various indices throughout the country was at
an all time high and the peak of the spiral was not
yet in sight. The cost of Operating a hospital was
no different from the cost of any other services through-
out the country. In 1946 for instance the cost per
patient day at Harper HOSpital was $16.06. This had
jumped until at the end of 1950 the cost per patient
day was $25.87. This was a considerable increase and
one about which the public was expressing greater and
greater indignation. Some people tried to minimize
this increased cost by saying that it was not out of
line with the increase in other phases of our economy.
This in no way lessened the gravity of the problem.

There was also another problem confronting the
hospital field and one which perhaps was even more
serious than the problem of increased costs. It was
not possible to obtain sufficient professional help

to answer the needs of the existing hospitals even

2
though sufficient money was available to pay the demands
of these peeple. In the Detroit area there was a need
for 613 more registered nurses to adequately handle the
existing facilities. There were plans in the making
or plans which had been completed by which it was in-
tended to increase the hospital facilities of the
Detroit Metropolitan Area. Some of these plans were
being held up merely because there was not sufficient
professional help available with which to staff the
added facilities if the proposed construction were
completed.

The shortage had been lessened to some extent
by turning over some work to practical nurses. There
were 781 peOple in this classification working in the
Detroit area but also there was a shortage of practi-
cal nurses with 284 more being needed to staff the
present facilities.

This was the situation that faced the Board of
Directors of the Harper Hospital, a 590 bed institution,
in the heart of MetrOpolitan Detroit in the summer of
1950. They did not feel, as trustees of the Harper
Hospital, that they should sit back and explain that
the increased patient cost and the shortage of pro-
fessional help was a matter of circumstances due to our

present economy and that nothing could be done about it.

B. The Approach to the Problem

With all of these factors in mind it was decided
that the situation was of a serious enough nature to
require the full-time study of some one skilled in the
management field.. Accordingly, a project entitled
”The Improvement of Patient Care” was organized at
Harper Hospital. A full time director was employed
to make a study of what could be done to remedy the
situation. Miss Marion Wright, since promoted to
Associate Director of Harper Hospital, was employed
to head the study. She eminently qualified for the
Job, having had eXperience as a registered nurse, as
a supervisor of nurses, and later having taken grad-
uate work in heapital administration. A preliminary
survey was made and an over-all plan was proposed.
This over-all plan was intended to be used as a guide
to outline some areas in which a detailed study should

be started.
C. The Over-all Aim

A statement of the over-all aim of The Improve-
ment of Patient Care Committee was, ”to plan ways and
means for providing adequate but safe patient care in

a manner most economical to the hOSpital and to the

patient."

4
In order to further define the purpose of

the committee the following proposals were set forth:

1.

2.

4.

To study current practices in the field
to gain helpful suggestions and ideas.

To find out the attitude of the patient
and the medical staff in order to obtain
from them suggestions that might assist
in improving patient care.

To analyze skill requirements in various
activities in order to make maximum utili-
zation of professional personnel by deter-
mining what activities the non-professional
may safely perform for the patient, both
mental and physical.

To study and now existing functions of

departments and assignment of duties of
personnel, realign and reorganize these
to provide a more efficient service to

patients.

To determine the amounts and kinds of per—
sonnel necessary to give this care by an
analysis of the patient and the activities
related to his care.

To determine the preparation and training
necessary for various classifications of
personnel and recommend plans to accomplish
this.

To investigate labor saving devices and

prove that their installation will reduce
the work load of personnel.2

D. The Purpose of This Report

A study of the seven subheadings in the state-

ment of the over-all aim of the Improvement of Patient

Care Committee showed that items 5, 4, 5, and 7 in

particular lent themselves to the type of work for
which the Industrial Engineer is trained. In the past,
industrial management had been confronted with prob-
lems very similar to those faced by the hospitals.
They had turned to the Industrial Engineer to work
out solutions to these problems and to obtain more
efficient operations. It was suggested that perhaps
the Industrial Engineer could contribute to the project
which was under way at Harper Hospital.

It is the purpose of this report to show how
the principles of industrial engineering as applied
by a committee of Industrial Engineers from the Detroit
area, working under the auSpices of the Society for
the Advancement of Management did contribute to the
solution of the problem; the improvement of patient

care.

CHAPTER II

THE SCOPE OF THE INDUSTRIAL ENGINEERING
APPLICATION AT HARPER HOSPITAL

A. The Industrial Engineering

Approach to the Problem

In the original discussions of the Industrial
Engineering group which was formed to consider the
problem at Harper Hospital, it was decided that the
problem should be attacked the same as any problem in
industry. A hospital was an industry just as much as
if it had been a manufacturing concern. Raw material
was received into the factory. It was worked on,
stored, handled, and after passing inspection it was
shipped from the factory.3

After making this decision it was decided that
the first step would be to become familiar with some

of the over-all problems which were faced by the hos-

pital. A trip was arranged for the Industrial Engineer-

ing group through Harper Hospital. On January 15, 1951

a considerable amount of time was Spent in making a

 

a The basic raw material is of course the sick patient
and the finished product is the well patient.

7
complete and thorough tour through all of the typical
units in the hospital and through all of the service
units. The result of this tour was to confirm the
original assumption of the Industrial Engineers, that

the hospital was, in effect, a fairly large factory.

B. Definition of the Scope of the

Industrial Engineering Program

After the Industrial Engineers had finished
the tour of Harper HOSpital a meeting was held in
order to outline a Specific approach that would be
used in working out solutions to the problem,the

improvement of patient care. After a considerable
amount of discussion, it was decided that the efforts
of the Industrial Engineers concerned could be best
utilized if they were applied toward seven Specific
fields. These fields were as follows:

1. To develop better methods for the per-
formance of needed tasks.

a. To serve as concrete examples of
what could be accomplished by the
application of industrial engineer-
ing principles to the hospital
situation.

b. To effect immediate cost reduction
in some areas where the Industrial
Engineers believed that a maximum
saving could be accomplished
immediately.

2. To study control procedures from the
point of view of simplifying the paper
work necessary to run the hospital.

5. To study or analyze the job content of
the various jobs in the hospital.

4. To develop standard times for hOSpital
jobs.

5. To conduct a work simplification train-
ing program for h03pital personnel.

6. To conduct a supervisory training program
for hOSpitaI personnel with the emphasis
to be placed on floor supervision.

7. To study the need for a training program
for all personnel excluding nurses.

A detailed study of the above objectives in-
dicated that the industrial engineering committee had
established a monumental job for themselves. It was
decided that it would not be possible to attack all
of these objectives at one time. A study of the ob-
jectives as listed seem to indicate that there was a
definite sequence in which they should be attacked.

First, there was the problem of convincing the
entire hOSpital industry that a bunch of "dirty" in-
dustrial engineers could come into a hospital and tell
them or show them how they could better run their

business.b The hospital field was, like many other

 

b There was much outspoken, and at times bitter, ex-
pression of the opinion that engineers who were used
to working with cold machines couldn't possibly under-
stand the cleanliness and compassion necessary when
dealing with human beings.

specialized fields, beset with traditional ways of
performing certain tasks. Even though the Industrial
Engineering Committee was operating at the request of
the Directors of Harper Hospital; all peOple concerned
were still somewhat skeptical as to the value which
could be expected from such a project. It was, there-
fore decided that the number one task for the Indus-
trial Engineering Committee was to immediately develop
some better methods and thereby convince the skeptics
that it was possible to apply the principles of in-
dustrial engineering to a hospital situation.

As a result of this decision, certain members
of the Industrial Engineering Committee were assigned
to begin work on some specific problems in order to

develop a better method for doing these jobs.
C. The Necessity for a Continuing Program

There was one practice which had continually
given the Industrial Engineering profession a bad
reputation. This was the practice of some consult-
ing engineers of going into a place of business on
the grounds of establishing more efficient operation;
and while solving a number of specific situations,
failing to provide some vehicle which would insure

that the more efficient operations would be continued

10
after the expert consultant had gone on to another
job.

It was the earnest conviction, of all con-
cerned with this program, that the only way that
Harper Hospital could be really helped by a group of
Industrial Engineers would be for the Industrial
Engineers to guide members of Harper HOSpital in such .
a way that they would be able to develOp more efficient
methods themselves. There would be little gained by
having the engineers act as a group of experts to
develop better methods, if after they had completed
the project, these better methods were left to be per-
formgd by people who did not understand their intent
or value. In most cases the uninformed persons would
not have been in favor of the proposed change regard-
less of its value and therefore would revert back to
the original methods at the first opportunity.

This problem was by no means peculiar to the
hospital field. Exactly the same situation was con-
stantly encountered in industry. Industrialists had
long recognized that a good method was only good if
it was understood and accepted by the people who were
to use it. When confronted with this problem it was
the custom of industry to establish a training program

to give to the people involved the information which

11
they should have had about the industrial engineer-
ing program. It had been found that to fully eXplain
industrial engineering was to take away most of the
fear that the Industrial Engineer would cause harm
to individuals or to the company as a whole.

It was decided that a training program should
be established at Harper Hospital in order that all
concerned could be given the basic information about
the industrial engineering program. This training
- program would be known as WOrk Simplification Train-
ing Program. I

It was decided also to institute at this time
the supervisory training program. It was noted in
the original survey that there was a decided lack of
uniformity in the methods by which the various super-
visors went about their jobs. It was thought, if a
maximum benefit was to be derived from the results
of the Improvement of Patient Care project, that the
part of a well trained supervisor would be an important
one.

A short time previous to this a supervisory
training program had been put on at Detroit Receiving
Heepital by the Detroit Civil Service Commission. It
was decided that the material content of this program,
with slight alterations to fit the Harper Hospital

12
situation, would be satisfactory. This program was
instituted and carried to a successful conclusion.

It will not be considered in further detail in this
report.

The develOpment of standard times for hospital
jobs and the analysis of job content on the various
jobs of the hospital was delayed until a future time.
It was not felt that standard times for the hospital
jobs, as they then existed, would have value in pro-
portion to the amount of effort which would be
necessary in obtaining the standard times. The only
probable value would be for the purpose of evaluating
the success of the study. It was thought that an
estimate of the value of the savings of the proposed
better methods would be sufficiently accurate for the
needs anticipated. The analysis of the job content
of the various jobs in the hospital was delayed only
until it was possible to undertake this project. This
was done later in the year and the results will be
included in this report.

A study of the control procedures, in view of
simplifying the paper work was not attempted by the
committee, because at the time it was not felt that
there was sufficient help available to carry out that

phase of the project.

15
The above discussion outlines the scOpe of the
industrial engineering project as it was conceived,
in January of 1951 by the Industrial Engineers in-
volved, after considering the existing situation at

Harper HOSpital.

