You are on page 1of 31

Section 2: Operations

research, work study and work


measurement

Operations research, work study


and measurement

Operations research, work study and measurement

Contents
Introduction ...............................................................................................................53
Objectives ..................................................................................................................53
Operations research ...................................................................................................54
Work study.................................................................................................................56
Work methods and method study ..............................................................................57
Work measurement techniques .............................................................................58
Performance rating ................................................................................................59
Allowances..........................................................................................................510
Measuring workload............................................................................................510
Use of work measurement data for workload monitoring systems.....................511
Workload validity................................................................................................512
Patient Assessment and Information System...........................................................513
Time study ...............................................................................................................514
Time study applied to nursing.............................................................................516
Predetermined time standards .............................................................................517
Work sampling ........................................................................................................519
Work sampling applied to nursing work .............................................................522
Self reporting ...........................................................................................................523
Time and work measurement ..................................................................................523
Principles of work study ..........................................................................................524
Use of self-recording to analyse work performed ...................................................525
Self-reporting studies applied to nursing.................................................................525
Professional judgements/estimates..........................................................................526
Skill mix ..................................................................................................................526
Summary..................................................................................................................527
References ...............................................................................................................527

52

Operations research, work study and measurement

Introduction
Section 2 of this course concerns the input, output and processes of health care
services that define and determine quality and performance. Input refers to the actual
work performed as well as the material and labour resources required to deliver
health care services. Operations research, work study and work measurement are
techniques to measure and analyse input and work processes with the objective of
improving performance by increasing efficiency and productivity. Health services
products or output can be assessed and documented using standards, guidelines and
indicators. These are discussed in Chapters 5 through 7.
This first chapter of Section 2 introduces you to the disciplines of operations research
and work study. The concepts are complex, but the time invested to understand them
is worthwhile as the concepts used are very useful when analysing an organisation, its
operations and the work performed by individuals with a view to improve
productivity and performance.
Once a health service enterprise expands to the point where it can no longer be
managed by one person, it becomes necessary to organise all operations associated
with the services provided. This is often referred to as operations management. The
use of an operations manager was and continues to be prevalent in manufacturing
industry. More recently we have seen the introduction of such positions in the health
care industry particularly in the private sector. One of the main characteristics of such
positions is the need to determine the most efficient way to use available resources.
This is where operations research became popular, as this methodology aims to
identify the optimum use of all available resources. This discipline is closely related
to that of organisation and methods, also referred to as work study, and incorporates
both methods and time study. These disciplines were very popular in the 1960s and
1970s as is evident from the literature of that period. The concepts and principles of
these disciplines are now being applied in the health sector often under the guise of
new terminology such as business process reengineering as we will discuss in
Chapter 10. From an informatics perspective there is an increasing realisation that
systems must fit in with workflows and work practices to be successful. This in turn
requires a sound understanding of how people work and all associated organisational
operations and information flow. The concepts and principles covered in this chapter
provide a sound foundation for the conduct of such analysis. These methods are often
referred to in the current health informatics literature as sociotechnical approaches.

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

understand the theories and practices of operations research and apply them to the
health services setting

demonstrate a reasonable understanding of work measurement and methods study


principles

understand the principles of methods study

identify meaningful units of work for various service areas

analyse how changes to work practices may impact on the outcomes (quality and
performance) of health service delivery.
53

Operations research, work study and measurement

Operations research
Operations research (OR) is a quantitative method suitable for use in the health
services field. Many definitions for OR exist, each emphasising the different elements
according to its specific use. For our purpose, operations research can best be
described as the study of processes or systems and the application of quantitative
methods to the systems to design decision-making models. These decision models
provide the means to determine an optimum course of action within a complex
system with limited resources. It is important to remember that these models do not
provide a solution, but can only be solved to an optimum, that is, there will always be
trade-offs due to the constraints of the system. In the case of health services, these
constraints or trade-offs would include material and human resources, cost, and
quality issues.
OR models are quantitative representations of systems based on random events
occurring in a changing or uncertain future. An OR model to predict random events is
based upon probability theory. The OR model is than solved to its optimum solution
by changing the variables and generating the results. Manipulation of input to arrive
at the optimal results by starting with a wide range of scenarios and then refining the
model with each iteration is known as simulation and sensitivity analysis. The arrival
of an optimum solution through many iterations of a model is done with computers.
OR relies heavily upon the use of computers to generate solutions for many different
scenarios without having to experiment on the actual system that is being studied.
OR uses a systematic scientific approach to problem solving. The five steps of the
scientific method are used.
1. Observe the system or process.
2. Define the problem.
3. Develop alternative solutions (models).
4. Find optimal solutions to the model.
5. Implement the optimal solution.
These five steps do not represent the end of the scientific approach, they are a
continuing cycle. As the optimal solution is implemented, more problems needing
resolution are uncovered. Changes to the system occur and refinements are needed on
an ongoing basis. This cyclical process of continuous improvement is also the basis
for total quality management (TQM) and continuous quality improvement (CQI)
which will resurface again in Section 4. Simply stated, for problem-solving and
decision-making, four basic questions must be answered:
1. What is being done?
2. Why is it being done?
3. How is it being done?
4. How can we do it better?

54

Operations research, work study and measurement

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


Examples are queuing, scheduling, distribution, inventory, maintenance, production,
supply versus demand and defective product type problems. Many of these types of
problems can be found in any health care setting. OR has three essential
characteristics:
1. systems orientation
2. use of interdisciplinary teams
3. adaptation of the scientific approach.
The two most common applications of OR to the hospital setting to date are queuing
theory and simulation models.
Queuing theory refers to the study of waiting lines. Waiting lines are generated by
random arrivals for the receipt of limited services and/or resources. The queuing
models purpose, combined with simulation, is to determine the optimal number of
people or services required to meet the needs of the waiting customers.
Simulation tests the model under different scenarios by changing the value of the
variables until an optimal solution is found. The various scenarios are tested by
running randomly generated numbers through the model to represent random arrival
times. If too many resources are made available, the waiting time is negligible
however the cost would be prohibitive. If too few resources are made available, the
cost is minimised but the waiting lines become unacceptable to the customers. There
will be cost associated with any system and in an environment of limited resources
there will be waiting lines. Operations research models provide a means to find
acceptable costs and risks to both the provider and the customer.
The practice of OR requires the construction and use of mathematical models
representing the problem. According to Ackoff and Rivett (1963, p. 24) all OR
models take the form of an equation in which a measure of the systems overall
performance (P) is equated to some relationship (f) between a set of controlled
aspects of the system (Ci) and a set of uncontrolled aspects (Uj). Thus expressed
symbolically, the basic form of all OR models is: P = f (CI Uj). In words this says that
performance depends upon significant controlled and uncontrolled aspects of the
system. Pidd (1977, p. 15) summarises the OR study as usually consisting of ten
stages, some of which may overlap and be undertaken concurrently.
1. Describe problem in its context
2. Collect preliminary information
3. Define problem explicitly
4. Set study objectives
5. Formulate the OR problems
6. Construct model
7. Collect detailed data
8. Test the model
9. Select solution from alternatives
10. Implement and monitor solution.

55

Operations research, work study and measurement

Specific examples of operations research techniques as applied to health services


include, but are not limited to, optimal staffing, identifying the number of rooms and
equipment required for emergency rooms, cardiac care units, neonatal wards, meet
expected demand, ward layout for optimal efficiency, optimal placement of clinics,
optimal use of blood-mobiles, etc. More information on these specific uses are listed
in the references at the back of this chapter.
In summary, OR can be considered both an art and a science as it attempts to apply
scientific methods to complex systems containing intangible elements including
random events, unpredictable human behaviour and subjective outcomes. Given these
considerations, operations research is highly applicable to health services
performance research in the ongoing quest to provide high quality service within the
constraints of limited resources.
Berg (1999 p. 89) notes that sociotechnical approaches emphasize that thorough
insight into work practices in which IT applications will be used should be the
starting point for design and implantation. This is seen as especially important in the
health industry where this concerns the work of health professionals. More
specifically their work activities coordinate many business processes or operations
such as scheduling, interactions among functional units, staff members, software
components, planning, reporting and more. The skills acquired by adopting the
various workstudy techniques detailed in this chapter are also very useful as the basis
for analysing workflow for the purpose of developing models or activity diagrams
using various modelling techniques such as the Unified Modelling Language (UML).

Work study
Work study is a specific type of operations research used to measure work being
performed in order to increase efficiency and productivity. Said another way, the ILO
(1978, p. 29) (see Reading 51) defines the term work study as a generic term for
those techniques, particularly method study and work measurement, which are used
in the examination of human work in all its contexts, and which lead systematically
to the investigation of all factors which affect the efficiency and economy of the
situation being reviewed, in order to effect improvement.
Work study techniques may be employed to study processes or operations as well as
for the study of people at work. Work consists of the basic work content plus content
added as a result of:

defects in equipment

deficits in knowledge and/or skill

treatment/care regimes used

use of inefficient methods

organisational or management shortcomings, such as scheduling, resource


allocation, location of supplies

inefficient time management by the worker.

