Time Management Building Blocks
Suzanne cannot effectively meet all of her responsibilities by working faster or putting in longer hours. Working faster offers less time to think, plan and evaluate, and leads to careless errors that jeopardize patient safety. Working longer hours results in stress and fatigue.
Suzanne must work smarter, not harder. Her greatest challenge to working smarter is providing structure in an ever-changing, unstructured setting. This article presents time management as the tool for working most effectively in the home care setting.
The following steps provide the building blocks for effective time management:
Step 1: Identify your goals
Start with what you are looking to accomplish with your time. Identify your professional and personal goals with realistic short-term and long-term time frames for attainment.
After listing your goals, assign each goal a priority number or letter (A, B, C or 1, 2, 3) in order of importance. This should be done weekly.
Step 2: Review your time utilization
Review your time utilization by keeping a daily activity log for 1-2 weeks. The log identifies how time is spent on both productive activities and time-wasting activities. Make entries into the log consistently during the day to ensure accurate recall of events and avoid relying on memory.
Step 3: Match your time utilization patterns with your goals
Compare the time utilization patterns on your daily activity log with your identified personal and professional goals. Identify patterns that present obstacles to your goal attainment. Center your attention on stealers of time or “time bandits” such as procrastination, interruptions, unproductive meetings, tasks that can be delegated, acting with incomplete information, poor planning, stress and fatigue.
Structure your schedule with a focus on goal attainment. Strategic planning serves to eliminate or minimize the time bandits that steal your most precious resource: time. According to the Pareto Principle, to best attain your goals you need to spend 80 percent of your time on the top 20 percent of most important items on your list. Differentiating between what needs to be done and what can be done helps in prioritizing between the top 20 percent items and the less important remaining 80 percent.1
On a Monday, Suzanne had scheduled seven home care visits: six revisits and one new admission. She needed to finish her workday on time to keep a dentist appointment. Her supervisor requested that she stop by the office in the afternoon to review some of her charts. Suzanne’s goals for Monday are to: a) end her workday on time; b) provide focused patient care; and c) complete her documentation for each visit during or immediately after the visit.
To attain these goals, Suzanne: a) reschedules her meeting with her supervisor to the end of the next day; b) schedules the initial visit, which is time consuming, for the first visit of the day when she is most energized; c) arranges her visits based on patient acuity level; and d) documents as she is collecting data and then asks the patient/caregiver for a quiet place to sit toward the end of the visit to complete documentation.
Step 4: Prioritize for better time management
Begin the task of prioritizing your activities for goal attainment by using a priority matrix. The priority matrix involves assigning one’s activities into four categories. The priority time management matrix (Table 1) lists many of the daily activities involved in the day of the home health nurse and assigns each activity to one of the four quadrants.
Tasks that need to be prioritized are placed in four categories:
1. Important and urgent
2. Important but not urgent
3. Not important but urgent
4. Not important and not urgent
The goal is to shift high-priority activities to the second quadrant, to which your important but not urgent activities are assigned. This shift is accomplished through anticipatory planning with a focus on minimizing emergencies, controlling time bandits and establishing realistic deadlines.
Compare your priority time management matrix to Table 1. What steps must you take to move your most important activities to quadrants 1 and 2? What can you do to control the number of activities that are classified as urgent?
Time wasters fall into the fourth quadrant labeled not important and not urgent. Identify time wasters by asking yourself what would happen if this were not done and strive to eliminate or control the time wasters.1
On a daily basis prioritize your work by creating a “to-do” list. Identify and plan which activities need to be accomplished in order of importance. Patient-centered activities are the priority.
Once you have identified and prioritized your tasks each day, write down those that need to be addressed immediately and placed high on the priority list, and those that can be addressed later in the workday or workweek. This to-do or plan sheet serves the purpose of recording and organizing the present and future plans for the workday.
Once the activities for each workday are identified and prioritized, organize them on your calendar or schedule in blocks of time. Anything that takes longer than 10-15 minutes should be recorded on your schedule in a block of time for your day.
Step 5: Battling the major time bandits
Reviewing your workday, identify time wasters and grapple with the worst offenders. The following are common time bandits and strategies for overcoming them:
Procrastination – Procrastination is a great thief of time. It signals internal conflict and indecision and results in the avoidance of difficult tasks. Procrastination involves performing low-priority activities in place of high-priority activities. Confront your procrastination by identifying what is holding you back and what is the price for delay. To handle procrastination, consider responding in the following ways:
Identify your high-energy periods during the workday and schedule your most difficult visits during these periods.