CHAPTER III

REVIEW OF THE INDUSTRIAL ENGINEERING APPROACH
WHICH WAS USED IN THE WORK AT HARPER HOSPITAL

A. The General Approach

From the very first, the Industrial Engineers
concerned could see practically no difference between
the situation at Harper Hospital and the situation
which faced these same engineers in industry. It was
decided that the approach to the problem, unless ex-
perience dictated otherwise, would be basically the
same as would be used in any industrial situation
where the end result was to find the most efficient
means of Operation.

In making the summation of the industrial
engineering approach, it was thought best to discuss
each time according to its position in the over-all
picture. As can be seen by the flow diagram (See
Figure I) this problem of finding a more efficient
means of operating was broken down into five phases.

1. definition of the problem

2. collection of the facts

5. analysis of the facts

4. formation of a new plan

5. implementation of the plan

I. DEFINITION OF THE PROBLEM II. COLLECTION OF THE FACTS HI, ANALYSIS OF THE FACTS IV, FORMATION OF A NEW PLAN V. IMPLEMENTATION OF THE PLAN

 

1. Statement of the over- I. V bal. ‘ - , 1. Developing acceptance
all problem. er 1‘ Movement. 1’ Eliminate attitude.
a. Patient Care Committee 2. written. g' gisgance. E. Sgfigiggzaggbgave‘ a. ParticipatiOE-l t
' ' . ' - - _ ~ 1m - ’ b. 3-dimensiona a ou .
I b. nggfiigggalres. a. Sgiiafigggrgg avail c. Effort. ments. 0. Interviews. y
r DOCPOP b. dums ke t b - _ d. Motion pictures.
Other hospitals Ngggggg. p y 2' morale. 2' Combine e. Training programs.
. ° . Two 'obs at same , 1 .
f 2. Definition of specific 3. Diagrammatic. g' gfigfifiied a time? 2. changing physmal
problems. , t ' ' b. Two jobs at one Situation.
a. Trouble epots 3' gigfiegiagiggsChar S. l 3' Worker specifications. location. a. Cost analysis.
b. Observed violation f . 1 . ~ . b. Procurement of new
P Principles of motiog 4. motion Pictures. ‘ :‘ HHZHEIIEIed 3‘ Simplify. materials. t
economy. ° . . ° se uence. c. Making .ayou
c. Suggestions from 5. Work Sampling. c. Over—qualified. a, Change q alterations.
d. g83v2§85y industrial 4. Questioning Attitude. 4. Devise New Plan. d. 2::2;$:2§,new
e ineers.
ng a. What
b. Where
” c. When way
d. Who
e. How
MORE EFFICIENT OPERATION
v 1. Savings in Operating Costs.
THE AB Vb ADDED TOGETTE GIVE. 2. Savings in Skilled Personnel.
3. Better morale of Employees.
4. Better Care for Patients.
Fig. 1 The Industrial Engineering Approach to a Problem
I

 

 

 

 

 

16

It can be seen that there is nothing new or different
about this approach. It is fundamentally the basic,
scientific approach to any problem. For purpose of
discussion each of these five steps is considered
separately and the industrial engineering principles

which were used in each step are discussed in detail.
B. Definition of the Problem

It was important when approaching the situation
at Harper HOSpital that there be an exactly defined
problem to work on in all cases. In fact. many times
it was found that when the exact problem was defined,
the analyst had gone a considerable distance toward
the accomplishment of the task.

It seemed that the problem at Harper Hospital
broke down into two main phases.

1. The statement of the over-all problem

which was to be considered.
2. The definition of individual problems
within the over-all problem.
The statement of the over-all problem was outside of
the scape of this report. However, it was briefly
mentioned as it did have considerable bearing on the
work that was done by the Industrial Engineering group.

The original statement of the over-all problem was

17
not actually a statement but rather a realization
that there was a need for study in the field of im-
proving patient care and lowering the cost of patient
care. Also, there was a need to supplement the supply
of professional help, either by obtaining more pro-
fessional help, or by better utilization of the help
which was available. Soon after the original patient

care committee was organized a formal statement of

the problem was made and even this was very general.

It was a lengthy report drawn.up primarily by Miss
Marion Wright (who had been appointed by the hospital
as full time director of the over-all program) in which
she listed all of the avenues of approach to this
program which were apparent at that time.

One of the first things that became apparent
was that there was very little factual information
about the make-up of a hospital and the hospital's
chief product which was the well patient. With the
cooperation of the School of Business Administration
at Wayne University a series of questionnaires were
distributed, collected. and analyzed. These helped
to better define the over-all problem. ‘These question-
naires covered three fields:

1. Patients -- to find out how they felt

about the situation as it was. and also

what they thought the situation should be.

18

2. Medical staff -- to determine their

reaction to the project and to obtain
any suggestions they might want to
offer. '

3. Other hOSpitals -- to determine their

comparative situations and to draw
on any eXperience they had accumulated.

As a result of these original steps, a rather
clear definition ofthe over-all problem emerged, and
at this point a similarity between the problems that
‘faced the hospital and those which were confronted
by industry as a whole, also emerged. When industry
was confronted by such problems, it turned to the
Industrial Engineer and utilized his knowledge of the
solving of industrial problems in order to obtain more
efficient operations. With this in mind the Harper
HOSpital Industrial Engineering Committee was organized.

One of the first acts of the Industrial Engineer-
ing Committee was to try to define some of the in—
dividual problems which they could work on. A general
tour of the total Operations had been made by the In-
dustrial Engineers with the Operation as a whole but
also so these trained observers could notice viola-
tions of the principles of motion economy. Several

Ciistinct violations of these principles were observed

19
and were noted for study and some of these studies
are included in the body of this report. Also, to
help in defining the individual problems it was made
known throughout the hOSpital that suggestions would
be accepted from any and all interested parties and
these suggestions were then analyzed in order to fur-
ther define the situation.

After a list had been made of individual prob-
lems which would warrant the attention of the Indus-
trial Engineering Group, a meeting was held and these
problems were given priority as to the order in which
they would be approached and then the individual

approaches were made.
C. Collection of the Facts

After a particular problem has been defined it
is necessary that all facts surrounding this situation
be collected. There are many techniques which can be
used and which are used by practicing industrial
engineers. The following techniques were used to solve
problems at Harper Hospital.

First, the technique of verbal interviewing
was used to a great extent. This problem of applying
the principles of Industrial Engineering to a hos-
pital situation was unique in that the peOple working

20
at the hospital were not familiar with the analysis
techniques used,-as are the workers in industry. It
was felt that the verbal interview would have a two
fold purpose. First, it would acquaint the worker
with the purpose behind the collection of facts.
Second, the Opinions Of the workers could be obtained
at the same time as any information which they might
have pertaining to the individual problems.

written records were used to a great extent
for collection of the facts. It should be stated that
it was found that the hOSpital kept more records than
the normal industry with which most of the industrial
engineers were familiar. There was a great volume
of potential useful information which was kept as a
matter of pure record. However, it was the job of
Industrial Engineers to determine what records could
be utilized in order to come up with a plan which
would result in more efficient operations. Therefore
alot of information concerning individual problems was
obtained from the formal records of the hospital.

Also it was found that due to the high level
of intelligence of many of the hOSpital personnel.
they could be depended upon to provide very accurate
written memoranda concerning a particular subject and

this technique was utilized to a great extent because

21
again it was felt that the participation of the worker
in the collection of the facts would be a great help
when.this particular worker was asked to participate
in a new plan.

The diagrammatic techniques of industrial
engineering were also used to considerable extent as
has been demonstrated in the body of this report.
Since these techniques are familiar to all industrial
engineering personnel they will not be discussed at
length in this report. The Flow Diagram, The Process
Flow Chart, Gantt Type Charts, Man-Machine Charts,
and Procedure Charts were used with success in this
program.

The motion picture also was used for this study.
It was used not only because it is a valuable tool
in collecting facts but as this was a project in a
field where the principles of industrial engineering
had not been previously applied, it was thought that
a permanent visual record would be of value in sell-
ing the total program. This was found to be true.

The technique Of work sampling, also known as
statistical ratio-delay studying, was really a
diagrammatic induStrial engineering technique. How-
ever, because it was a new technique and was so well

adapted to play a major role in the study at Harper

22

Hospital, it has been considered as a separate item

in this report. It was noted that not only did the
work sampling technique show that the principles of
industrial engineering could be applied to the hos-
pital situation, but the use of the work sampling
technique in the hospital situation showed that work
sampling was an ideal tool to use in an over-all sur-

vey of any non-repetitive job.
D. Analysis of the Facts

The next step in the industrial engineering
approach was to make an analysis of the facts which
had been collected. The work of collecting the facts
doesn't help at all in the direct solution of the
problem. Many organizations have collected a large
number of facts and yet have failed to benefit by
this labor. Value will be received from this work
only if the collected facts are properly analyzed.

The first step of the analysis perhaps was
not analysis at all but a refinement of the collection
technique. This part of the procedure might have
been included in section two under collection of the
facts. However, since it was a phase which was per-
formed only by those peOple who were going to make

a detailed analysis, and was the first step in

23
differentiating a proper analysis of the facts from
a mere collection of the facts, it is included under
the phase of analysis of the facts.

Tnis step was the collection of the facts and
the sorting of these facts into their respective
position in order to get a properly balanced picture
of the Job which was being analyzed. Not only was
there a sorting and a collation of the facts, but
also a certain amount of judgment was used at this
time in order to decide which facts were pertinent
and which were merely extraneous facts relating per-
haps, to the total situation but adding no value to
the analysis which was anticipated. A great deal of
judgment was required in the accepting or rejecting
of facts to be used. Items which appeared to have no
value to the untrained analyst may be very significant,
in fact, may be the key to the situation when viewed
by a qualified analyst trained in the principles of
motion economy and in the other industrial engineer-
ing techniques.

After the facts had been sorted properly and
gathered together into their respective positions in
the total picture, the next step was to make a de-
tailed analysis of each of these facets of the total

situation. In making the detailed analysis each

24
individual item is considered in terms of the follow—
ing: '
What?

Where?
When? I fifll}?
Who?‘ "
Howl

‘ This approach which was used seemed like a very
simplified approach to a difficult problem but, when
prOperly followed in the correct order, it gave a very
clear and concise analysis of all the situations which
were encountered. There is a very definite order in
which these questions should be asked and it is in
this order that they will be discussed.