Similar to the methodology described previously for operations research, work study
examines work to identify the factors which contribute to the time required to
perform the work. Work study techniques are then used to review the objectives of
56

Operations research, work study and measurement

the work, the prevailing constraints, search and formulate possible solutions, evaluate
each alternative and to select the most efficient and effective way to perform the
work (the optimal solution).
Thus, work study is a systematic way to effect change and improve efficiency by
applying the following steps (compare to the five steps of the scientific method listed
previously):
1. Observe work being performed.
2. Identify factors contributing to performance time.
3. Review work objectives and work constraints.
4. Formulate solutions and evaluate alternatives.
5. Select most efficient method.
Once you have documented a process you are ready to examine it by challenging
every step of the process. The aim is to eliminate all unnecessary work, combine
operations, change the sequence of operations and simplify the necessary operations.
The latter may require an in-depth analysis of specific steps in the process.
Reading 51 below by the International Labour Office (ILO) is an overview of the
principles and basic procedures of work study. Reading 52 is taken from Currie,
1977 and discusses some of the human aspects of performing work study. These
principles have not changed.
Reading 51

ILO 1978
pp. 2935

Optional reading

Currie 1977
Ch. 23, pp. 247257

Work methods and method study


The study of methods and processes employed to perform work logically leads to
improved efficiency. Some methods are more efficient than others in terms of
resource usage and time and effort required. The preparation phase of work
measurement is an appropriate time to analyse the system as a whole and the methods
used to perform the work.
The purpose of method study is to facilitate the performance of work while meeting
pre-determined standards using the least amount of time, effort and resources. The
best way to conduct method study is in collaboration with the people actually
performing the work to be studied. The people doing the work usually have the best
insight into how methods may be analysed and improved.
Conducting a method study is as simple as questioning everything that is being done
and the manner in which it is being done and then ask why it is being done and is it
necessary? Although, as we have stated, the people performing the work may have
the best idea of how to streamline and improve the work being done, their reaction to
this questioning may be the initial response of but weve always done it this way.
Many activities represent habits or artefacts from the past that no longer serve a
57

Operations research, work study and measurement

useful purpose and may sometimes even hinder the achievement of stated objectives.
It is human nature to avoid change and frequently people are reluctant to let go of the
past at first.
By conducting method study, significant savings of resources, time and money can be
achieved by eliminating unnecessary activities. To complete method study
successfully, one needs to ask the following questions:

Why is it being done?

How else can it be done?

Is it being done by the appropriate person?

Is it being done at the appropriate time?

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

Any work process can be studied, applying the methods described above, in very
general terms or in minute detail. The challenge in methods study is to maintain focus
and degree of granularity (level of detail) on the subject matter being studied. To aid
in this objective, standard and reliable data collection methods and consistent
methods of recording and analysing work are paramount. The following reading from
Anderson is a discussion of how to record work through charts and lists of activities.
Reading 52

Anderson 1973
pp. 69106

Work measurement techniques


The following optional reading taken from Currie, 1977 provides an introduction to
work measurement and work measurement techniques.
Optional reading

Currie 1977
Ch. 12, pp. 136145

Techniques used to measure and quantify work vary in terms of degree of difficulty,
accuracy and cost. The type of work to be measured, the desired degree of accuracy
to be achieved and the resources available to conduct work measurement can
determine which work measurement techniques should be used. One needs to choose
the most appropriate work measurement technique for the work to be measured.
Work measurement techniques may be applied to measure any type of work, be it of a
repetitive or variable nature, efficient or inefficient in its use of human resources. The
measurement technique chosen needs to be appropriate to suit the objectives and the
purpose of the study.
There appear to be many misconceptions in the health-care industry regarding work
measurement techniques and their applications as judged by the applications
observed by this author. Many reported research (work measurement) studies
conducted by people not trained in work study reveal major deficiencies in the area of
work measurement and the quantification of workload when compared with industrial
engineering principles. The application of work study concepts and principles within
the healthcare industry is more complex than in the manufacturing industry. Work
may be quantified in a variety of ways ranging from very precise; that is, within
58

Operations research, work study and measurement

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


degree of precision.
Principal work measurement techniques listed by the ILO (1978, p. 192) are; work
sampling, stop-watch time study, predetermined time standards (PTS) and standard
data. Currie (1977, p. 138) lists the following; time study, synthesis, predetermined
motion time system (PMTS), analytical estimating, comparative estimating,
estimating, activity sampling and rated activity sampling. Another method is the
modular arrangement of predetermined time standards (MODEPTS) developed in
Australia by Heyde (1966) and promoted by the Australian Association for
Predetermined Time Standards and Research.
Work measurement has traditionally been applied in industry as evidenced by work
study and industrial engineering texts which primarily use examples from the
manufacturing industry (Barnes 1980; Maynard 1971). Indeed the work of Taylor and
others early in the 1900s was encouraged by the American Society of Mechanical
Engineers (Hammond 1971). Work measurement is used to establish time standards
and to identify the amount of ineffective time used to perform the work being studied
to improve efficiency. This requires the work to be broken down into elements of
work, so that the work content may be examined in some detail. Work measurement
is either preceded or followed by method study to reveal shortcomings of design,
tools, procedures, work organisation, flow of production processes, holdups etc., and
to find ways of overcoming such inefficiencies. Following the introduction of
improved methods, work measurement is again applied, for the purpose of setting
standard times and to document the impact of new methods (Antis 1971). This
includes costing previous and new methods for comparative purposes.

Performance rating
In addition to basic work measurement, the work study practitioner needs to be able
to assess whether the person performing the work is working at an effective speed
relative to standard rating. Barnes (1980, p. 292) noted from his observations and
experience that there are wide differences in the capacities and abilities of
individuals. In fact he found that the fastest worker produced up to twice as much as
the slowest worker. Also people tend not to work consistently throughout the day or
from day to day. Hence the convention in work study to determine the rating factor
used to adjust measured time values to standard time values. Various methods have
been developed for this purpose (Barnes 1980). Anderson (1971) describes
performance rating as including all procedures which have as their purpose the
adjustment of observed time values to correspond more closely to the time which is
deemed to be reasonable and fair for doing the work in question. It is important that
the time standard ultimately arrived at is appropriate for the average worker. As an
average worker does not exist, one aims to include a sufficiently large sample of
workers so that they approximate a normal distribution curve.
Standard performance is defined by the ILO (1978, p. 240) as: the rate of output
which qualified workers will naturally achieve without over-exertion as an average
over the working day or shift, provided that they know and adhere to the specified
method and provided that they are motivated to apply themselves to their work.
This rate is generally accepted as being equivalent to the speed of motion of the
limbs of a man of average physique walking without a load in a straight line on level
ground at a speed of four miles (6.4 km) an hour (ILO 1978, p. 240). This may be
59

Operations research, work study and measurement

slightly less for women. Performance ratings are used to adjust times arrived at by
means of time study.

Allowances
Another issue relevant to work measurement is that of allowances. It is recognised
that no worker can be expected to work consistently without taking time out to meet
personal needs for rest and other interruptions beyond the workers control. Standard
time values need to be realistic and be applicable to the total job, thus specific
allowances are added to the basic time as measured in accordance with the specific
demands for the work studied. These may include allowances for physical strain,
stress, posture, restrictive clothing, highly repetitive work, noise etc. Some special
allowances may be included in each workers industrial award.

Measuring workload
The measurement and monitoring of workload provides very valuable information
about production processes which can then be related to organisational inputs,
outputs and outcomes for improved understanding and decision making. It is a
prerequisite to cost accounting which in turn forms the basis for the measurement of
performance regarding departmental and organisational efficiency. Thus it is an
important component in being able to control costs. Furthermore, workload statistics
assist in projecting future departmental costs and budgets. Costs are expenses
classified by a standard chart of account. Costs are then allocated directly or
distributed according to a uniform method of apportionment and transformed into
unit costs by dividing the total costs by consistently defined and generally accepted
units of service or work units. The sum of these units is referred to as departmental
workload which may be equated directly with labour resources. For example in
nursing the departmental (ward) workload may be expressed in terms of the number
of patients serviced by patient dependency category (unit of service), where each
category has an associated nursing hours per shift.
Once the workload in various departments is quantifiable one needs to decide how
these data are to be used. Usage will determine data collection frequency and the
timing for data analysis. Workload monitoring systems should permit comparisons to
be made between resource usage performance standards and actual resources used
per defined work unit (output measure). As a result of rostering practices, rounding to
the nearest full-time staff member, unexpected staff absences or movement between
departments or unexpected major changes in workload, the workload actually
generated and the corresponding standard staff hours required to perform that work,
rarely matches with the actual staff hours made available. Thus a distinction needs to
be made between the standard values and actual resource usage. Standard values, if
arrived at by means of valid work measurement techniques, should reflect a
performance standard (benchmark) which is defined by Herzog (1985, p. 356) as:
... a measure of how much time it should normally take for one individual to do a
particular job under the particular working conditions in effect. A performance
standard does not set the fastest nor the slowest time in which an operation may be
performedit represents the desirable time required. The conditions under which
work is performed affect the resulting standard.