Set priorities for each visit and focus on one problem at a time. Visualize the end result of each visit and what you wish to accomplish during the visit time. Inform your patients and caregivers about the purpose of your visits to elicit cooperation.2
Define your own deadlines to develop a time frame in which to plan and fit the task into your own schedule. (For example, schedule an extra patient visit to make sure you have enough work for the day.) Create deadlines. As stated by Alec Mackenzie, author of The Time Trap: Managing Your Way Out: “Self-imposed deadlines are one of the most effective techniques of insuring productive effort by monitoring progress.”3
Poor planning or unrealistic planning – To manage your time is to control your time rather than having time control you. To control time, you must plan. Planning takes time and must be scheduled into each day. Use 10-15 minutes of planning time either at the beginning or end of your day to do the following:
Assign time each day to review how you are planning to use your time.
List your activities for the day on your schedule and review your time frames to determine if the time assigned to each activity is realistic.
Plan time during the day (lunch or coffee break) to regroup, using your list of activities to center yourself.
Analyze your use of time by asking yourself regularly during the day, “Am I using my time effectively right now?” “Are my objectives clear?”4
Perfectionism – Perfectionism can be paralyzing and is a common trait among home heath nurses. Avoid perfectionism by developing reasonable standards of practice. Strive for excellence by doing your job well and using the resources provided by the agency. Ask for guidance and suggestions from other experienced nurses.3
Computerized Documentation
If your agency has computerized documentation, familiarize yourself with the computer as quickly as possible. If your agency is not yet computerized, encourage your administration to move in that direction.
Computerized documentation can save time. At the Visiting Nurse Service of New York (VNSNY), staff using the newly updated computerized documentation system reports that the system eliminates duplication of effort, efficiently manages work requirements with clinical “prompts” and reduces trips to the office with electronic transmission of visit notes. The computerized documentation at VNSNY also efficiently and effectively supports best clinical practice, agency policies and procedures, and regulations with its comprehensive software program.
Plan and Manage Your Schedule
Choose a planner that suits you and keep it with you at all times. If your agency has computerized documentation with e-mail, such as Microsoft Outlook with a calendar integrated into the software, begin using the electronic calendar for scheduling your activities.
If your agency’s documentation is not computerized, you may want to try a personal digital assistant, such as the Palm Pilot. The Palm Pilot has a calendar, telephone book and “to-do list” note pad. These features can be utilized, respectively, to track visits, store and update work-related telephone numbers, and prioritize activities. The Palm Pilot also has the capability of storing a drug database, such as www.epocrates.com, which can be downloaded from the Internet. If you use a loose-leaf paper calendar, write in pencil to allow revisions.
Whether you choose an electronic or paper planner, it is recommended that you do the following:
Keep one daily, 12-hour calendar for scheduling both professional and personal activities.
Schedule your daily activities into blocks of time starting at 15-minute intervals.
Create a to-do list for activities that require less than 15 minutes to complete. Be certain to allot the appropriate amount of time for your high-priority items.
Block out time on your calendar for recurring events including preparing for the field, field visits, travel time, completing required documentation, team meetings, coordination telephone calls, meals and workday review.
Be realistic when planning your calendar, and always schedule contingency time for the unexpected.
Develop a system for checking off activities as you complete them and carrying over incomplete activities to a later date.
Strive to schedule items on your calendar 2-4 weeks in advance.
Doing the Whole Job
Single handling through task completion involves resolving a question, making a decision, contacting a physician or resolving patient care issues the first time the situation occurs.
During a home visit, do the “whole job” by completing all the required steps in providing patient care including assessment, technical procedures, patient education, necessary telephone calls and documentation. Doing one thing at a time and completing the task is a timesaver that avoids the need to reorient or refresh your memory.
OASIS Management
The Outcome and Assessment Information Set (OASIS), mandated by the federal government as a condition of participation for certified home health agencies, is clearly here to stay. This systematic collection of data is designed to minimize subjectivity and provide the basis for consistent measurement of patient outcomes over time. OASIS data is also used to determine the reimbursement to home care agencies by CMS for services provided.
The effficient collection of accurate OASIS data is essential for the survival of a certified home health agency. Every nurse or therapist who has completed an OASIS visit knows this data collection can be extremely time consuming.
A combination of methods for the efficient collection of accurate data can serve to streamline OASIS visits. These methods include interviewing, direct observation and physical exam. To begin, sort the OASIS items into pre-visit, visit and post-visit categories to facilitate data collection (see Table 2).