First, what was being done and what was the pur-
pose of doing it? Why should it have been done? These
questions determined the value or the useful purpose
of doing the particular detail which was being considered.
It was determined if each detail did what it was supposed
to do and also why it should have been done. Dr.
Lillian Gilbreth once said, "Entirely too many opera-
tions are studied that should never be done at all."
Therefore, this question was never drOpped until it‘
was determined that it was absolutely necessary that

the detail should be performed. The question of what

25
was being done was always considered first because
if a detail could be eliminated there was no need to
further analyze that portion of the Operation.

Next, where was the detail being done? This
was considered in the light of where was the best
place to do the detail? Why was it done there? These
questions were asked to be sure that if the detail
was necessary that it was performed in the right place.

When was the detail done? ‘When was the best
time to do the detail? And why was it done then?
These questions were asked to be sure that if the
detail was necessary, that it was done at the right
time. It was also asked at this point if it were not
possible that this detail could be performed at the
same time as some other detail. Or if it was possible
to perform it before or after other detail in order
to make the Operation more efficient.

Who did the detail? Again this question was
asked in light of who should have done the detail?

And why should this person have done it? This ques-
tion was especially apropos in the work at Harper
Hospital. A major consideration was the determina-
tion of whether or not the work being performed on
a particular detail was being performed by a person

who was qualified to do that work, or a person who

26
was unqualified to do the job, or a person who was
over-qualified to do the job. When it was found that
a job was being performed by a person of higher skill
than was necessary for that particular task, a person
of lesser training was utilized to perform the task.

How was the detail performed? And why was it
done that way? In analyzing the detail in light of
this question, such things were taken into considera-
tion as; the distance traveled in performing the task,
the time necessary to perform the task, the effort
put forth in order to perform the task, and whether
or not a satisfied or dissatisfied patient resulted
from the performance of the task. Also, the morale
of the person performing the particular task was con-
‘ sidered. In many cases a change in the job improved
the attitude of the person toward that particular job.

In order to help the analyst do a better job
of analyzing each function a motion economy check list
was used in order that they constantly would be cog-

- nizant of the points that should be considered. This
motion economy check list served to point out that
very few jobs were anywhere near perfect and that each
and every job should be questioned. The attitude was
develOped that all jobs could be improved. It was

proposed to develop this questioning attitude to a

27
point where each individual considered the good of
the entire organization rather than that of any one
department or any one individual. The cultivation of
this attitude eliminated useless and unnecessary work.
It determined where and when the work could be most
economically performed, and it evened out the flow
of work. It was very important that the people
making the analysis maintain an open mind. In order
to improve an operation it was necessary that the
people concerned actually believe that it could be
improved. In order to get real constructive results
from each analysis, all of the separate steps had to
be honestly questioned.

E. Formation of a New Plan

In the formation of a new plan to perform a
particular job in industry, it was found that the
problem usually resolved itself into one of two classes.
The first way of develOping a new plan was considered
a revolution and the second way of develOping a new
plan was considered evolution. In the first case
there was a total revision of the basic process, a
radical departure from the previous method of perform-
ing the job. While in the second case the same basic

process was continued but the process was improved so

28
that it could be performed in a more efficient
manner.

In the work at Harper HoSpital the first
method of planning, that of revolution, was not used
to any great extent. There were two reasons for this:

First, the Industrial Engineers working on the
Harper Hospital project did not feel that they were
qualified to criticize the basic processes used in
the hospital field. No member of the Industrial
Engineering team that worked on the project had any
training in medical procedures or practices and in.
the course of this project it was not deemed possible
for the members of the committee to spend the time
necessary to gain such knowledge. Furthermore, for
the purpose of the project as it was established it
was not thought that such a step was necessary or
even prudent at this time.

The second reason that the revolution technique
was not used at Harper Hospital was because it was
thought that such a step might jeopardize the status
of the entire project. It was the attitude of many
people in the hospital field that in order to make
improvements in their field it would be necessary to
change the basic processes that were being used.

These peOple had established, because of fact or

29
tradition, that because they were dealing with the
lives Of human beings in hospital work, certain ways
of performing a task were almost sacred, and no one
should tamper with the basic method. It was not the
purpose of this project to challenge the wisdom of
such an approach but it was the purpose to consider
how this point of View of many hospital pe0ple affected
the project. It was thought that because of such a
point of view it would be foolhardy for the Industrial
Engineers concerned to attempt to make a change of any
basic process in view of the almost certain flood of
criticism which such a move would bring about.

The basic purposes of this project were to show
the hospital peOple that the principles of industrial
engineering could be applied to a hospital situation;
to win the enthusiastic support of the hospital people
for a continuation of such a program at Harper Hospital;
and to Spread the use of these principles to other
hOSpitals throughout the country. It was brought out
that it was the eXperience of the Industrial Engineers
concerned that the use of the evolution technique
brought forth less resistance in most cases from the
top management people than did the revolution tech-
nique. This was because the tOp management pe0ple

were responsible for a new method regardless of who

30
put that method in effect. Therefore they have a
measure of security in maintaining the same basic
processes that have been used in the past.

In forming a new plan it was noted that all
productive tasks were made up of the following three
parts. First, was the ”make-ready." In the "make-
ready" for the job were all of the elements which
were necessary to get the materials and the tools
and the persons in the position to perform a parti-
cular task. The second part of the task was the
"do." The "do" part of the task was the actual per-
formance of the task. A ”do" operation usually added
progress to the task or provided a service for some-
one. The third step in any operation was the "put—
away." The "put-away" was as the title implied the
placing of the object or objects in the prOper loca-
tion or the removal and storage of tools, equipment
and/or personnel.

An analysis of the above steps showed that the
more efficient job had a minimum of “make-ready" and
"put-away" and a maximum amount of effort went into
the "do" Operation. In the industrial situation this
has been carried to the ultimate in some factories
where an automation program has been carried out. In

such a situation the work is automatically passed from

51
one "do” operation to the next "do" operation and the
”make-ready" and "put-away" has been virtually
eliminated. This-was the aim of the planners of all
operations. However, in the unmechanized work en-
countered in the hospital field, such a solution was
merely a goal and was seldom realized.

There were four distinct steps which were
followed in evolving a new plan for performing an
existing process. The first was to look over the
existing plan and eliminate any "do" Operations which
could possibly be eliminated from the old method. If
"do" operations were eliminated, all of the operations.
tranSportations, and storages concerned with the
”make-ready” and the ”put-away" which applied to that-
particular Ado" were automatically eliminated. The
easiest details to challenge in most cases were the
transportations and the storages. Whenever back-
tracking of work, heavy lifting or carrying, bottle-
necks, or skilled peOple doing unskilled work, the
question was asked, "Can this work be eliminated?"

Secondly, after all possible details were"
eliminated, a check was made to see if it was
possible to combine any of the Operations which re-
mained. This combination of Operations often re-

sulted in the performing of the total amount of

52
labor for the cost of performing one of the Opera-
tions previously. Likewise it was possible in many
instances to combine transportations and storages so
that they were performed by the same person or piece
of equipment. Combining Operations also improved the
quality of the operations in some instances because
of the benefit deriVed from the interrelationship.

At times mistakes and delay between Operations were
eliminated when there was a combination of Operations.

Thirdly, after all possible operations were
eliminated and feasible combinations were made among
those remaining, a check was made to see if it was
possible to change the sequence of the operations in
order to accomplish the task more efficiently. By
changing the sequence of an operation it was possible
to eliminate back tracking or duplication of effort
in many cases. Sometimes the order in which the
Operations were performed was necessary to the process,
however there were many instances when a change of
sequence could be made with real saving.

The fourth step that was taken in developing
any new plan was to simplify any operations which
- were determined to be necessary for the performance
of the task. Note that this step of simplifying the
work was taken only after all possibilities for

35
eliminating, combining, or changing sequence of work
had been exhausted. Unfortunately it was found that
the majority of untrained people intending to improve
an Operation will attempt to simplify the operations
as the first step. Usually this resulted in a stirring
up of the bad methods rather than any distinct improve-

ment.
F. Implementation of the Plan

There are three basic factors to be dealt with
in putting any new plan into effect. These are:

l. The preparation of the suggested methods

change.

2. The technical changes and or problems in-

volved.

3. The human problem involved.

In preparing the suggested methods change, it
was necessary to test the basic plan which was de-
velOped in step four in our analysis technique and
work out the details which had to be answered before
the plan could be put into effect. Such problems as
the following had to be considered and answered if
the new plan was to accomplish just what the planner
had in mind when the plan was evolved:

1. Will other supervision be affected?

2.

10.

ll.

It

54
Will new equipment be required?
Will the change require stoppages in
operation during the change-over
period?

What staff or service departments will
be involved in the change?

Will the change require a higher skilled
Operator?

Will a lower skilled operator be capable
of performing the new task?

What is the cost of the proposed change?

Will the present operator accept the new
method with the proper enthusiasm?

Will the present Operator or any new
Operators need special training to perform
the new method?

Will the new methods require additional

- study as to manpower requirements?

Will the new method reduce over-all cost,
improve quality, reduce mistakes and
scrap and improve efficiency?

was not only necessary to consider these

questions and to arrive at satisfactory answers but

it was necessary that these answers be recorded and

the information made available to those people re-

quiring the information to implement the new plan.

As many of the plans required technical changes

in equipment and building facilities, it was also

necessary that the following problems be considered and

answered before the new plan could go into effect:

35

1. Will the suggested change require more
floor space or less floor Space?

2. Will the suggested change reduce the
amount of movement and effort required
to handle the materials involved in
the Operation?

3. Will the tools and materials be located
in such a manner that they can be used
most efficiently?

4. Were the principles of motion economy con-
sidered in making the physical changes?

It was also necessary in all methods changes
to consider the human factor. Frequently this was
more important than all of the mechanical and tech-
nical problems involved. It was recognized that any
person could make a mediocre plan work efficiently
if he was enthused about the plan and had a desire
to make it work efficiently. Also most persons would
make a good plan work poorly if they were not in agree-
ment that the plan should have been put into effect.
It was always remembered that any time a job was
improved it was an inference that the person who was
doing the job previously was not doing as good a job
as was possible. Naturally, this created a certain
immediate resentment on the part of the person towards
any methods change. It was known that it is a trait
of all peOple that they resent change and yet that
they like progress. It was the job of the Industrial

36

Engineers to see that the person was properly con-

ditioned so that the trait in the person which desired

progress overpowered the trait which resented change.

In the work at Harper Hospital a simple list was

drawn up and used as a guide in approaching people

about the method plan. It was felt that if these

rules were followed a minimum of resistance would be

incurred.

l.

2.

5.

4.

They were as follows:

People like to be in on the know. Always
keep the personnel informed in advance of
anticipated changes.

People will usually support an idea that
they have had a part in forming.

People like to buy. They do not like to
be sold.