Such a standard provides a baseline measure against which actual resource usage may
be measured. As a result of computerisation, the details underpinning many workload
510

Operations research, work study and measurement

monitoring systems are hidden from the user who tends to concentrate on the user
interface and reporting capabilities. Prior to the selection of such systems the
purchaser must be satisfied that the formulae and algorithms used, to convert data
entered into the system into workload information, are valid.
Contrary to some statements (Picone et al. 1993, p. 46), it is not necessary to replicate
work measurement studies in individual hospitals, departments or healthcare
facilities. One needs to be satisfied that the time values used by the workload
monitoring system represent valid standards or benchmarks against which individual
performance may be measured. Furthermore the standard time values must be
applicable to the type of work being monitored. It is also necessary to monitor the
systems usage in terms of data collection reliability.

Use of work measurement data for workload


monitoring systems
Clinical practice has been quantified in the past primarily for the purpose of arriving
at the number of staff required to care for a stated patient group. When evaluating the
various techniques used to quantify clinical practice through the use of a workload
monitoring system, a distinction needs to be made between the work measurement
techniques themselves and the methods employed in applying these techniques to
represent workload. Invariably methods of application have become extraordinarily
complex making it difficult, if not impossible, to evaluate validity. One of the main
difficulties encountered is the conversion of work measurement data into a staffing
formula relative to identifiable groups of patients. Frequently the use of professional
judgements cloud the use of empirical data. The method of data collection ultimately
determines the degree of accuracy of the source data. Hence it is as important to
examine this as it is to examine the work measurement technique itself. Only from a
close examination of the application of the method adopted is meaning provided to
the results stated.
Gault (1982, p. 62) found this when critically examining the derivation of the
Aberdeen Formula, a product of Scottish Home and Health Department studies
conducted during the 1960s and which aimed to determine nursing establishments.
On the basis of his findings one needs to examine any clinical workload measurement
system regarding the following:

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


objective, reliable?

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

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

The philosophical basis and purpose of the study which underpins the workload
measurement system.

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

511

Operations research, work study and measurement

Many of the reported nursing studies were limited to one hospital only. This then
limits the applicability of results obtained to other hospitals as these may not be
representative of the norm. Available resources during any study constitute a very
significant variable influencing the final time value per work unit. Given that it is
well known that currently resources in Australia are inequitably distributed between
hospitals, the use of data obtained from one hospital only, is a valid concern.
Another limitation is the difficulty in defining the boundaries of the domain of any
type of clinical work due to the variations known to exist between health services.
Yet when evaluating if a workload measurement method adequately reflects human
resource usage and costs, one needs to be able to establish if the universe of the type
of work measured is accounted for. That is, does it include all the work performed by
a given staff category or only components thereof.
For example some nursing workload measurement systems use time values which
reflect patient/nurse interaction (direct care) only. As this component of hospital
nursing work takes up less than 50% of all nursing time (Hovenga 1990, 1995, 1996)
one needs to ask how the remainder of nursing work is quantified. One needs to
establish whether the identified nursing resource usage reflects the nursing services
needed and whether the predicted nursing service requirements, on which actual
nursing resource usage is commonly based, were services actually provided. Finally
in terms of costs one needs to establish whether the costs identified reflect standard
costs, that is standard time values multiplied by an hourly rate, or actual costs where
total costs were distributed on a relative basis. This continues to be a topical issue.
Duffield Roche and Merrick (2006) have recently undertaken a critical review of the
methods applied to measure Australian nursing wotkloads. They explored the
strengths and limitations of each approach in terms of their reliability and utility.
There is a strong relationship between nurse staffing levels and safety outcomes.

Workload validity
To a large extent, the selection and application of work measurement techniques
determine the validity of any workload monitoring system. Validity of any workload
monitoring system is as much a function of the system itself as its usage or
application. The validity of using either activity based workload measures or patient
classification models to reflect degree of patient dependency and human resource
usage is dependent upon the following:

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

the ability for the model or system to represent all work

consistency of data collection in accordance with the model or system


requirements

categories of staff included in the time values used by the model or system are
identical to the actual staff hours with which workload comparisons are made

ability of the classification model to consistently discriminate between the


categories on the basis of resource usage (validity)

the ability of the model to represent the norm and thus be used as a valid proxy of
actual resource usage.

The key question when evaluating individual studies or workload monitoring systems
is whether the underlying work measurement technique chosen was the most
512

Operations research, work study and measurement

appropriate for the purpose. Standard time values are either applied to individual
activities, to defined units of work or to output measures. Secondly validity, in terms
of how well do the resultant time values reflect actual human resource usage, must be
demonstrable. The degree of accuracy achieved must be acceptable to the purpose for
which the resultant information is used. Estimates and self reported source data lack
the precision achievable when the most appropriate work measurement techniques is
used are qualified work study officers. The measurement of work refers to the process
adopted to translate reality into numbers.
According to Knapp (1985, p.189) any measurement involves three concepts, the
construct C; the true score on the variable, T (work); and the obtained score on that
variable, X. Validity issues arise when the fit between the construct and the true score
is studied. Reliability issues arise when the fit between the true score and the
obtained score is studied.
For example:
C = time required by a qualified worker to perform the work
(the standard = validity),
T = actual time used to perform the work, mean of a representative sample
(reliability),
X = measured time, a measure of time used in one setting over a specified period.
Although most studies aim to quantify or measure actual human resource usage (T),
this value is commonly expressed as the staff time required (C). Thus it is assumed
that the actual time measured was appropriate and adequate to meet the objectives of
the provision of services measured and that these values have a predictive quality.
When these time values are later used as a basis for costing services, it is further
assumed that patients/clients did actually receive the services identified as required to
produce the desired outcomes.

Patient Assessment and Information System


The Patient Assessment and Information System (PAIS) was first developed in 1981
and continues to be used extensively throughout Australia. PAIS consists of two
components; work measurement and patient classification methodology. Work
measurement techniques were used to develop and test the patient classification
model and to assign time values to the dependency categories. The patient
classification model was developed using work-sampling methodology.
The PAIS model was tested using different patient populations. The use of work
measurement methodology permitted detailed comparisons to be made between
patient populations. The original medical/surgical data were compared to data
collected from studies involving obstetrics/gynaecology, midwifery, and paediatrics.
The research design for the development of PAIS consisted of collecting random
samples of naturally occurring nursing work events. The study was designed to
provide information on nursing resource usage including nursing work, patient
characteristics and ward staffing levels.
The following reading by Hovenga is an overview of the development of PAIS.

513

Operations research, work study and measurement

Reading 53

Hovenga 1994
Four preliminary pages plus pp. 144

Time study
Various timing devices may be used depending on the nature of the job being studied
and the precision required. These include various types of stopwatches, electronic
timers and cameras. Time study may be conducted by reading the stopwatch
intermittently, referred to as the snapback method, or continuously. Either way
predetermined elements of work are identified and related to time. Such elements
usually require only a minute or less to perform. The time study method is most
suited to those jobs which are repetitive in nature and which are required to be
performed according to a clearly definable method. Time study is task-oriented and
should only be conducted by people trained in work study. The time study and
predetermined time standards methods may effectively be applied to those elements
of work for which procedures and methods of performance are clearly defined. These
methods are appropriate when individual procedures are being evaluated in
conjunction with method study for the purpose of improving efficiency and the
establishment of time standards. It is most suited to production line type of activities
such as in the central sterilising department, or other work which has clearly defined
procedures such as cleaning, and which may be broken down into small components
of work.
Time study was originally applied to direct work where the work was performed in
one location. It was used in an era when jobs were narrowly specialised and
repetitious. During the 1930s, the emphasis was on maximising throughput per time
unit and the use of available resources. Each workers job generally consisted of one
particular task and was most suited to a less educated workforce. Todays nursing
practice does not relate to such a description of work. It is probably more in line with
other industries where since the 1960s and 1970s the emphasis has been on designing
jobs which have greater variety. In particular the aim has been:

to improve employee job satisfaction and work involvement

to raise productivity and improve quality

to improve efficiency by reducing costs associated with symptoms of


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

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


satisfaction (Dunphy 1981, p. 162).

Time study may be used for non-repetitive work. In such instances the work needs to
be carefully analysed noting in particular the variable components of the work.
Non-repetitive work also has longer cycles.
The work of any health professional can be described this way. When time study is
applied to this type of work, problems arise regarding the attainment of a
representative distribution of the procedures studied, documenting the precise method
used, estimating the degree of accuracy, relating the time values to output and in
arriving at a representative sample of the work components studied.

