Chapter 7: Quantitatve Methods in Health Care Management Yasar A. Ozcan 1 Chapter 7. Staffing.

Chapter 7: Quantitatve MChapter 7: Quantitatve Methods in Health Care Maethods in Health Care Managementnagement

Yasar A. OzcanYasar A. Ozcan 11

Chapter 7.Chapter 7.StaffingStaffing

Chapter 7.Chapter 7.StaffingStaffing



OutlineOutline Workload Management Overview The Establishment of Work Standards and Their

Influence on Staffing Levels Patient Acuity Systems Internal Work Standards

– Utilization of FTEs– FTEs for Nurse Staffing– Coverage Factor– Reallocation-Daily Adjustments

External Work Standards Productivity & Workload Management



Importance of Staffing DecisionsImportance of Staffing Decisions

Human resources is the greatest expenditures of many health care organizations.

In manufacturing, determination of skill-mix and staffing levels is fairly straight forward.

In healthcare, uncertainty makes staffing particularly difficult.



What would you do?What would you do?Staff for peak levels at all times?

Staff for minimum census and acuity levels?

Staff for minimum census and acuity levels and hire part time agency nurses?

What are problems with each approach?

A solution-- flexible staffing!



Flexible StaffingFlexible StaffingFlexible StaffingFlexible Staffing

Setting a core level staff based on a long term needs assessment which is then augmented by short-term (daily) adjustments using various methods to match staffing levels and patient needs.



Staffing Scheduling

Reallocation

Productivity

Workload Standards

Staff Utilization

Costs Staff Satisfaction

Patient Satisfaction

Figure 7.1 Workload Management



Workload Management: the componentsWorkload Management: the componentsWorkload Management: the componentsWorkload Management: the components

StaffingStaffing-- -- determining the appropriate number determining the appropriate number of full-time equivalents (FTEs) to be hired in of full-time equivalents (FTEs) to be hired in each skill class (RN, LPN, aides, MHA, MBA, each skill class (RN, LPN, aides, MHA, MBA, etc..)etc..)

SchedulingScheduling-- -- who is on and off duty and when; who is on and off duty and when; operational procedure operational procedure

ReallocationReallocation-- -- fine tunes the previous fine tunes the previous decisions; daily if not shift by shiftdecisions; daily if not shift by shift



To staff efficiently we need a standard!To staff efficiently we need a standard!To staff efficiently we need a standard!To staff efficiently we need a standard!

Work standard-- Work standard-- a predetermined allocation of a predetermined allocation of time available for each unit of service time available for each unit of service (presumably at the appropriate quality level)(presumably at the appropriate quality level)– Acuity Adjusted-- Acuity Adjusted-- patient days are adjusted for patient days are adjusted for

the acuity level of the patients being servedthe acuity level of the patients being servedExample: Nursing hours per patient Example: Nursing hours per patient

dayday– Procedural standard-- Procedural standard-- when the unit of service when the unit of service

is a procedure, such as a lab test or x-rayis a procedure, such as a lab test or x-rayExample: Technicians per CT scanExample: Technicians per CT scan



Standard developmentStandard developmentStandard developmentStandard development

Historically based solely on estimated average Historically based solely on estimated average census of the entire organizationcensus of the entire organization

What is a problem with this approach?What is a problem with this approach?

1) Doesn’t account for unit to unit variation.1) Doesn’t account for unit to unit variation.

2) Dependent upon a physician estimate of LOS.2) Dependent upon a physician estimate of LOS. Today, precise estimates of LOS can be Today, precise estimates of LOS can be

determined from information systems.determined from information systems.



An adequate staffing system An adequate staffing system contains three components.contains three components.An adequate staffing system An adequate staffing system contains three components.contains three components.

Reliable patient classification and acuity Reliable patient classification and acuity system that determines patient need for system that determines patient need for services based on patient specific services based on patient specific characteristics.characteristics.

Development of time standards to reflect Development of time standards to reflect the time needed to provide services based the time needed to provide services based on the patient classification system.on the patient classification system.