People fear, or are suspicious of, things
that they do not understand.

PeOple resist change unless they can see
a personal benefit in changing. Be sure
to always eXplain the benefits of new
ideas.

People want to be recognized. Give the
person proper recognition for his part
in any new plan.

People like to give advice. Each person
is an expert on his own job. Always ask
for his advice.

Most people feel that their skill and
knowledge is best. Don't insult a person
because he has been using an obsolete
method. He probably was very skillful at
performing the obsolete method.

57

The above guides were followed in spirit as
well as in fact during the entire study at Harper
Hospital and it is felt that there was a minimum of
resistance to the changes when they actually took
place.

The actual mechanics of changing a method at
Harper HOSpital were not changed from those which had
been in effect previous to this study. The established
line organization was utilized in all cases for putting
plans into effect. There was close supervision and a
considerable amount of guidance by the Work Simplifi-
cation Committee as to how the implementations should
take place; but at no time was the line authority

superceded in the actual performance of the duty.

CHAPTER IV

THE INDUSTRIAL ENGINEERING PROJECTS

A. Method of Presentation

It is the purpose of the body of this report
to present in detail representative examples of the
projects which were undertaken by the Industrial
Engineering Committee at Harper Hospital. It is
thought that the most effective way of making such a
presentation will be to take each project and carry
it to a conclusion as a separate section. Also there
will be a discussion of how the various units were
coordinated into the effective program which has

resulted.

B. The Work Simplification Training Program

As was stated in the Opening section of the
report, it was considered by the Industrial Engineers
serving on the Harper Hospital Improvement of Patient
Care Committee that one of the most important con-
siderations in the entire project was the problem of
insuring that the methods improvement program was to
be a continous one. If it was to be an active program

only while the outside eXperts were on the job, and

59
would die from lack of stimulation when their enthusi-
asm had been removed, the total program would have
to be considered a failure.

If this program was to be a continuous program
it would be necessary for people within the hOSpital
organization to thoroughly understand the program and
to be skilled enough in the use of the approach which
was proposed so they could continue the project on
an ever growing basis.

Probably the greatest proponent of the need
for properly trained peOple in the use of industrial
engineering is Allen H. Mogensen, Director of the
Management Training Clinic at Lake Placid, New York.
Work Simplification is a term which was coined by Mr.
Mogensen and it aptly fits the concepts which he pro-
poses.4 Work Simplification is a way of improving
work output in an organization with a minimum of
capital eXpenditure. It is a combination of the
principles of scientific management, industrial
engineering, salesmanship, and plain common sense.5

It was decided that the term, Work Simplifi-
cation, could be well adapted to the work which was
being attempted at Harper Hospital. It was a clearly
accepted fact that the time of telling people how to

do a job was past. This has been shown by the

40
successful efforts of the unions and labor in general
to resist or circumvent organizational mandates. .
Only if there is a change in the sentiments of peOple
involved in the change, will that change be entirely
successful. And in industrial engineering it is
necessary to work constantly on the theory that the
best method in the world is useless unless it is
used on the job as it was intended that it should be
used.

All people have a basic fear of change. This
fear is aggravated in the lower class of workers be-
cause Of their position in the social stratum. The
ordinary worker is at the bottom of the heap and he
is nearly always in the position of having to adjust
himself to changes which he does not have a part in
initiating and which he does not understand. Add to
this, the fear Of being completely displaced from his
job by the specter of the push-button factory and it
is easy to see why workers resist new methods.6

Top management is prone to resist new methods
too, and fundamentally it is the same basic fear of
change which affects our top management.7 However,
the approach to top management is somewhat different
than the approach that is made to the rank and file

workers. Top management usually recognizes the need

41
for change to a greater extent than the worker. But
still they have a basic fear of the unknown and so
the job in top management usually in one of gaining
a complete understanding of the principles and appli-
cations which the industrial engineer is going to use.

Recognizing the fact that the sentiments of
the people involved in the methods change must be
altered it is evident that if a methods change is to
be successful you must sell the idea to the users.
Allen Mogensen advocates that the best way to sell
a person on a methods change is to consult the person
involved. Not only does consulting the person in-
volved in the methods change help to sell the person
on the change but alot of valuable ideas will be dis-
covered by talking to the person who is doing the
particular job. It is a fact that no one knows the
job as well as the man doing that job.

The eXpert approach is no doubt a very prompt
and efficient way of developing better methods. How-
ever, when the better methods are impressed on the
workers the results are not always as anticipated.
The consulting approach takes more time than the ex—
pert approach in the initial applications, however
each applications results in more confidence and en-

thusiasm on the part of all people involved. As a

42
result, the original extra time investment is more
than repaid in future savings.

A very definite point should be made of the
necessity of having top management support for any
work simplification program. A policy statement
should be made by top management, to all employees,
that no person will be displaced due to a methods
improvement in a case of a change in a basic process.
Such major changes should be thoroughly discussed
with the workers involved. Usually all people dis-
placed can be absorbed by the labor turn-over. Top
management also must realize that a major change in
employee attitude is necessary to institute a success-
ful work simplification program. This change in
attitude will require the concerted effort of all
levels of management as well as a considerable
amount of time. T

In order to demonstrate to management the
importance of their position in the training set-up
it was decided that the first series of classes would
be composed of the tOp people in the hospital group.
Not only was it deemed necessary that these people
should become acquainted with the industrial engineer-
ing approach as it was to be applied to the hOSpital
situation, but these peOple would have to give their

45

ardent support to the program if it were to be a
success at Harper Hospital.

As a result of the above discussion a training
program was worked out and presented to a ”pilot“
group composed of the following people:

Mr. George Cartmill, Associate Director, General

Dr. Donald McKinley, Associate Director, Medical

Mr. Joseph Rourke, Associate Director, Out

Patients' Service and

Buildings

Miss Marion J. Wright, Associate Director,
Special Studies

Miss Lucy D. Germain, R. N., DirectOr Of
Nursing Service and Nursing
Education

Miss Mary M. Harrington, Director of Dietetics
and Dietetic Education

Mrs. Martha J. Ballard, Executive Housekeeper

Mr. Harvey Caddell, Administrative Assistant.
Building and Plant Depart-
ment

Miss Margaret O'Connell, Administrative Dietitian

Mrs. Esther Ashton, Associate Director of Nursing

Miss Margaret MacLean, Instructor in Nursing,
, Medical and Surgical Nursing

Miss Jayne Walters, Unit Kitchen Dietitian
It should be noted that the people on the above

list are top management people. It was thought that,
if peOple in such positions as these, could be put

44
through the training course, and be thoroughly con-
vinced Of the value and of the need for the WOrk
Simplification Program, the program, itself, would
be well on its way toward success. These people were
in a position where they could exert a maximum of in-
fluence on the attitude of all of the people at
Harper Hospital. Conversely, these were the pe0ple
who, if they did not ardently support the program,
could put a damper on the entire program.

. The WOrk Simplification Training Program at
Harper HOSpital was started in May of 1951. The
detail of the training program is not to be covered
in this report. It is felt that the detailed in-
‘formation on the principles of industrial engineering
has been sufficiently covered in standards texts.8
However, a skeleton outline is given in order to show
what information was covered in the course. This out-
line follows:

Session I. Introduction to Work Simplification
A. Outline of the course.
B. Aims of the course.

C. Need for the course in the hospital
situation.

D. ProgreSs in work simplification in the
hospital field to date.

45

Session II. Arouse Interest in Work Simplifi-
cation.

A. Demonstration of motion economy by the
use of the peg board.

Session III. How to Pick a Job to Improve.

A. DeveIOping an awareness that most jobs
can be improved.

B. Practice in spotting ineffective methods.
Session IV. Principles of Motion Economy.

A. Presentation of the principles of motion
economy.

B. Practice in using the principles Of
motion economy.

Session V. How to Analyze a Job.
A. Process Flow Chart.
B. Demonstration of Process Flow Chart.

Session VI. Practice in Using a Process Flow
Chart.

A. Group participation in making a Process
Flow Chart.

B. Discussion of the chart and the principles
involved. '

SesSion VII. Process Flow Chart Review.

A. Review of the use of the Process Flow
Chart.

B. Presentation of the Flow Diagrams and
Work Station Sketches.

C. A discussion of charting complex problems.

D. Need for the use of trained personnel to
assist in solving complex problems.

 

 

3 4 cu! . ..u.fl:1_ul.r'_,..flw.

-1

w .p “—1.75.

46
Session VIII. Analyzing a Job.

A. Discussion of what, where, when, who,
how, and why.

.B. Discussion of eliminate, combine, and
simplify.

C. Review of the above in connection with
the Flow Process Chart.

Session IX. Developing a Better Method.
A. Discussion of using the principles
studied to date in developing a better
method.

B. Demonstration of developing a better
method.

Session X. Developing a Better Method.
A. Practice in developing better methods.

Session XI. Preparing Proposals for Improve-
ment.

A. Importance of proper preparation of
proposal.

B. Practice in preparing proposals.
Session XII. Applying the New Method.

A. Technical problems in applying a new
method.

B. Personnel problems in applying a new
method.

C. Selling the new method.
D. Follow-up and control of new method.
E. Analyzing the results of a new method.

Sessions XIII and XIV. Discussion of PrOposals
for Improvement.

A. Each member of the training group will
prepare a proposal for an improvement

47
in his or her own personal work area.
Note: This should be brought to the
group's attention several sessions in
advance in order that they shall be
prepared.

The first series of training classes was con-
ducted by the Industrial Engineers who were working
on the project at Harper HOSpital. In line with the
.stated intention that Harper Hospital should take
over the program as quickly as possible, Miss Mac-
Lean of the School of Nursing, and Miss welters of
Dietetics, as noted on the original class roll, were
trained to take over the future Work Simplification
Training Classes at the hospital. The first sessions
were finished in July of 1951. In September of 1951,
two additional groups composed of the next level of
management in the hospital were started with Miss
MacLean and Miss Walters as conference leaders. In
order to assist these leaders a weekly meeting was
held with members of the Industrial Engineering group
in Order to help arrange the coming sessions and to
discuss points of interest which had been brought up
in the previous sessions. When this second round of
sessions had been finished it was decided that the
hOSpital people were capable of carrying on with this
phase of the industrial engineering program themselves.