514

Operations research, work study and measurement

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


perform them. For example, wound care activities can range from one minute to
several hours. This broad range is true for most commonly performed clinical
activities. The time required to perform individual activities is influenced by the
reason for hospitalisation, the severity of illness of, and total degree of dependency on
nursing services by the patient, as well as the skill and performance of the clinician
and the time available.
Hodson (1971) notes that because of the variable sequence of the work elements
which make up any one activity or cycle of work, and the variables that may exist
within a given work element, it is essential to rely heavily on the standard data and
the building block concept of work measurement to time non-repetitive work. Either
time study or predetermined motion times can be used for this purpose. The only
nursing study found by the author to adopt this approach when using time study as the
work measurement technique was de Zwart (1991) who was commissioned by the
Health Department of Western Australia to conduct a nurse staffing study in that
State.
The definition of work measurement requires that only qualified workers are studied
and that the work is performed according to a specified method. This implies that
time study is not suitable to measure work where the methods employed are likely to
vary according to the situation within which the work takes place, unless only basic
work elements are studied as opposed to a total procedure. Recognised work study
texts stress that any one time should refer to one specified method (ILO 1978;
Maynard 1971; Barnes 1980; Currie 1977). A method of performing work or
elements of work, may be defined in infinite detail as seemingly minor differences
may impinge on the effort required to perform the work.
The timing device chosen for the job needs to match the purpose of the study, the
nature of the work being studied and the degree of accuracy desired. Short and/or
highly repetitive cycles of work requires either a decimal hour stopwatch or a camera.
These instruments are also required when it is necessary to time many short elements
of work making up a particular task. Each work element consists of a sequence of
basic human motions.
Cameras are more accurate as timing devices, as a permanent record is created,
permitting the observer to stop the action at required intervals in order to document
what is being observed. Direct observation using a stopwatch, together with rating,
can lead to inconsistencies and non-acceptance by workers of the standard times thus
developed.
It is necessary to conduct many individual time studies of the same task performed by
a large variety of qualified workers in order to ensure that the study is representative
of normal conditions and that a normal distribution of occurrence was in fact
measured. There are many variables which influence the number of observations
required. They include the length of the work cycle, number of repetitive elements in
each work cycle, skill of the worker, variations in method and the number of
interruptions. Barnes (1980, p. 273) provides the mathematical methods of
determining the number of observations required to determine time values at a
desired level of confidence. These are based on the following formula:

515

Operations research, work study and measurement

X =

where

= standard deviation of the distribution of averages

= standard deviation of the universe for a given element

= actual number of observations of the element.

Time study applied to nursing


None of the nursing work research studies reported in the literature referred to the use
of any mathematical formula to calculate the number of time study observations
required to achieve the desired degree of accuracy relative to the work under study.
In 1928 Rottman, Director, Nursing Service, Bellevue and Alfred Hospitals (USA)
reported that the best study undertaken was that by Margaret Tracey who has been
able to present a chart outlining the average time required per treatment in minutes,
for 21 procedures common to surgical patients (cited by Aydelotte 1973, p. 8),
others followed; Edgecombe (1965); DesOrmeaux (1977); CSF Australasia (1975,
1986, 1990); Clark and Diggs (1971); Meyer (1978); Bendigo Home and Hospital for
the Aged (1981); Anderson (1983); Sherrod (1984); Overfelt and Ballash (1982);
Sawyer et al. (1986). In respect to time study, Aydelotte (1973, p. 29) concluded that:
an individual must be very attentive as he (she) reads reports since the operational
definitions used for categorising activities differ from one study to another. The
differences in category descriptions make comparisons either impossible or highly
questionable.

The use of standard times and their applicability to individual institutions and
individual units were questioned by Murphy et al. (1986, p. 86) as even within the
same hospital there may be considerable variance in the manner and thus the time in
which the same activity is performed in different units. Furthermore Kuhn (1980,
p. 6) asserts that standard times for procedures are not appropriate since the amount
of nursing fluctuates according to patient differences. In other words the use of time
study was not considered appropriate for nursing due to the variable nature of nursing
work. This issue has been addressed by the Trendcare system where users are
required to verify times used by the system. It is achieved through the use of patient
types and the measurement of activities via a stop watch relative to those patients.
It is considered difficult if not impossible to document and consistently use precisely
the point where each nursing activity begins and where it ends for time study
purposes. Methods used to perform individual nursing activities are rarely identical.
This work measurement method requires activities to be broken down into definite
and measurable elements and (to) describe each of these separately (Barnes 1980,
p. 269). McHugh and Dwyer (1992, p. 24) noted that this is a time consuming and
expensive method. They went on to say that original standard time measures should
be validated when these standard time values are used by another hospital. The
reasons given were the use of different types of equipment, methods and experience
levels of nurse which may alter the values of standard task performance times.
The continuous time study observation method goes some way towards overcoming
some of the difficulties identified previously. This method permits the measurement
of all nursing work performed by at least one nurse and records the sequence in
which elements of work take place. To measure all the work generated by all patients
516

Operations research, work study and measurement

in a ward would require continuous observation of all staff performing the work. This
method was also rejected for the empirical work reported in this thesis as it was
perceived to be too costly, intrusive, unpopular with staff and likely to influence the
results through a Hawthorn effect. The total cost is a function of the purpose of the
study and the subsequent sample size required. Abernethy et al. (1988) used
continuous observations to test the degree of accuracy of self-reported data. This is
discussed in Section 3.2.
In summary, the difficulties associated with using time study or continuous
observations to measure nursing services include:

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

Representativenessdo the number of activities included in the measured sample


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

The universe of nursingdo the sum of the activities equal the universe of
nursing services?

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


example bedmaking consists of many individual activities and combinations
thereof; similarly wound care or activities associated with hygiene, mobility etc.
To what detail should nursing practice be analysed and measured?

Estimating the degree of accuracy.

Relating the time values to output.

Predetermined time standards


As a result of breaking down jobs into elements of work for the purpose of time
study, it became apparent that many seemingly different jobs contained common
elements of work at the lowest level of analysis. Clinical work is no exception. Once
those elements had been studied many times over, standard time values were readily
available for those work elements. Therefore once a job was analysed and broken
down into work elements these standard time values could be applied, avoiding the
necessity of further time studies. Various predetermined time systems are now in use.
They vary in the level and scope of application of data, motion classification and in
time units used. A predetermined time standard is defined as a work measurement
technique whereby times established for basic human motions (classified according
to the nature of the motion and the conditions under which it is made) are used to
build up the time for a job at a defined level of performance (ILO 1978, p. 313). The
method has been used to measure some nursing work (CSF 1986).
The application of predetermined time standards requires detailed job analysis. This
documents individual basic motions used to perform human work, such as move an
object or walk from A to B or grasp an item, and includes noting the conditions
surrounding the movement of a limb or limbs. Variables noted are such things as the
distance moved, the weight moved, the control required and whether the motion
begins and ends with the hand at rest. Once a job is analysed and broken down into
the work elements corresponding with the system to be used, the appropriate standard
time values may be applied. This avoids the need for further time studies.
The use of predetermined time standards has the advantage of consistency as the time
standards are well researched and represent the norm in terms of time required by a
517

Operations research, work study and measurement

qualified worker to perform these basic elements of work. It may be applied during
the job design stage permitting changes to layout and design of the workplace to
achieve optimum production with minimum worker effort. Their use also makes it
possible to estimate costs when evaluating alternative methods of work. It is often
less time consuming and hence less costly to apply when compared with other work
measurement techniques. The use of predetermined time standards does involve a
considerable amount of calculation. The use of computer technology reduces the time
required to use this method of work measurement.
Historically, Gilbreths ideas on the basic human motions, he called Therbligs,
sowed the seeds for a predetermined time standards system. Segur, around 1927,
realised that all human work is made up of Therbligs and put forward the idea that
the time required for a qualified worker to perform these basic human motions would
be constant (Currie 1977, p. 192). Since then various systems were developed
including the methods-time measurement system (MTM). Maynard et al. (1971),
the originators of MTM during the 1940s, noted that the main cause for wide
variations in work performance, was the method employed. As various methods were
employed to perform the same or similar tasks, they set out to time common elements
of work. A special synchronous cine-camera was used to perform the extensive time
studies relative to basic motions of work, from which the MTM system was
developed. The classification of work elements used by MTM and associated with a
TMU value, consisted of 300 separate values and a further 200 or so could be
determined by interpolation.
Later generations of MTM reduced this number considerably. A simplified version
derived by Imperial Chemical Industries has 97 time values (Currie 1977). The Serge
Birn Company developed the master standard data (MSD) system by averaging,
eliminating, and combining MTM elements which resulted in 49 categories
(Anonymous 1980). Other systems such as the modular arrangement of
predetermined time standards (MODAPTS) do not require as much detail (Heyde
1966). MODAPTS has only 21 elements, although different combinations of
activities enable an enormous variety of tasks to be documented. This system has
incorporated the results of extensive research into valid physiological recovery time
required when the work is physically heavy. Notwithstanding the loss of detail,
MODAPTS is applicable for widespread general use and has modules for special
applications such as office and transit modapts. The latter was first published in
1974 and is suitable for studying work performed in warehouses and other places
where physical distribution occurs. It is possible to develop a nursing modapts
module.
To appreciate the level of precision used by each system one needs to consider that
MTM uses TMUs as its time measurement unit where each TMU is equivalent to
.036 second (Barnes 1980, p. 376). MODAPTS uses MODs where one MOD is
equivalent to .129 second for normal time and .143 second for allowed time. The
latter includes an allowance of 10.75% for physiological recovery (Heyde 1966). As
the number of categories with associated time values decreases, degrees of precision
are lost. It now has software to support its use. You can learn more about MODAPTs
by visiting their website at http://www.modapts.com/
The use of predetermined time standards has the advantage of consistency as the time
standards are well researched and represent the normal distribution of time required
by a qualified worker to perform elements of work. It may be applied during the job
design stage permitting changes to layout and design of the workplace to achieve
optimum production with minimum worker effort. Their use also makes it possible to
518