OASIS items can be sorted into purposeful activities for data collection. Sheila Neder, RN, research clinician with the Visiting Nurse Service of New York, in the “VNSNY Outcomes Initiative News,” recommends asking your patient to walk with you to the bathroom when you perform your routine hand washing. If you observe your patient closely, this simple activity yields data for the following OASIS items:
(MO660) ability to dress lower body/put on footwear;
(MO690) transferring;
(MO700) ambulating;
(MO490) shortness of breath;
(MO310), (MO320), (MO330) living arrangements/structural barriers and hazards;
(MO520), (MO540) incontinence, if garments appear soiled;
(MO420) grimacing or report of pain interfering with movement; and
(MO390) visual acuity/awareness of obstacles in path.
While in the bathroom, ask your patient to demonstrate the following activities of daily living:
(MO680) ability to get to and from toilet;
(MO640) ability to groom; and
(MO670) ability to get in and out of tub or shower.
Staying Focused on Visits
Prior to each visit, establish goals that will focus the activities of the visit. Prior to the visit, also gather needed clinical supplies and written teaching materials to be used in providing patient care.
Upon arrival in the patient’s home, inform the patient and caregivers of your goals for the visit. Refocus the visit each time it strays off target. Document at the completion of the visit, emphasizing the focus of the nursing care you have provided.
Telephone Management
Utilize the telephone as a time management tool by carrying a cell phone in the field and using voice mail. Include the following points in your voice mail message:
the schedule of times when you check your voice mail (e.g., early morning and late afternoon);
the number to call in case of emergency when an immediate response is needed; and
the time of day that you return telephone calls. This gives callers a time frame when they can expect to receive a return call from you. It also gives you the flexibility to answer non-urgent messages during planned telephone time.
Incorporate a daily telephone agenda and outcomes log into your calendar. Schedule time on your calendar for listening to voice mail and making calls.
Prepare a script for coordination calls with members of the multidisciplinary team to keep you focused on essential topics for discussion.
Keep frequently called numbers in your planner telephone book and at regular intervals update your database for telephone numbers.
A tip for improving the effectiveness of your telephone communications is to schedule face-to-face visits to frequently called telephone contacts that you have never met in person. These contacts include private physicians and their staff, clinic physicians and clinic nurses, who are involved with your home care patients.
A quick introduction and handshake will save you much telephone time in the future when it comes to receiving signed or verbal orders or requesting responses to your telephone messages.
Stress Management
Managing your stress is essential for maintaining your own health and avoiding the kind of stress overload that will sabotage your best-laid plans for effective time management. Some practical ways to avoid, reduce or relieve stress include the following:
Anticipate your needs. Regularly charge your cell phone and computer, fill your car with gas, obtain enough coins for meters, tolls, telephones, and carry batteries for your beeper, snacks and water.
Prepare for morning the day before by replenishing your clinical and documentation supplies.
Call your patients and caregivers the day before to schedule your visit. For daily visits, schedule with the patient/caregiver for the following day during your visit.
Establish a quiet place of your own to work, relax and think.
Take advantage of your body rhythms for scheduling activities that require high energy and concentration.
Reward yourself after stressful activities. Take time out to breath deeply, stretch and talk to a sympathetic listener.
Say “no” more often if you are meeting others needs at the expense of meeting your own.
Structure for Success
By employing these techniques, Suzanne Brown can complete her seven home visits, meet all of her coordination and documentation responsibilities, and still have time for her personal life.
You too can structure your time in the ever changing and demanding home care environment to meet your professional and personal goals. Always strive to integrate your personal with professional goals when managing your time. Plan your schedule around a 12-hour day to include daily self-care.
Personalize your schedule as much as possible. Build personal rewards and stress management into your workday schedule to avoid burnout. Maintain control of your time by building flexibility into your schedule.
Remember, the availability of home health care is dependent upon the survival of you, the home health care nurse.
References
1. Covey, S.R. (1989). The 7 habits of highly effective people (pp. 151-156). New York: Simon & Schuster.
2. Pratt, J. (2000). Time management: ‘The hurrier I go, the behinder I get.’ Home Health Care Management and Practice, 12(4), 61-63.
3. Mackenzie, R.A. (1972). The time trap: Managing your way out (p. 25). New York: Amacom.
4. Douglass, M.E., & Douglass, D.M. (1980). Manage your work, manage yourself (pp. 2-6). New York: American Management Association.
5. Home Care Association of NYS Inc. (2002). Back to basics: Communication techniques, nursing process, and outcome bases quality improvement (p. 12).
Resources
Marrrelli, T., & Hilliard, L. (1998). Manual of home health practice. St. Louis: Mosby.
Sherry, D. (2002). Time management strategies for the home care nurse. Home Health Care Nurse, 20, 340-341.
Susan Wittenberg is education manager and Mari Moriarty is college relations manager with Visiting Nurse Service of New York.