Since then, several additional groups have been put

48
through the training program and it is the intention
of the hospital people to continue the Work Simplifi-
cation Training program until all peOple at Harper
H03pital are completely informed as to the purpose
and the principles of the Work Simplification con-
cept. If the Work Simplification program is to have
maximum effectiveness it is necessary that the peOple
who take the training program not only submit a pro-
posal for use in the class on Work Simplification but
that they continue to submit preposals on improvements
throughout their working career. In order to see that
this occurs, there should be set up a permanent organ-
ization for the handling of proposals and the trainees
in the Work Simplification Training program should
be made aware of the functioning of this part of the
organization. A discussion of how this was accomplished'

will be taken up as the next part of this report.
C. The Work Simplification Organization

It was emphasized in the first part of the re-
port and again in the discussion.of the Work Simpli-
fication Training program that the application of the
principles of industrial engineering to the Harper
HOSpital situation would be a success only if there

‘was a continuance of the program and an expansion of

 

'IH til-d1. H.

v'

49
the program even after the consulting engineers had
left the scene.

The first step in implementing this idea was
the WOrk Simplification Training Program, in which
it was proposed that all people in the hospital, who
would be affected by the program, would learn the
basic principles of industrial engineering as they
were to be applied. As part of this Work Simplifi-
cation program each participant was required to make
a proposal for improvement within his or her work
area. The reason for this prOposal for improvement
(See Figure 2) was three-fold. First, it was hOped
that there would be definite savings realized in the
operation of Harper HOSpital through these proposals
for improvement. Secondly, the preparation of a
proposal for improvement and the following through
with the installation of the improvement would force
the participant to apply the principles whicn had
been discussed in the early sessions of the Work
Simplification Training Program. As a result of
applying these principles the participant would gain
confidence in their application. Thirdly, the parti-
cipant in the Work Simplification Training Program
would receive instructions and practice in the opera-

tion of the proposal system. The participant would

 

“L. .. ‘22.. ‘ (N.,.vifi, V:

 

NO.
HARPER HOSPITAL

 

 

 

 

 

SUBMITTED 51: DATE: __
DEPARTMENT NO.: Phone Ext. ‘._.___.______..._._.._
1‘ LEAVE BLmfig
To: (Immediate Supervisor) iN:
Gd __..______.,....__._.
COPY mg: i‘ReC’d .. ___.__

DESCRIBE YOUR PROPOSAL: Be Brief; don't elaborate—~just jot it dOwn.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_-. N.” i__l. _,
(Space on Reverse Side for Supervisor's Comments).

(Make out Process Flow Charts on the Present and Proposed MethOdS, along with any
drawings, sketches, etc. which would make your prOposal easier to understand.
Attach this material to the original of this form only.)

51
discover that there was a very definite tie-in between
the Work Simplification Training Program and the
Wbrk Simplification Organization which was set up at
the hospital.

In the original discussions of the over-all
program this point was repeatedly emphasized; it
would be necessary that all participants in the Work
Simplification Training Program understand that if
the total program is to be a success their submission
of proposals for improvement will not stOp after the
one required prOposal is made during the training
sessions. In other words the program had to have a
backing from some particular office or place in the
organization so that, after the participants in the
Work Simplification Training Program had graduated,
they would have an office whose primary duty was to
'work with them in order to expedite future proposals.

It was decided that for the present time this
authority should be vested in the office of Miss
Marion wright, Associate Director of Harper Hospital.
However, the actual function of running the program
would be carried out by a committee of five peeple.

It was decided to use this committee approach
for two reasons. One, at the present time the program

was not sufficiently far advanced so that it was

52

thought that a separate Operating department could
be established. And secondly, it was thought that
in view of the necessity for selling the entire
program, that the inclusion of some of the major Oper-
ating heads on the directing committee would strenghten
the program as a whole. Accordingly, a committee
was set up with Miss Wright as chairman and including
the following people:

Assistant Director of Nursing

Administrative Dietitian

Housekeeping Supervisor

Maintenance Representative

Work Simplification Conference Trainers
(three at present)

It should be noticed that included in the personnel
of the committee were people from the main depart-
ments which would be instrumental in submitting the
majority of proposals. Figure 3 is a flow chart of
the presentation of a typical prOposal and its path
through the organization.

There were two types of proposals which were
encountered. First, was the type of proposal which
affected a change in procedure or layout of one
particular department and which affected no other

department. This type of proposal, especially if the

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54
eXpenditure was low, was implemented by the person
making the proposal, c00perating with the depart-
mental head. In this case a record of the proposal
was sent to the WOrk Simplification Office only so
that the entire history of the program could be
properly kept at a central location. The Work Simp-
lification Office did not intend to assume any
authority which was formerly held by individual de-
partments,in fact it encouraged the assuming of more
authority by these individual departments. The skill
acquired by the peOple associated with the Work I
Simplification Office from the handling of prOposals
in the many departments was utilized by the various
departments on a consulting basis. However, anything
that could be handled by a particular department was
not officially considered by the Work Simplification
Office unless help was Specifically requested by the
department involved.

The second type of preposal which was en-
countered was that type of prOposal which involved
more than one department or a large amount of study
and analysis and/or a large capital outlay for equip-
ment or facility changes. This type of proposal was
submitted through the worker's immediate supervisor

and thence to the Work Simplification Office. The

55
Wbrk Simplification Office distributed copies of the
proposal to the various interested persons and got
their reaction and then the entire proposal was sub-
mitted to the Work Simplification Committee. The
committee then called any interested departments,
persons possessing special skill, requested outside
advice if necessary, and in short coordinated the
entire study, and then made the final decision as to
the adoption or rejection or modification of the pro-
posal.

The Work Simplification Office also implemented
the installation of the prOposal in that it was
responsible for notifying the proper parties that they
should take action. With Miss Wright, Associate
Director of Harper HOSpital, as chairman of the com-
mittee, it is well within the powers of this committee

to take such action.
D. The Pharmacy Delivery Service

One of the first things which was noted at
Harper Hospital by those concerned with the improve-
ment of patient care was the fact that alot of
skilled pe0ple seemed to be traveling from place to
place in order to get some object or to perform a

small task. The Industrial Engineers noted this

56
great amount of walking as an indication of a potential
saving of time. It was thought that perhaps some of
the walking could be eliminated.

In the initial discussions about the problem
and after interviewing some of the floor personnel
to obtain some evidence upon which a study should be
based, it was found that by far the greatest single
type of errand which was carried out by the floor
personnel was the making of trips to the pharmacy to
pick up drugs for administering to the patients. It
was decided that in order to get some work under way
immediately, a pharmacy delivery service would be
established.

The people connected with the Operation of
the pharmacy held a meeting and decided that a cen-
tral pharmacy delivery service could be set up.
Routine deliveries to all floors would be made by a
delivery man pushing a cart from floor to floor.
Thus cart was loaded with a supply of drugs needed
at the various floors. Also it was decided that
all standard drugs would be stocked at the various
locations and that these stocks would be replenished
automatically by the pharmacy delivery man. In order
to do this it was necessary to set up standards for

all of the various drugs on each floor. This was

57
done by a head nurse on each floor after examining
her past usage records.

This delivery service was started and it was
found that one man could make the complete rounds of
the hospital in three hours. It was estimated that
sixty-eight hours per week of floor personnel time
was saved. This was a partial fulfillment of one of
the original objectives of the project. Previous to
the establishment of the delivery service, a check

showed that approximately twenty trips were made to,
the pharmacy each day and that each trip averaged
about thirty minutes.

As will be seen by the study which was made
before establishing the general messenger service,
there were some trips to the pharmacy for emergency
orders or for special orders which should not be
handled by the delivery man. But all people con-
cerned with the pharmacy delivery service feel that
this service is a worthwhile and profitable one.

As a direct result of the establishment of
this delivery service by the pharmacy the people con-
nected with the pharmacy became interested in the
problem of saving time, and on their own initiative
have gone ahead and made two further improvements in

their service to the rest of the hospital. First,

58
they have worked out a system of pre—packaging almost
all of the standard medicines that are used through-
out the hOSpital (See Figure 4). Secondly, they have
found that many of the medicines which were used can
a be supplied in larger units than had been used in the
past and that this has resulted in a saving of both
time and packaging materials to the heapital at large.
This point should be noted because that is a mani-
festation of the attitude that it was hoped would be
established at Harper Hospital as the result of this

industrial engineering work.

E. The Central Messenger Service

It was thought that before a general messenger
service was established, an activity study of the
hospital at large should be made in order to determine
just what type of a messenger service should be
established and how effective it would be. It was
decided that such a study could be made by the
floor personnel themselves. The purpose of the study
was eXplained to the nurses and head nurses on four
representative floors of the Harper Hospital and
they agreed to keep a record of all errands which
took them off of their own floor. This record was

kept for a period of two weeks.

zuw noun-nun. cu»...-

w.»

Eran-nm"

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1'18 A Pro >
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Dummy ,0 th. Unizsmmncy Awaiting

60

It was thought that the four floors selected
were representative of the hospital as a whole. In
these four floors were a total of 105 beds or 18.6%
of all beds at Harper Hospital. Table I was made to
show in condensed form the results Of this study.

As a result of this study it was decided that
a central messenger service should be established.

A central messenger service was established within
the communications section of the hospital. The ser-
vice was under the direct reSponsibility Of the chief
telephone Operator.

A check was made on the messenger service
after it had been in existence for eight weeks and
for the eighth week it was found that the messenger
service handled 1,815 errands of which a study
showed that at least 1,400 would have been made by
floor personnel. In addition to this the messenger
service handled 515 admissions and 559 discharges;
these duties have been taken over by the general
messenger service. The messenger service also has
taken over the job of staffing the ambulance entrance.
This had previously required three people to cover
the three shifts.

In order to provide the above services, twelve

full time messengers were employed. These jobs were-

TABLE I

TWO-WEEK SUMMARY OF "OFF—FLOOR" ERRANDS
(Four typical floors - 18.6% of tbtal beds)

 

 

>« 0' H E34
.2
. In
a 5; é a 5 5 >4
9‘: 51 H g a e m
U} (9 m U) {1] E Q:
>i I Z O a " (D O O 8
o . a g a g g a w
5 a a g m' a E a M a g
a s a a :5 m . 5 a 5 H g 8 g g E g
j g ‘34 a >5 0 E04
Nurse 15 10 215 5 10 ' 15 270
Practical Nurse 11 85 16 18 § 35 5 170
Orderly 5 977 107 15 30 4o 15 48 3 201 57 60 1555
Ward Helper 70 466 25 20 133 66 10 113 1 85 20 5 115 20 1149
Ward Clerk 72 95 15 5 82 79 30 50 p 5 16 27 41 15 40 10 583
TOTAL 152 1550 147 340 261 185 78 221 ‘ 125 35 228 41 83 215 45 3727
PROJECTED TO ENTIRE HOSPITAL FOR ONE 1va
Nurse 726 minutes 3 12 hours, 6 minutes
Practical Nurse 45? minutes = 7 hours, 37 minutes A
Orderly 4180 minutes = 69 hours, 40 minutes 3
?
Ward Helper 3088 minutes = 51 hours, 28 minutes I
Ward Clerk 1567 minutes 2 27 hours, 7 minutes
TOTAL 10018 minutes = 166 hours, 55 minutes

(This equals approximately 4.17 men for ‘1 week)

 

 

 

lg

61
filled by pe0p1e with practically no training, except
for an orientation to the hOSpital situation. Many
of the messengers were college students worked to-
gether to handle a shift. ,

Another check also was available on the
efficiency of the messenger service in that the
messenger service was established during the same
week in which the work sampling study of the activity
of floor personnel was made. The work sampling study
had been going on for two days when the messenger
service was established. During those first two days
a few errands were noted, but by the end of the work
sampling study, one week later, there were practi-

cally no off the floor errands being performed by

the personnel under study.
F. Linen Cart Exchange Service

One of the principles of better materials
handling is that material should not be rehandled
unless absolutely necessary. The ideal flow Of
materials is where a material is received into the
plant and is moved once, directly to the point of
use.9 It should be used immediately or if storage
is necessary, it should be stored at the point Of
use so that the person who will ultimately use it,

62
will be able to get it without additional handling.