Operations research, work study and measurement

estimate costs when evaluating alternative methods of work and for budgeting or
tendering purposes. It is often less time consuming and hence less costly to apply
when compared with other work measurement techniques.

Work sampling
Work sampling is a work measurement technique usually applied to groups of people
or machines. It was first used by Tippett in the British textile industry in 1934 and has
increasingly been applied to areas not previously measured (Barnes 1980). Work
sampling, also referred to as work measurement sampling, requires an observer to
record the actual work being done at the moment of observation. Work sampling
consists of a large number of observations (N) taken at fixed or random intervals.
Prior to taking these observations the work situation is noted and the purpose of the
study identified. Then, predefined categories of activity pertinent to the work
situation and purpose of the study are incorporated into a classification system unique
for each study. This permits observations to be made relative to these predefined
activities which collectively make up the universe of work performed in the area
under study. Work observations may be recorded relative to any number of variables
depending on the purpose of the study, and the questions to be answered. For
example, defined nursing activities may be recorded relative to the patient for whom
they are performed or relative to the category of staff performing each activity.
From the proportions of observations (p) made regarding each activity, inferences are
drawn concerning the total work under study. These proportions are referred to as
percentages of occurrence and are derived by expressing the number of observations
(n) made per activity measured, as a percentage (p) of the total number of
observations (N) made during the study.
The frequency of observation rounds depends upon local circumstances. The number
of observations to be made will depend upon the purpose of the analysis and the
degree of accuracy required for the activity being studied (Brisley 1971). When
measuring ward work, observations may be made of all nursing and other staff
allocated to that ward on every round, or by observing a randomly selected staff
member every two minutes (or at some other time interval) or by observing patients
for direct patient/nurse interaction for any chosen period of time.
According to Brisley (1971, pp. 347) work sampling works because a smaller
number of chance occurrences tends to follow the same distribution pattern that a
larger number produces. This sampling technique does not assume that the
momentary observation is continued throughout the intervening observation interval.
It is based on the fact that the number of times an activity is observed being
performed is closely correlated with the total time spent on its performance (Manual
of the USDHEW 1964 cited by Kuhn 1980, p. 13). For example if an activity is
observed 10 times out of a total of 100 observations then it is assumed that the
activity consumed 10% of the total time made available during that observation
period. The 10% denotes the percentage of occurrence (p) of all observations (N)
made. A sample taken at random, such as nursing work relative to a defined patient
population, tends to have the same pattern of distribution as the total patient
population. If the sample is large enough, the characteristics of the sample will differ
little from the characteristics of the group. (Barnes 1980, p. 406).

519

Operations research, work study and measurement

Brisley (1971, pp. 365) referred to one of the first work sampling studies in a
hospital conducted by Marion Wright in 1950 at the Harper Hospital in Detroit,
Michigan. He used it to illustrate some of the shortcomings inherent in the design of
this study. As a result of the Wright study the American Hospital Association became
interested in this methodology. The purpose of the 1950 study was to analyse the
activities of the various categories of staff working in a ward. The staff participated in
analysing the data and used the results to make improvements in their jobs. The result
was that many tasks being handled by higher skilled people were passed on to lower
skilled personnel.
Many of the studies reported in the literature as using self-reporting, continuous
observation or time-study have also used the work sampling method (Overfelt &
Ballash 1982; Bendigo H & H 1981; Edgecombe 1965; Medicus Corp. cited in
Jelinek & Dennis 1976; CSF 1986) mainly to establish distribution and/or frequency
of specific nursing activity occurrence; for example, proportion of direct versus
indirect or as a rough measure to check validity. As most studies do not indicate the
total number of observations or the percentage of occurrence of the activity being
measured, the accuracy of the results cannot be ascertained.
The advantage of using work sampling as a work measurement technique is its ability
to state statistically the degree of accuracy of the results obtained. It is noteworthy,
however, that none of the studies referred to previously noted this fact. Another
advantage of work sampling is its applicability to answer a variety of research
questions regarding the distribution of work relative to what, where, why and by
whom, the work is performed. Intermittent observation is non-intrusive, and sampling
observations may be made by people with no previous work study experience.
Observer bias was found to be negligible by Murphy et al. (1978) who also noted that
observations made at regular fixed intervals achieved the same results as observations
made at random. The latter is due to the variable nature of nursing.
Using work sampling for purposes of work measurement requires that the work
sampling study is related to a defined observation period within which the total actual
hours and the number of units produced are noted. The personnel being sampled are
usually performance rated. The formula for arriving at a standard time value is as
follows:
Standard time=

actual hours % of occurance (p) average performance rating


number of units produced

Brisley (1971) notes that in some instances it is difficult to determine what the work
count should be and suggests that this may require some innovative approaches. In
nursing studies the work unit may be a defined as a patient-day. Allowances are
then added as per time values arrived at by the use of time study.
The underlying theory of work sampling is, that the percentage of observations (p) for
any activity provides an estimate of the percentage of time actually spent on that
activity, to a known degree of accuracy. Statistically this theory is based on the laws
of probability and uses Bernoullis theorem, random variable and distribution laws
and the law of large numbers (Barnes 1980; Brisley 1971; von Mises 1981;
Gnedenko and Khinchin 1962; Walpole 1982).
The laws of large numbers require mutually independent random variables. In work
sampling these variables are the observations made per activity under study. Every
activity is mutually exclusive from another. The sum of these mutually independent
random variables divided by the total number is as close to unity as we please
520

Operations research, work study and measurement

(Gnedenko & Khinchin 1962, p. 96). It needs to be understood that each observation
within a data set of observations has the same value, whereas an individual
observation viewed as a proportion of the data set, frequently takes on a value far
removed from its mean. The arithmetic mean of a large number of observations,
viewed as a proportion of the data set expressed as a percentage of occurrence,
behaves differently to the mean of a very small number of observations within the
same data set. The larger percentage of occurrence is a far more accurate estimate of
the actual mean than the small percentage of occurrence.
To make effective use of these random variables there is a need to identify as
precisely as possible their laws of distribution. For example if we want to know the
range of time taken for wound care we would assume that some average range exists.
The difference between the actual and average range may be referred to as the error,
whose magnitude will vary from one action to another. This will depend on a number
of other variables which act independently of one another. The final error represents
the total effect on the time taken to provide wound care. All such errors are
approximately distributed according to normal laws. This law was discovered in the
middle of the last century by Chebyshev, a Russian mathematician.
This knowledge enables the calculation of the number of observations (N) required to
obtain work sampling percent occurrences (p) for a desired relative accuracy to yield
a confidence interval of 95 percent. As both p and S are unknown, the number of
observations (N) required for any study is calculated by using an estimate of the
percentage of occurrence (p) for the event of interest and the desired relative accuracy
(usually 0.05). Values required for the calculation of the standard error of each
activity or event measured, are the corresponding percentage of occurrence (p) and
the total number of observations (N) made. The relationship between these three
variables is such that the smaller the desired standard error and the percentage of
occurrence (p) the greater the number of observations (N) required in the total study.
To ensure that the results obtained can be represented by the 95% confidence interval
it is important that unusual circumstances are avoided during the study period. A
daily control chart may be used for this purpose (Brisley 1971; Barnes 1980). A
formula is used to ascertain the daily limits of error relative to the percentages of
occurrence of interest. It needs to be emphasised that the percentage of error reduces
as the number of observations increase.
An estimate of the number of observations which may be made on any one day
together with the total number of observations required determines the duration and
cost of a work sampling study. The daily number of observations possible is
dependent upon the number of staff to be included in the study and the duration and
frequency of each observation round. In addition the study period should be at least
as long as the longest period of any cyclical behaviour or characteristic being studied.
In the case of nursing this means for all days of the week and at least all day shifts,
desirably every full 24-hour period for seven days. The sampled population (staff and
patients), from which inferences will be drawn, must be similar to and representative
of the population to which the results will be applied (Brisley 1971; Barnes 1980).
Work sampling is very suitable to measuring work with many variable characteristics.
It is therefore an appropriate method to measure all aspects of nursing work. It has
the advantage of permitting the calculation of the degree of accuracy of the results
and of being more cost-effective in terms of study period and sample size required,
from which inferences may be made with a degree of confidence, relative to the
population studied. It is a very useful method to identify possible inefficiencies from
521

Operations research, work study and measurement

which individual aspects of nursing work may be evaluated. Work sampling may be
used in conjunction with normal supervisory duties. Studies may be designed to
answer any number of research questions. Work sampling lends itself more readily to
be related to an output measure as all work is easily included in the measurement.

Work sampling applied to nursing work


A number of researchers have used this work-measurement technique exclusively.
(Abdellah & Levine 1954; Hovenga 1983; Scott 1982; Jacobs et al. 1968; Lindsay et
al. 1985; Crowther & Heip 1986; Giovannetti 1983). Howarth (1976) used work
sampling to identify what was being done and by whom, in response to a 1968
standing Nursing Advisory Committee report which had stated that nurses continue to
carry out a wide range of duties that do not require nursing skill. More recently
Hendrickson et al. (1990) used work sampling to determine how nurses distribute
their time. This was also measured as a by-product in the empirical work reported in
Hovengas thesis (1995). The latest work sampling study known to have been
undertaken in Australia was in 1995 for Queensland Health (HOvenga and
Hindmarsh 1996)
Contrary to popular belief, the work-sampling methodology does in fact include the
measurement of sophisticated cognitive processes used by nurses during the course of
their working day. It does this by accounting for all time spent by nurses caring for
patients. As such cognitive processes are not usually readily observable as a separate
activity, they are not listed in the work measurement taxonomy used for the PAIS
studies. These cognitive processes tend to occur concurrently with observable
activities although the latter then usually take longer to perform than when these
same activities are performed in the absence of such cognitive processes. The only
time both observable and cognitive activities are truly concurrent is when the
observable activity is a routine one performed by an expert, such as bedmaking.
Other researchers who have used work sampling in hospitals were Boyd (1982);
National Association of Childrens Hospitals & REI Institute (1978); Norby et al.
(1977); Lindsay et al. (1985); Giovannetti (1973); Kuhn (1980). Kuhn (1980) used
activity sampling, measuring both direct and indirect nursing activity concurrently at
15-minute intervals for eight hours per day only. Both direct and indirect activity
observations were assigned to the patient for whom they were performed. Indirect
activities which could not be assigned to a specific patient were assumed to relate
equally to all patients. These latter nursing activities consumed between 46% and
51% of all nursing time. The original PAIS study (refer Chapter 7) reported that all
nursing time was distributed between direct (with patients) 34.2%, indirect 45.3%
and non-productive (including meal breaks) 20.4%. A more recent US
work-sampling study (Hendrickson et al. 1990) reported that nurses spent an average
of 31% of their time with patients. It is this direct interactive time which is
distributed between all patients on the basis of need (nurse dependency).
Although most of the work-sampling studies cited did identify the proportion of
nursing time used for direct, indirect and non-patient related activities, few studies
concurrently related the sampling observations of direct care activities to individual
patients as was done in this study (Hovenga 1983). A choice needs to be made
between observations attributing to individual activities and staff category or
individual patients. It is possible, although difficult, to capture all three. During the
trial for the original data collection for PAIS, different colours were used to denote
each staff category to create a three dimensional data collection method. It was found
522

Operations research, work study and measurement

that, practically, this proved to be fraught with inaccuracies due to the resultant
complex nature of data collection.
Lindsay et al. (1985) chose the work-sampling/work-measurement technique as it
was considered by far the best technique to collect the required information for the
following reasons:
1. All staff and patients could be observed together with the minimum disruption to
their daily routine.
2. That the intensity of the activity sample planned would make the data collected
as accurate as that collected using any other technique.
3. Not only would the information collected using activity sampling give a good
overview of the daily routines in the wards, but could also be analysed in such a
way as to create a base of standard data, on which it would be possible to build
the proposed dependency system.
4. No other technique would allow for a comprehensive survey to be completed
with only one weeks observations in each ward.

Self reporting
Another method popular in health service organisations is the self recording or
logging method. This requires each worker to record how much time is actually spent
on various activities. Much debate continues regarding the accuracy of this type of
data. It is favoured because it is thought to be a low cost method and is said to be
accepted by the workers themselves due to their participation. However it is open to
manipulation, distortions, omissions and gross inaccuracy. Much depends on the
commitment by the staff involved in the study and the controls that are in place
during data collection. It is not a recognised work-measurement technique as it lacks
precision in measurement terms, but may be useful for some purposes.

Time and work measurement


Quantifying workload, which involves the measurement of human resource usage, is
a prerequisite to cost accounting. This in turn forms the basis for the measurement of
performance regarding departmental efficiency. Thus it is an important component in
being able to control costs.
To a large extent, the purpose for which the workload is to be measured determines
what is to be measured. Defining what is to be measured is also associated with how
the organisation has divided the work and responsibilities. Quantifying the workload
should assist individual departmental managers in allocating their human resources.
The aim is to match resource availability with workload generated. Where the
number of staff exceed the number required to perform the work, then there is an
unnecessary cost to the organisation. On the other hand if there is insufficient staff
then there is a cost to individual employees and the service may be compromised.
That is the quality of the work may not conform to standard practice. Staffing levels
need to be such that individual staff members are able to perform the work, in
accordance with quality requirements, within the specified time.

523

Operations research, work study and measurement

Work measurement implies the ability to express human work quantitatively, in terms
of a common unit which assumes that a quality standard is consistently achieved. The
common unit used is that of time expressed as day, hour, minute or second. This is
achieved by defining work relative to fixed units of time. Various techniques may be
employed to define work this way as were discussed in the previous chapter. It
requires the work content of any job to be related to its most suitable characteristic or
unit of work. In healthcare these are the services provided to produce the desired
outcome per patient/client per day.
Work measurement is defined by the British Standards Institution as; The
application of techniques designed to establish the time for a qualified worker to
carry out a specified job at a defined level of performance (ILO 1979). Work
performed by health professionals includes creativity and decision making. These
activities are not directly observable, hence do not lend themselves to being
measured. Yet sufficient time needs to be allocated to allow for these activities.
The objectives of work measurement are to improve overall efficiency and
effectiveness of the workforce. Work measurement data provide a reliable reference
for use in calculating staff requirements for current and projected workload and for
scheduling and controlling work and staff. These data are also widely used in
standard cost accounting systems and for budget formulation. It contributes to the
organisations statistics regarding human resource usage and utilisation relative to
overall performance and utilisation of services.

Principles of work study


Work measurement evolved as a consequence of applying the basic questioning
approach of what, how, where and when to any human work. The purpose was
usually to find a better way of performing the work to either increase production
within a given time span or, to reduce the effort required in the performance of the
work or, to improve the quality or utility of the work. The use of work measurement
in conjunction with productivity has been recorded throughout the ages by such
notables as Leonardo Da Vinci, Babbage, Boulton, Watt and Sons to name a few
(Currie 1977). Adam Smith (1776 in Hicks 1977) was the first to use the concept of
designing a work process to efficiently use the available workforce by introducing
specialisation of labour. The improved productivity was expressed in terms of how
many pins could be produced by one worker per day. Taylor (Hicks 1977) is better
known than Smith for his contribution to the science of work study, encompassing
both work design or methods study and work measurement. Other contributors to the
science of work study were the Gilbreths who first applied motion study to find the
best way of doing a job (Currie 1977). Thus from the industrial engineering
perspective, work measurement should not be viewed in isolation. It is intricately
linked with all facets of resource usage influencing productivity. Contemporary Work
Study as a science draws on numerous concepts within disciplines such as economics,
engineering, ergonomics, behavioural sciences, computer science, statistics and
management science.
Work measurement has traditionally been applied in industry to identify the amount
of ineffective time used to perform the work being studied in order to improve
efficiency. This requires the work to be broken down into elements of work, so that
the work content may be examined in some detail. Work measurement is either
preceded by, or followed by, method study to reveal shortcomings of design, tools,
524

Operations research, work study and measurement

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


ways of overcoming such inefficiencies, most of which are outside the control of
individual workers. These need to be considered when individual performance is
being evaluated. Following the introduction of improved methods, work
measurement is again applied, this time for the purpose of setting standard times and
to document the impact of new methods. This includes costing previous and new
methods for comparative purposes.
The effectiveness of the time values arrived at is dependent upon whether the right
technique was used for the type of work measured and the purpose or desired use of
the data. Analysing work is a valuable exercise in determining areas for productivity
improvement, such as deficiencies in the system, equipment or work methods. Most
activities are measurable, although for some the cost may be too high compared with
the potential benefits. One needs to select work which is highly labour intensive and
of a large enough volume to make work measurement profitable. One could use the
overall cost or percentage of the total cost as a criteria for deciding which activities
should be measured and which are better estimated. For example if a service
consumes less than 1% of the allocated resources then improved precision in work
measurement is unlikely to provide significantly greater benefits compared with a
more pragmatic approach.
Generally speaking work which requires a high degree of creativity and decision
making is very difficult to measure. In health services one must also consider the
stand-by component. That is, resources allocated may be there for reasons other than
the services needed as measured by volume. For example for safety or security
purposes.