This ultimate goal is not always reached. There

are other problems such as insufficient storage

room at the point of use, control of materials re-
ceived and disbursed, and maintenance of inventory,
which.may call for modifications of the above prin-
ciple. However, the ultimate in efficient operation
would be realized if the above were adhered to
strictly.

The Industrial Engineers in their initial
observations of the hospital noticed that there was
one flagrant violation of the principle of minimum
rehandling. This was the handling of the linen be-
tween the laundry and the point of ultimate usage,
that is the patients room. The handling of linen in
a hospital as large as Harper Hospital is a major
problem, so any savings, however slight percentage-
wise, would be rather large. Therefore, it was felt
that this problem.was of a magnitude which justified
a rather careful analysis. The volume of flat linen,
which was the object of this study, was about five
tons per day.

The point that caught the attention of the
Industrial Engineers was the multiple storage system
used in handling the linen. A cursory study of the

65
problem indicated that a Flow Process Chart would
probably be best adapted to the solution of this
problem, so an analysis of the problem was made,
using a Flow Process Chart. (See Figure 5.)

As can be seen from examining this chart, the
original study included only that portion of the linen
cycle after it was passed through the mangle and until
it had been placed on the patient's bed or in the
patient's room. The return of the dirty linen was
not studied at this time, because the dirty linen
was being returned from the various floors to the
laundry by placing it in bags and dropping it down
a chute. This chute led directly into the sorting
room in the laundry, then the linen was taken through
the washing and the drying cycle. The laundry was
set up according to standard commercial practice and
appeared to be rather efficiently operated, so it was
thought that a study of this portion of the cycle was
not justified at this time.

As can be seen by reference to the chart, the
linen was being handled as follows: Starting with
the linen as it came from the mangle, it was first
placed on a large cart. The custom had been to wash
items of a similar nature in the same batch, so the

linen came from the mangle roughly divided according

 

M. 5 [in hunt Snnr‘ of "can thud u!
Sunlvt" :1." Ln” to hunt”. bun

65
to the type of material. A girl folded it as it
came off of the mangle and placed it in a large,
shelved cart. When loaded, this cart was pushed to
a central storage area in the laundry. This was a
distance of 70 feet. Next the cart was unloaded and
all of the linen was placed on shelves in the central
storage area and kept in storage on these shelves
- until such time as it was requisitioned by an in-
dividual floor. When a requisition was received from
a floor, it was filled by taking the prOper items
from the shelves in the central supply area and plac-
ing them on a cart, which a worker would then take
back to the ordering unit. When the worker reached
the unit with the linen he would place the cart in
or near the storage closet and then would transfer
the clean linen from the cart and place it on the
designated shelves in the storage closet. Linen packs
were made up by nurses aids to include all of the
linen used for a bed. A typical pack was as follows:

1 Spread

large sheet
draw sheet
pillow case

face towel

:4 F4 re FJ I“

wash cloth

 

66
1 bath towel

1 gown
The total usage in the hospital was 600 packs similar
to this each day. It took,58 minutes per pack to
make them up. These packs were stacked on the closet

shelf until such time as they were needed to make up

:_7—- —--—---—--gr

‘yfia‘mm'. ‘:

a bed. The linen pack would remain in the storage
closet until such time as it was needed for use in

a patient's room. Then the nurses aid or practical
nurse or other person making up a bed would come to
the closet, and move the required number of linen
packs to the patient's room. Then the linen would be
used in the patient's room.

An analysis of this chart shows that there were
six operations performed of which only two contributed
toward the fulfillment of the task which was provid-
ing clean linen in the patient's room. The other
four Operations merely expedited the fulfillment of
this task and therefore, were subject to elimination ‘
if it was possible to perform the task without the
operations. Operation Two, placing the linen on the
cart, was not eliminated. It was combined with the
storage problem in the laundry. The carts, which
were pushed up next to the mangle so that the linen

could be placed directly on to the carts, were used

67
as the storage facility while the linen remained in
the laundry. Operation Four, placing the linen from
the cart to the shelves, was eliminated. This also
eliminated the need for the storage on shelves in the
central laundry. Operation Six, placing the linen

on the cart, was not eliminated although it was con-

.7737

siderably changed and simplified. Operation Eight,

. . D »._,, ‘ h. "Ina—P.—

placing the linen on the shelf in the floor closet,
was eliminated and the same cart which took the linen
to the floor was used as a storage facility. In con-
nection with the elimination and combination of these
various Operations a saving of one tranSportation
was also effected. However the total tranSportation
distance remains approximately the same. Because the
linen carts could be rolled from room to room with

a complete supply of all items, the need for making
up linen packs was eliminated, and the movement of
linen to the rooms was greatly simplified.

It was decided to perform the operation of
supplying clean linen to the patients' rooms as
follows: (See Figure 6) Starting at the same point
as before, that is, when the linen comes from the
mangle, it was decided that it would be placed on
the same carts as had been used in the Old method.

However, these carts would be used in an entirely

 

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69
different manner (See Figure 7). The carts now
would be merely a movable storage bin so that, as
the various items came from the mangle, they could
be stored and moved sufficiently away from the mangle
so that the mangle Operators would have room in which
to continue working. Next, the linen would be trans- - f<
ferred directly from the storage carts in the laundry
to a specially designed cart which would go to the
floor. This cart was so designed that it would con-
veniently carry all of the linen needed for a full
day's OperatiOn in any unit in the hospital. It
also was designed so that it could be easily stored
in the closet which had formerly been used to store
the linen on separate shelves. Enough carts (See
Figure 8) were procured so that there would be two
carts for each unit in the hospital. One cart
would be on the floor, acting as a movable storage
unit, and the second cart would be in the laundry,
awaiting refill so that it could be transferred to
the floor for the next day‘s operation. Each cart
had on it a standard load, which had been determined
by studying the past requisitions of each floor and
adding a sufficient surplus of each of the various
items. This load list was attached to each cart.

As the carts were loaded any Old linen which had been

 

 

Fig. 7 laundry Cort hing landed Directly from
the hub

 

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a L1 1:». "art ‘. 11.2.1 in Ithul from N-,sm g.
Hour: In 1: WI

 

71
returned from the floor from the previous day, was
credited to that floor and was placed on the front
side of the cart so that it would be used first in
the next day's operation. The laundry kept track of
the usage of each floor as had been the custom. Each
a worker from the laundry took a fully loaded cart
to each floor and exchanged it for the depleted cart
on the floor. The loaded cart was placed in storage
in the closet which had been previously used to store
the linen on shelves. Then, when it came time to
make up the beds in the unit, the cart would be wheeled
down the hall, from room to room, and the linen would
be taken from the cart and used in the individual rooms.
It also was found that this cart made a very convenient
I‘ack on which to carry the dirty linen bags during
the period of remaking of the beds and this added con-
Venience was beneficial to the Operation.

A cost analysis of the total operation was
ChPawn up (See Figure 9) to show the savings. It can
be seen from the cost analysis even though there was
a Capital eXpenditure of over $5,000.00 to install
this system of handling linen, that through the saving
in labor alone this investment was paid off very

quickly. The actual period of time that was required
to pay off the investment was .84 years. The study

a
1
.'
r
I

 

 

CAPITAL INVESTMENT
42 new carts @ 123 ea. .
l4 remodeled cafts @2350.00 ea. $5738.88
Total Capital Investment Required $5876.50

SAVINGS IN LABOR

Deliveries frdaon muggy 1“to floors
(4 hrs. per y - s. a year
@ $1.06 per hr.) ' $1547.60

Pre i linen packs
(Gogarpagfis per day - 35 seconds per pack ‘
5.8 hrs. per da - 2117 hrs. per year,
e $1.07 per hr. $2265.19 1

Stacking from mangle to shelves .
(3 hrs. per day - 1095 hrs. per year, ‘

@ $1000 Per hr.) W ‘-
Iotal Estimated Savings $4907.79

DEPRECIATION

(5 Years - 20% p.a.) pllle 4% for taxes and insurance,
10% for maintenance, and 8% return on investment equals
$2468.13 Annual Fixed Charges.

ANNUAL SAVINGS $4907.79
ANNUAL FIXED CHARGES 2468.13

A. .3 1‘?
|

Net Savings $2439.66
(equals 49.7%
on investment)

ANNUAL FIXED (HARGES

Depreciation (20%) $1175.30
32:3: and Inguragice (4%) 235.08
enance 10% 587.65
Total 1998. 01

ANNUALACTUAL SAVINGS
(Gross savings less fixed charges
not including interest on investment) $2909.78
(equals 57.5%
-on investment)

Fig. 9 Cost Analysis of Use of Linen Cart System

73

showed that if the cart were to be depreciated over

a period of five years, and allowing 4% for taxes

and insurance, 10% for maintenance, and 8% for re-

turn on investment, that an annual savings of $4,540.87
would be realized for the five year period.

The cost analysis gave the tangible benefits
which were realized from the use of the linen cart
exchange system. There were other advantages which
were of an intangible nature and for which it would
be very difficult to determine the actual value of
the benefit. Some of these items were:

1. The saving in space which was realized
in the central laundry due to not stor-
ing the linen on shelves.

2. The saving in Space which was realized
in the floor closets due to not storing
the linen on shelves in this location.

3. The saving in time required to make up
beds due to not having to make frequent
trips to the linen closet for more linen.

4. The impetus which was given to the entire
improvement of patient care program by
the hospital-wide display of the results
of an accepted project.

A great deal of attention was paid to the

problem of getting all personnel at the hospital to

properly accept this new system. Many interested
parties were consulted before the final plans were

drawn up. When it was finally decided what should

I 2.1..”
3.

&-"es\.|a-..-:u—...-__ _
‘ _ . \ .. . _

74
be done, two experimental carts were constructed by
reworking some carts which were on hand so that they
would fit the purpose. These two experimental carts
were then used to service a floor according to the
plan. After these carts had serviced a floor for a
week, they were shifted to another floor and given !
a week's run in the next location. In this way a
great percentage of the personnel became familiar with

the use of the linen cart exchange system before they

‘i " . gun‘s.” M'mi‘s “-9-.-..

were actually committed to constant use of the new
system.

It was found that instead of receiving protests
because they were forced to use the system, in most
cases the workers protested because the experimental
carts were taken away from their floor at the end of
the trial period. This reception insured that when
the permanent carts were available for use, there
would be no great amount of resistance to the rapid

implementation of the plan.
G. The Work Sampling Study

In the early phases of the Harper Hospital pro-
ject there had been alot of work performed to find
the duties of the persons directly caring for the

patients. This work had been limited to the use of

75
questionnaire and survey techniques. It was realized
that a survey could determine exactly what an in-
dividual thought his Job was, but some check was
needed to determine if the job was being performed

as the individual thought it was being performed.

.uf

It was necessary for a study to be made of activities
in the hOSpitals to determine exactly what the actual
picture was as to the care which a patient was re-

ceiving.

 

It would have been possible to obtain such
information by the use of long term studies. How-
ever, the amount of labor involved would have made
the cost prohibitive. It was thought also that the
use of the stop watch in the hospital might release
a flood of protest, because at this stage in the
program the acceptance was not complete; therefore
it was decided to try a relatively new industrial
engineering tool. This tool was Work Sampling.

The Work Sampling procedure was selected be-
cause it was thought that all of the information
desired could be obtained in a relatively short time
and with a relatively small amount of labor involved.
It was thought that the results, while perhaps not
as accurate as those which would have been obtained

by the use of a long term time study, would be

76
sufficiently accurate for the purposes for which the
information was desired. That was to analyze the
functions of the people who were caring for the
patients so that the professionals' time could be
most profitably utilized. Also, because random ob- §
servations were used instead of continuous observa-
tions, it was possible for one observer to get infor-

mation about many operations during the same period

'M—u-‘lrm J r- n - '. "
.
~

of time.

Work Sampling is a recent name given by the
magazine Factornganagement and Maintenance to a pro-
cess that was formerly known as Ratio-Delay.lo This
technique originally was applied by Professor Robert
L. Morrow, of New York University, principally to an
examination omeachine down-time.ll However, the
technique has been eXpanded to include almost any set
of sample observations designed to simplify or improve
productivity. It seems probable that when referring
to observations of human activities that the term
Ratio-Delay is distasteful. Work Sampling is the
.name which was used at Harper Hospital for this tech-
Ixique.

Work Sampling is based upon the laws of prob-

éitxility. If a sufficient number of observations are

‘téalcen at random times, of the same operation, the

77
results will come surprisingly close to what could
be discovered by the use of continuous observation.
This is often demonstrated by the throwing of dice
or flipping of a coin. If, for example, a coin were

tossed one hundred times, the laws of chance favor

ran. .4. x". u...
;‘|I

that it would land fifty times with the head up and
fifty times with the tail up. In any sample of one

hundred tosses, however, there might be a considerable

 

1w _~

distortion such as sixty-five heads and thirty-five
tails, but clearly the more sets of throws that are
made, the closer will be the results to the fifty-
fifty standard. Or, the more Samples taken, the
closer is the accuracy of the average which is ob-
tained as the result.

It should be understood that random observa-
tions are exactly what they seem to be. If it is de-
cided that observations are going to be made of a
given activity on a random basis for one week, it
must then be decided in advance how many such obser-
vations will be made in the course of a day. Then,
.if it is deemed advisable to make ten observations
(during an eight hour period, those observations should
lae made at irregular times, and not one every 48

-nxinutes. From an adequate number of observations it

<3€un be determined what percentage of time is actually

 

78
Spent in performing any specific function, what per-
centage of the total time is taken up by unavoidable
delay, and the areas in which it can be expected that
improvement can be made. The percentage of interruptions
or delays to the total time of the function is what f
gave the technique its original title of Ratio-Delay. _ i
It stands to reason that the maximum amount of

information could be obtained about a particular

 

activity by continuous observation. But continuous i'
observation is expensive and would have required the
services of people trained in observation, calculation,
and interpretation of the results. WOrk Sampling has
these advantages over continuous observation:

1. It gets the facts at one-third to one-
sixth the cost.

2. It does not require observers with
special skill and training.

3. It provides the accuracy required.

4. It makes it practical to get facts that
otherwise would not be collected.

5. It produces fewer complaints from opera-
tors who are being studied.

6. It produces less distortion in the routine
of the Operator than does continuous
observation.12

In the study at Harper Hospital it was desired

't<> find out two things. These were, first, what

peeple were actually doing in the unit; and secondly,

79
how much time it actually took to do those things.
That is, what percentage of the time was being spent
by professional personnel on a certain job and what
percentage of time was being spent by non-professional
personnel on the same job.

Because of the complexity of the duties in a
nursing unit, it was necessary to set up job classi—
fications. There were in excess of 500 different
functions being performed in a typical nursing unit
in one day. After considerable discussion with
pe0ple in the unit and other pe0ple involved in the
study, these functions were consolidated into twenty-
nine classifications with a list of what was to be
included under each classification. The personnel
was broken down into the following major types:
graduate nurse, head nurse, practical nurse, ward
clerk, housekeeping maid, student nurse, nurses aid,
orderly, and dietary maid. So with this pattern
established it was possible, upon the successful com-
pletion of the study to determine what percentage of
his or her time each of the above types of personnel
Spent in doing each of the twenty-nine classifications
of work.

Three observers were trained to make the actual

study. They checked very carefully the twenty-nine

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80
classifications so there would be common understand-
ing as to exactly what work would be placed into
each class. Then one observer was assigned to each
of the three shifts in the hospital, giving twenty-
four hour coverage. It was decided to run the study
for seven consecutive days.

A tally sheet was used (See Figure 10) to tabu-

late the observations as the observer made them. It

was decided that each observer would make approximately

ten observation tours through the three teSt units
during each shift. These trips would be made at ran-
dom intervals. At the end of each day, the total
observations for that day were placed on an accumula-
tion sheet (See Figure 11) and the percentage of
occurrence of each classification was calculated.

This calculation was made on a cumulative basis. Some
of the more critical items were then plotted on a
graph in order to determine if the study was being
run for a sufficient length of time to get the desired
accuracy. It was known that it was characteristic

.of a statistical sampling study such as this that the
more observations which were accumulated the greater
the accuracy. Figure 12 shows the plotting of some
of the activities of the head nurse. It was observed

that during the first few days of the study these

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84
activities fluctuated greatly but from the fifth day
of the study on to the completion they smoothed out
rapidly and it was believed that additional study be-
yond the seventh day would not be justified, as the
.information that was accumulated was sufficiently
accurate for the purposes desired.

At the completion of the study it was found
that a tremendous amount of information had been
secured. It was then necessary to analyze this data
in order to determine which functions were out of
line and how those functions could be realigned in
order to make for more efficient operation.

Preliminary to the actual job of analysis,
the following charts were plotted using the data which
was gathered during the study:

l. Amount of care received by patients.

2. Amount of time and percent of total
direct patient care contributed by each
type of personnel. (Separate charts were
compiled for each shift.)

5. Amount of time and percent of total in-
direct patient care contributed by each
type of personnel. (Separate charts were

compiled for each shift.)

4. Percent of personnel time spent on each
activity. (Separate charts were compiled

for each shift.)

5. Percent of personnel time spent on direct
and indirect care of patients by shift.

10.

85

Amount of time in minutes spent by each
type of personnel on each type of activity.
(Separate charts were compiled for each
shift.)

Total care in minutes per day given by all
types of personnel in each of three test
units. (Separate charts were compiled for
each shift.)

Staffing of units during test week.

Comparison of acuity study and percent of
time spent by personnel on activities.

Questionable activities of professional
staff and time involved.

The making of these tables placed the information

gathered by the study in groupings and relationships

so that it could be analyzed in terms of improving

the Operations at the hOSpital.

A committee was formed composed of people famil-

iar with the operations which had been tested, and

people skilled in job analysis, in order to study the

material which had been assembled. It was the pur-

pose of this committee to interpret the data in order

to realign the functions so that the operations could

be improved.

The following observations were representative

of those made. It was found that the head nurse was

giving four per cent of the baths in bedside care and

was also giving seven per cent of the medications on

the 7:30 to 5:30 shift. Although neither of these

L0
C)

duties were considered head nurse functions. The
head nurse also was giving 236.213 of the treatments;
again this was not a head nurse function. It was
found that the head nurse was Spending 17% of her day
in charting and yet she was spending only 52% of her
time on truly supervisory functions. She was spend-
ing l5% of her time giving medications, 3% of her
time giving treatments, and 1% of her time in cler-
ical work. It was immediately asked, are bed making,
charting, clerical work, medicine and treatments
proper head nurse functions, and shouldn't she be
spending more than 32% of her time supervising.

In the field of the graduate nurse it was
found the average graduate nurse spent 65.9% of her
time giving direct bedside care on the 7:00 to 3:00
shift; 48% of her time on the 5:00 to ll:00 shift,
but only 30.8% of her time on the 11:00 to 7:00
shift. As one of the purposes of the entire program
was to determine the best utilization of professional
skills, the question was raised as to why a graduate
nurse was Spending only 50.8% of her time on the 11:00
to 7:00 shift doing direct bedside care. Couldn't
she be spread over a wider range of patients if some
of the functions which she had been performing were

allocated to other persons? For instance, she was

S7
doing 85.3% of all the clerical work on the 11:00 to
7:00 shift, 49.7% of the supply storage, and 37% of
all the supply equipment movement on this same shift.
This work should not have been done by a professional
person. These questionable activities of the pro-
fessional staff are shown in Figure 13.

Another activity which was considered was
that of idle time and interruptions. For example,
on the 11:00 to 7:00 shift the idle time was as
follows: 4.7% for the graduate nurses, 11.6% by the
practical nurses, 34.5% for the aids, 31% for the
orderlies. This indicated that the less training the
individual had, the more supervision was necessary
in order that a prOper job be performed. This was
added evidence that the head nurse should have been
Spending more than 32% of her time in a supervisory
capacity. A far greater amount of available time
was lost by idle time in other classes of work due
to the lack of supervision, than could possibly have
been gained by the performance of duties by the head
nurse.