Use of self-recording to analyse work


performed
The self-recording method is not a work measurement technique. It is essentially a
method used for job or position analysis and requires workers to record, either
continuously or intermittently, how they spend their time. This may include self
timing of individual activities. Alternatively it may require the listing of activities
performed during any one time period and the documentation of the frequency of
occurrence of such activities. When recorded intermittently, the data are the result of
a self-recorded sample as distinct from a continuous log. There are a variety of
methods by which self reported data pertaining to work may be captured. Each is
specific to the purpose of the study.

Self-reporting studies applied to nursing


In the development of methods for determining use and effectiveness of nursing
service personnel, the San Joaquin General Hospital study teams major thrust was
the testing out of data collection tools and procedures for use in a nurse staffing
methodology (Murphy, Williams & McAthie 1976, p. 40). Self recording was
compared with observer recording of nursing activities. The observer recording
method resulted in 31% more activities being recorded during the same study period.
It was concluded that unless there was exceptional personnel commitment to
accurate data collection, self-recording as a method should be seriously questioned.
525

Operations research, work study and measurement

Because of the error rate in self-recording, the results obtained through the use of the
method were considered as suggestive only. Other reports in the literature, about the
inaccuracy of, or problems associated with this method also exist (Williams 1977;
Grimaldi & Michelleti 1982). Sovie et al. (1984) set out to overcome the reporting
problems by requiring each nurse to total all time recorded in each category to reach
a grand total time in minutes for each shift. This was compared against the actual
minutes worked. Sovies method only demonstrated that all nursing time was
accounted for and did not test the reliability or validity of what was actually recorded.
Abernethy et al. (1988) in an Australian nurse costing study, decided to capture data
for two mutually exclusive categories only, to overcome definitional problems. These
were patient-related nursing activities and non-patient-related activities. The time
was estimated by nurses themselves on a relative basis once per shift. Degree of
accuracy of the data thus captured was tested by continuously observing one nurse
per shift for 40 shifts. There was a strong correlation between nurse and observer
time (r = .83, p<.001). These results did lead to the implementation of some
improvements into the major study. Notwithstanding these results are probably better
than the actual accuracy due to a Hawthorn effect created by continuous
observations, i.e. the act of observing tends to positively influence the results. Also of
concern in this study was the amount of missing data resulting from non-compliance.
This meant that data for individual patients throughout their length of stay was rarely
complete. However the researchers argue that as these are random occurrences the
remaining data are representative (personal communication with Abernethy 1987).

Professional judgements/estimates
Reaching agreement regarding notional times or relative values between defined units
of work is referred to as using professional judgement. Professional judgements may
also be used to estimate the frequency of occurrence of certain work activities. It is
not a work-measurement technique.
An example where these methods were used to quantify nursing work is the
development of the Resident Classification Instrument (RCI) (Commonwealth/State
Working Party report 1988). It also plays a major part in the development of
departmental service weights (relative value units), which express relative resource
usage or costliness of defined work units, used in conjunction with both clinical
costing and cost modelling systems. Service weights are explained elsewhere.

Skill mix
So far only the quantity of human resources, in terms of total hours required to
perform the work, has been examined. Another factor to be considered is the quality
of the human resources, which is usually referred to as skill mix. There are many
different types of healthcare workers. Even within each category of worker there are
various levels based on formal qualifications plus years and type of experience.
Providing the right number of staff hours for the work to be performed, does not
necessarily mean that the desired outcomes are achieved. One may achieve
performance efficiency but not performance effectiveness.

526

Operations research, work study and measurement

Summary
This chapter included a detailed description of the processes involved in work study,
work measurement and work sampling. The most important point to take away from
this chapter is the value and importance of operations research, including work study
in performance measurement in health care and as a method to undertake extensive
and in depth studies of work practices, work and information flows. Such studies are
required to analyse and document system requirements which in turn may be used to
evaluate the applicability of proposed information systems implementation. The next
chapter will provide more information on the applications of work measurement
including patient assessment, staffing and costing, and individual performance
evaluation.
Activity 51
Describe how you would design an operations research or work study experiment in
your organisation or individual department with the aim of improving performance.
Include the rationale and methodology (using the five step method) listing what data
elements you would include and how you might record the data.

References
Abdellah, F.G. & Levine, E. 1954, Work sampling applied to the study of nursing
personnel, Nursing Research, vol. 3, no. 1, pp. 916.
Abernethy, M.A. & Stoelwinder, J.U. 1987, Development of a model for costing
nursing wards in public hospitals, Internal progress report on pilot study, Monash
Medical Centre.
Ackoff, R.L. & Rivett, P. 1963, A Managers Guide to Operations Research, John
Wiley & Sons, New York.
Anderson, C.A. 1971, Performance rating, in Industrial Engineering Handbook,
3rd edn, W.B. Maynard, McGrawHill, New York.
Anderson, J. 1983, Design and evaluation of a patient dependency tool at the Royal
Melbourne Hospital, unpublished paper.
Anderson, R.G. 1973, Organization and Methods, Macdonald & Evans, London.
Anonymous 1980, Lecture notes, Footscray Technical College, Industry Service
Department, Victoria.
Antis, W. 1971, Stopwatch time study, in Industrial Engineering Handbook,
3rd edn, W.B. Maynard, McGraw-Hill, New York.
Aydelotte, M. 1973, Nurse Staffing Methodology: A Review and Critique of Selected
Literature, USDHEW pub. no. (NIH) 73433, Washington DC Government Printing
Office.

527

Operations research, work study and measurement

Bardossy, A., Bogardi, I. & Duckstein, L. 1993, Fuzzy nonlinear regression analysis
of dose-response relationships, European Journal of Operational Research, vol. 66,
no. 1, pp. 3651.
Barnard, C. & Esmond, T. 1981, DRG based reimbursement: The use of concurrent
and retrospective clinical data, Medical Care, vol. 19, no. 11, pp. 10711082.
Barnes, R.M. 1980, Motion and Time Study Design and Measurement of Work,
7th edn, John Wiley and Sons, NY.
Bendigo Home & Hospital for the Aged 1981, Patient-nurse Dependency, Report of
study undertaken, Bendigo, Victoria.
Berg, M. 1999, Patient care information systems and health care work: a
sociotechnical approach, International Journal of Medical Informatics, vol. 55,
no. 2, pp. 87101.
Boyd, J. 1982, Prediction of staff to acuity: A confirmation of nursing judgement, in
Nurse Staffing Based on Patient Classification, AHA, Chicago.
Brennan, J.E., Golden, B.L. & Rappoport, H.K. 1992, Go with the flow: Improving
Red Cross bloodmobiles using simulation analysis, Interfaces, vol. 22, no. 5,
pp. 113.
Brisley, C.L. 1971, Work sampling, in Industrial Engineering Handbook, 3rd edn,
H.B. Maynard, McGrawHill, New York.
Butler, T.W. 1995, Management science/operations research projects in health care:
The administrators perspective, Health Care Management Review, vol. 20, no. 1,
p. 19.
Butler, T.W., Kawan, K.R., Sweigart, J.R. & Reeves, G.R. 1992, An integrative
model-based approach to hospital layout, IEE Transactions, vol. 24, no. 2,
pp. 144152.
Clark, E.L. & Diggs, W.W. 1971, Quantifying patient needs, Hospitals JAHA,
vol. 45, pp. 96100.
Community Systems Foundation (Australasia) 1975, Hospital Work Measurement.
Crowther, L. & Help, A. 1986, Report Royal Park Hospital - PAIS psychiatric model,
unpublished report.
Currie, R.M. 1977, Work Study, 4th edn, Pitman, London.
Datta, S. & Bandyopadhyay, R. 1993, An application of O.R. in micro-level
planning in India, Computers & Operations Research, vol. 20, no. 2.
Davies, R. 1994, Simulation for planning services for patients with coronary artery
disease, European Journal of Operational Research, vol. 72, no. 2, pp. 323332.
DesOrmeaux, S.P. 1977, Implementation of the CASH patient classification system
for staffing determination, Supervisor Nurse, April.
de Zwart, J. 1991, Nurse Staffing Methodology, Health Department of Western
Australia, Perth.
Duffield C, Roche M, Merrick E.T 2006 Methods of measuring nursing workload in
Australia. Collegian Vol.13 No. 1 pp16-22
Dunphy, D.C. 1981, Organizational Change by Choice, McGraw-Hill Book Co.,
Sydney.
528