As a result of the analysis that was made, a
staffing pattern was planned for the test unit based
on all of the information which had been collected

so far. This included not only the information which

HEAD NURSE Time in minutes

2.3 shift 3.11 shift 11.2 shift

Bedside care 26.4 none on duty none on duty
Bed making 9.6
Charting 84.0
Medicines 98.0
Treatments 16.8
Total 234.8

GRADUATE NURSE
or
STUDENT NURSE (acting as replacement)

Bed making 28. 8
Charting 61.3* 75.6* 94.8".
Clean and scrub 8.8 1.4 18.3
Feeding 10 . 8
Nouri shments 10.8
Supply movement 19. 8 7. 2
Supply storage 8.8
Clerical work 55.8 119.4
T o P OR. 12. 0

Total 149. 1 152.0 262.5

I! excessive

Fig. 13 Questionable Activities of Professional Staff

89
had been collected by the Work Sampling study but
also that which had been obtained by using the ques-
tionnaires, and the changes in functions which had
been accomplished by some of the central services
which had been set up.

In this new staffing pattern the amount of
treatment which each type of patient needed, was
determined and professional help, aid help, practical
nurse help, and clerical help were assigned to the
wards in the proper proportions so that each person
could do the task which he or she was best qualified
to do. A head nurse was placed in charge of two
units and she was able to supervise the care of from
forty to forty-six patients on the theory that the
graduate nurse was a charge nurse responsible for the
direct supervision of personnel working with her.
Patients were assigned directly to a graduate nurse.
She delegated the duties and planned for the nursing
care of the assigned patients. The function of the
head nurse was that of ward manager, coordinator, and
teacher.

A training program was established to teach
all of the personnel selected for the test unit, the
new staffing pattern and the duties which went with

each job.

90

The plan was put into Operation and after it
had been Operating for approximately four months the
unit was re-surveyed in order to determine the
effectiveness of the plan. A second WOrk Sampling
study was conducted and it was found that the plan
was actually Operating very nearly as it was intended
it should operate. A great deal of credit for the
proper carrying through of the plan was given to the
training which was provided for all personnel as to
the duties they would be eXpected to perform under
the new staffing pattern.

The patients were surveyed regarding their
satisfaction with the care provided under the new
staffing pattern. There were eleven items in the
survey relating to nursing care, and when the new
survey was compared with the survey which had been
made under the Old staffing plan, it was found that
there was increased satisfaction on seven items in
the survey. Three items remained about the same. 0n
only one item was there a drop and this was only 2.5%.

In addition the personnel actually using the
new staffing pattern were surveyed regarding their
satisfaction with the pattern, and their comments were

in the main complimentary to the new staffing pattern.

CHAPTER V
CONCLUSIONS
A. Restatement of Problems

In the beginning of the study, two main prob-
lems which were faced, for which it was hOped there
would be a solution, as the result of this study.

These problems were:

1. To get maximum utilization of professional

personnel.

2. To reduce, or prevent further increases

in operating costs.
The following conclusions will indicate how well these

Objectives were met.
B. Utilization of Professional Personnel

There are two indications of a solution to the
problem of utilization of professional personnel.
These are: First, as a result of the realignment of
functions which took place in the test units, it is
possible to use less professional personnel to cover
those units. This program, which was proved in the
test, was put into effect throughout the entire hos-

pital. As a result of the implementation of this

92
plan, Harper Hospital has been able to Open more beds
than at any time in its history. The professional
personnel on the payroll, even with this increased
number of beds for patients, has been materially re-
duced. Interested parties can obtain the exact
amount by contacting the author or by corresponding
directly with Harper HOSpital.

There are other indications of the savings of
professional personnel which were of a nature which
made them extremely hard to measure directly. These
savings were manifested by an interest on the part
of professional peOple throughout the hospital in the
application of the principles of industrial engineer-
ing to their particular jobs. In many cases there
was no change in the staffing pattern but it is be-
lieved that, as a result of minor changes which took
place because of the questioning attitude on the part
of these peOple, the persons in question were able

to better perform their jobs.
C. Reduction in Operating Cost

It is concluded that the objective of reduc-
ing Operating cost was accomplished. However, it had
been decided early in the study that the reduction

in cost would not be publicized as a major achievement.

93

This was done for two reasons. First, it was
felt that there might be a reaction on the part of
the patients if they thought they were getting
"cheapened" care. It was decided that the emphasis
would be placed on giving the patient better care
and not on the reduction of cost to the patient.
Secondly, it is thought that there might have been
unfavorable reaction among the employees of the hos-
pital if these savings were publicized.

There were several studies made which could
be directly analyzed in terms of reduction in cost.
The one chosen, as representative, for inclusion in
this report was the use of the linen exchange carts.
This improvement resulted in an annual savings in
direct labor of $4,907.79 and a net savings after
deducting for fixed costs of $2,439.66. This repre-
sented an annual return of 57.7% return on the
$5,876.50 invested.

There are savings in Operating cost which were
not directly analyzed in terms of dollar savings.
One manifestation of these savings is the fact that
after the nursing group had taken the work simplifi-
cation classes and had been eXposed to the study for
some time, on their own initiative, they revised

fifteen of the nursing procedures in light of the

94
principles of motion economy.- It is their intention
to continue this project until all nursing procedures
had been completely checked.

Another similar manifestation is the work per-
formed by the people in the pharmacy in the pre-
packaging of drugs in order to get a more efficient

Operation.
D. Employee Morale

As a result of this project there is a distinct
change of attitude among the employees at Harper
Hospital. Because of the realignment of functions
in the nursing units, there is a feeling that there
has been a rise in the status of the professional
nurse. The so-called "menial” tasks have been re-
moved from her sphere of responsibility and she is
able to concentrate on the professional tasks for
which she has been trained.

As a result of taking many tasks away from
the professional and giving them to lower classfi-
cations, the status Of these jobs also has been
raised. This is evidenced by the attitude of the
housekeeping maids. They are given the entire respon-
sibility for preparing rooms to take a new patient
after the check-out of the previous patient. This

95
includes the responsibility of notifying the admitting
office when the room was ready for occupancy. Previously,
a professional had to check the room, and the maids

had considered this a slighting of their ability.
E. Better Care for Patients

As a result of the transfer of many non-
professional tasks to workers other than the pro-
fessionals, the professionals are able to spend more
time actually caring for patients. This is true even
though the professionals have been given more patients
to care for. The Work Sampling study which was made
after the new staffing plan had been put into effect,
shows this added care to the patients is an actual
fact.

Also, the survey of the patients themselves
definitely shows that they are better satisfied with
the care they received under the new staffing pattern
than they had been with the care which they had re-

ceived previous to that time.

F. Areas for Future Study

It is felt at the conclusion of this study,
that the original objectives have been satisfactorily
accomplished. However, it is also felt that the

96
project itself is not completed, but is actually
only beginning. It is thought that the following
areas could have been explored profitably.

In spite of the fact that there was an accomplish-
ment of the original objectives, it is realized that
several improvements could be made in the areas which
were studied. This would include refinement of the
techniques which were used, and a continuation of the
Work Simplification Training program until such time
as all responsible parties in the hospital had re-
ceived this training.

It is thought that time standards could have
been applied to the hospital situation. This was dis-
cussed during the original project but it was decided
that it was not the Opportune time to install time
standards when the study was just beginning. But it
is thought that time standards should be installed
at some future date. Such installation would provide
a means of measuring changes in methods and would in-
sure control of methods which had been installed.

It is thought that there is a large amount Of
work to be done in the field of paper work simplifi-
cation. This matter was not approached during the
original study because of the lack of personnel to

do the large job which would have resulted.

97

In the original study the operating rooms and
the medical staffs were not included except at such
times when their work and the work being performed in
the nursing units coincided. However, it is felt
that in the future the techniques which were applied
elsewhere in the hospital can be equally well adapted
to those areas.

Due to a desire to stay away from radical
changes, in order to get acceptance, and also due to
a lack of knowledge of basic processes, the study as
it was performed did not challenge any of the basic
medical processes. However, it is felt that if per-
sons with a good medical background, were properly
trained in the industrial engineering techniques,
many of these processes could be challenged and altered
in order to Obtain more efficient Operation, without
in any way impairing the care which the patient would
receive.

It was and is the earnest resolve of all per-
sons connected with the project for the improvement
of patient care at Harper Hospital, that the appli-
cation of the principles of industrial engineering
to a hospital situation, could be promulgated through-
out the entire country. There are evidences that

this will take place in the near future.

1e

3.

4.

5.

8.

BIBLIOGRAPHY

Committee report of The Improvement Of Patient Care
Comittee, Harper Hospital, Detroit, Michigan, 1950.

Industrial Engineering Sub-committee Of The Improvement
of Patient Care Comittee of Harper Hospital, Detroit,
Michigan, minutes of Feb. 5, 195 meeting as amended
Feb. 0, 1951. '

Hogensen Allan H. , "Work Simplification can Speed War
Production" from Aviation, Vol. 41, July, 1942.

Mogansen Allan H., "Work Sim lification" from gin},
Oil and Chemical geview, Vo . 111, Nov. 11, 1 .

Diebold, John, Automatic The Adven of the Automa ic
Eactory, D. Van Nos a Company, Inc., 1952, p. .
Mogansen, Allan H. , ”Applying Methods Improvements"

from Eactogy Management and Maintenancg, Vol. 107,
July, .

Osborn, Alex, and Weis, Gerald E., "Your Ideas-410w to Put
Them Across" from 0 Mana e a Ma c , .

Vol. 108, Feb., 1950.
Osborn, Alex, “About IdeaeuWhich Kind of Bose Are You"

from W: Vol-o 108.
Mam, .

Barnes, Ralph M. t on d ime tud John Wiley and

Sons, Inc. (Thir! Eéitioni, I949, p. 460.

Morrow, Robert L., Time Study and Motion Econm, The
Ronald Press Company, 19 .

lundel, narvin E., Moflgn and Time §§gdy, Prentice Hall,
Inc., 1950.

9

10.

11.

12.

Stocker,Harry Materialg Handliggi ggigciplef,
Equipment, and .fietho s Seco t on , Prent ce
Ha

c.’ ’ p. 5.

Brisley, Chester, "'ork Sampling-«A New Tool to Help
Cut Costs, Boost Production, Make Decisions" from

[aftory Management and Maintenange, Vol. 110,
Ju y, 195 e

Op. Cit., Morrow, Robert L., p.175.

Loo. Cit., Brisley, Chester.

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