Operations research, work study and measurement

Edgecombe, R.H. 1965, The CASH approach to hospital: Commission for


Administrative Services in Hospitals reports on first projectimprovement of
nursing service management, Hospitals JAHA, vol. 39, pp. 7074.
Giovannetti, P. & Mayer, G.G. 1984, Building confidence in patient classification
systems, Nursing Management, vol. 15, no. 8.
Giovannetti, P. 1984, Staffing methodsimplications for quality, in Measuring the
Quality of Care, L.D. Willis & M.E. Linwood (eds), Churchill Livingstone, NY.
Giovannetti, P. 1985a, DRGs and nursing workload measures, Computers in
Nursing, vol. 3, no. 2.
Giovannetti, P. 1985b, Compatibility among existing patient classification systems
with a nursing minimum data set, Nursing Minimum Data Set Conference,
Wisconsin.
Giovannetti, P. & Johnston, J.M. 1990, A new generation patient classification
system, Journal of Nursing Administration, vol. 20, no. 5, pp. 3340.
Gnedenko, B.V. & Khinchin, A.Y. 1962, An Elementary Introduction to the Theory
of Probability, Dover Publication, New York.
Hammond, R.W. 1971, The history and development of industrial engineering, in
Industrial Engineering Handbook, 3rd edn, H.B. Maynard (ed.), McGraw-Hill, New
York.
Hendrickson, G., Doddato, T.M. & Kovner, C.T. 1990, How do nurses use their
time? Journal of Nursing Administration, vol. 20, no. 3, pp. 3137.
Heyde, G.C. 1974, Modular Arrangement of Predetermined Time Standards
(MODAPTS), The Australian Association for Predetermined Time Standards and
Research, Sydney.
Hodson, W.K. 1971, Fundamentals of indirect measurement, in Industrial
Engineering Handbook, 3rd edn, H.B. Maynard, McGraw-Hill, New York.
Hovenga, E. 1992, Universal nursing career evaluation system, manuscript.
Hovenga, E. 1994, Casemix, hospital nursing resource usage and costs: The basis for
a nurse staffing and costing system, PhD Thesis in Health Administration, University
of New South Wales.
Hovenga, E. 1994, An overview of the patient assessment and information system
(PAIS), Manuscript.
Hovenga, E. 1995, Performance measurement, in Management in the Australian
Health Care Industry, C. Clinton & D. Scheiwe (eds), Harper Educational, Australia.
Hovenga E.J.S. and Hindmarsh C 1996 Queensland Health - PAIS Validation Study:
Results and Issues for Nursing Cost Capture. Proceedings of the Eighth Casemix
Conference in Australia, Sydney Sept.
Howarth, M.H. 1976, Activity sampling in nursing, International Journal of
Nursing Studies, vol. 13.
ILO 1979, Introduction to Work Study, 3rd edn, International Labour Office, Geneva.
International Labour Office 1978, Introduction to Work Study, 3rd edn, International
Labour Office, Geneva.
International Labour Office (ILO), Job Evaluation, Geneva.
529

Operations research, work study and measurement

Jacobs, S.E., Patchin, N. & Anderson, G.L. 1968, Nursing Activity Study Project
Report, American Hospital Association, Chicago, Illinois.
Jelinek, R.C. & Dennis, L.C. 1976, A Review and Evaluation of Nursing Productivity,
DHEW pub. no. (HRA) 7715
Kramer, R.N. & Douglas, J.V. 1999, Planning for performance, in: Performance
Improvement Through Information Management, M.J. Ball & J.V. Douglas (eds),
Springer-Verlag, New York.
Kuhn, B.G. 1980a, Prediction of nursing requirements from patient characteristics
part 1, International Journal of Nursing Studies, vol. 17.
Kuhn, B.G. 1980b, Prediction of nursing requirements from patient characteristics
part 1, International Journal of Nursing Studies, vol. 17.
Lapsley, H.M. 1981, Hospital efficency, Australian Health Review, vol. 4, no. 3.
Laufer, A.C. 1984, Production and Operations Management, 3rd edn, South-Western
Publishing Co., Cincinnati.
Lindsay, J.N., Gillman, R.D. & Melrose, A.M. 1985, The Development of a Nursing
Dependency System Using Computerised Standard Data, The Resource Management
Services Unit, Canterbury Hospital Board.
Lindsay, N., Gillman, R., Melrose, A. & Kurta, G. 1987, Nursing dependency system
using computerised standard data, New Zealand Health Review, vol. 7, no. 2.
Maynard, H.B. (ed.) 1971, Industrial Engineering Handbook, 3rd edn, McGraw-Hill,
New York.
McHugh, M.L. & Dwyer, V.L. 1992, Measurement issues in patient acuity
classification for prediction of hours in nursing care, Nursing Administration
Quarterly, vol. 16, no. 4.
Meyer, D. 1978, GRASP - A Patient Information and Workload Management System,
MCS, Morganton, NC.
Murphy, L.N., Williams, M.A. & McAtchie, M. 1976, Development of Methods for
Determining Use and Effectiveness of Nursing Service Personnel, San Joaquin
General Hospital PHS Contract No. 1 NU 34048.
Murphy, L.N., Dunlap, M.S., Williams, M.A. & McaAtchie, M. 1978, Methods for
Studying Nurse Staffing in a Patient Unit, DHEW pub. no. HRA 783.
Nascimento, E.M. & Beasley, J.E. 1993, Locating benefit posts in Brazil, Journal of
the Operational Research Society, vol. 44, no. 11, pp. 10631066.
National Association of Childrens Hospitals and Related Institutions, Inc. 1978,
Study to Quantify the Uniqueness of Childrens Hospitals, Wilmington, Delaware.
Norby, R.B., Freund, L.E. & Wagner, B. 1977, A nurse staffing system based upon
assignment difficulty, Journal of Nursing Administration, Nov.
Overfelt, F.C. & Ballash, D.W. 1982, A broad perspective on patient condition
related staffing, in Nurse Staffing Based on Patient Classification, AHA, Chicago.
Pallin, A. & Kittell, R.P. 1992, Mercy hospital: Simulation techniques for ER
processes, Industrial Engineering, vol. 24, no. 2, pp. 3537.
Pidd M. 1977, The operational research method, in Operational Research for
Managers, S.C. Littlechild (ed.), Philip Allan, Oxford.
530

Operations research, work study and measurement

Roff, J.T 2003, UML: A beginners guide, McGraw-Hill, New York.


Sawyer, J., Levy, J., Harris, C. & Dixon, B. 1986, Indirect hours of care per patient
per day in a midwest extended care facility, Nursing Management, vol. 17, no. 10.
Sieferd, S.P. & Benton, W.C. 1992, Workforce staffing and scheduling: Hospital
nursing specific models, European Journal of Operational Research, vol. 60, no. 3,
pp. 23346.
Sieferd, S.P. & Benton, W.C. 1994, A decision model for shift scheduling of nurses,
European Journal of Operational Research, vol. 74, no. 3.
Scott, W.D. 1982, Recommended Methodologies for Determining Nurse Staffing
Levels, Report to the Capital Territory Health Commission.
Sherrod, S.M. 1984, Patient classification system: A link between diagnosis related
groupings and acuity factors, Military Medicine, vol. 149.
Segall, R.S. 1992, Deterministic mathematical modelling for the spatial allocation of
multi-categorical resources: With an application to real health data, Journal of the
Operations Research Society, vol. 43, no. 6, pp. 579589.
Shahani, A.K., Korve, N., Jones, K.P. & Paynton, D.J. 1994, Journal of the
Operational Research Society, vol. 45, no. 8, pp. 916926.
Song, F., Rathwell, T., Long, A. & Clayden, D. 1994, Three value estimates of input
variables and health manpower projections, Journal of the Operational Research
Society, vol. 45, no. 5.
Thomas, J.W. & Longo, D.R. 1990, Application of severity measurement systems
for hospital quality management, Hospital & Health Services Administration,
vol. 35, no. 2.
Van de Velde, R. & Degoulet, P. 2003 Clinical Information Systems: a component
based approach, Springer-Verlag, New York.
Veney, J.E. & Kaluzny, A.D. 1984, Evaluation and Decision Making for Health
Services Programs, Prentice Hall, Englewood Cliffs, New Jersey.
Von Mises, R. 1981, Probability, Statistics and Truth, Dover Publications, New
York.
Walpole, R.E. 1982, Introduction to Statistics, 3rd edn, Macmillan, New York.
White, D.J. 1985, Operational Research, John Wiley & Sons, New York.
Wolstenholme, E.F. & Corben, D.A. 1994, A hypermedia-based Delphi tool for
knowledge acquistion in model building, Journal of the Operational Research
Society, vol. 45, no. 6, pp. 659672.

531