A method of converting total service time A method of converting total service time needed to FTEsneeded to FTEs



The patient classification and acuity systemThe patient classification and acuity systemThe patient classification and acuity systemThe patient classification and acuity system

Departmental acuity adjusted census is best for Departmental acuity adjusted census is best for determining workload standardsdetermining workload standards

Fewer staffing adjustments are necessary when Fewer staffing adjustments are necessary when an admissions monitoring information system is an admissions monitoring information system is based on the unit’s patient care requirements based on the unit’s patient care requirements rather than unit census.rather than unit census.

An illustration: Who requires moreAn illustration: Who requires more

care, a patient in the ICU or one care, a patient in the ICU or one

recovering from minor surgery?recovering from minor surgery?



Before developing acuity Before developing acuity standards. . .standards. . .

Before developing acuity Before developing acuity standards. . .standards. . .

A patient acuity system is necessary to A patient acuity system is necessary to measure the amount of care required by measure the amount of care required by any given patient.any given patient.

Also called patient classification systemsAlso called patient classification systems



Types of Acuity SystemsTypes of Acuity SystemsTypes of Acuity SystemsTypes of Acuity Systems Prototype systemsPrototype systems

– Classify according to type of care neededClassify according to type of care needed– Patients grouped into 3-10 categories based on Patients grouped into 3-10 categories based on

expected time commitments, diagnosis, expected time commitments, diagnosis, mobility, and education neededmobility, and education needed

– Highly subjective; easy to implementHighly subjective; easy to implement Factor-analytic systemsFactor-analytic systems

– Establishes classes by summing relative values Establishes classes by summing relative values assigned to individual tasks or indicators of assigned to individual tasks or indicators of patient needs (Example: GRASP, MEDICUS)patient needs (Example: GRASP, MEDICUS)



Table 7.2 Daily Census, Required Labor Hours, and Acuity Level Statistics for a Medical/Surgical Floor.

Census

Based on Patient Classification-- Required Hours per Patient Day

Number of Patients in Acuity Level

Date Day of Week

AM

PM Night Total AM PM Night Total 1 2 3 4

01/02/05 SUN 12 13 12 12.3 2.3 1.4 0.8 4.5 6 7

01/03//05 MON 13 12 12 12.3 1.9 1.6 0.9 4.4 6 7

01/04/05 TUE 22 22 10 18.0 2.1 1.7 1.0 4.7 1 5 16

01/05/05 WED 9 9 9 9.0 2.1 1.7 1.0 4.8 2 7

01/06/05 THU 11 11 9 10.3 1.8 1.4 0.9 4.1 3 3 5

01/07/05 FRI 12 12 12 12.0 1.6 1.3 0.7 3.6 6 4 2

01/08/05 SAT 12 12 11 11.7 2.0 1.6 0.9 4.6 3 3 4 2

If staffing was based on unadjusted census, inaccuracies would result. For instance, compare January 5 (Census = 9) and January 7 (Census =12). Which day would require a greater number of FTEs?



Census

Based on Patient Classification-- Required Hours per Patient Day

Number of Patients in Acuity Level

Date Day of Week

AM

PM Night Total AM PM Night Total 1 2 3 4

01/02/05 SUN 12 13 12 12.3 2.3 1.4 0.8 4.5 6 7

01/03//05 MON 13 12 12 12.3 1.9 1.6 0.9 4.4 6 7

01/04/05 TUE 22 22 10 18.0 2.1 1.7 1.0 4.7 1 5 16

01/05/05 WED 9 9 9 9.0 2.1 1.7 1.0 4.8 2 7

01/06/05 THU 11 11 9 10.3 1.8 1.4 0.9 4.1 3 3 5

01/07/05 FRI 12 12 12 12.0 1.6 1.3 0.7 3.6 6 4 2

01/08/05 SAT 12 12 11 11.7 2.0 1.6 0.9 4.6 3 3 4 2

But, if we look at acuity levels, we observe that 80% of patients on January 5 are in categories 3 and 4, compared to only 17 percent in these categories on Jan. 7. The greater acuity is reflected in the greater number of required hours.

Table 7.2 Daily Census, Required Labor Hours, and Acuity Level Statistics for a Medical/Surgical Floor.



Table 7.3 Average Census, Required Labor Hours, and Acuity Level Statistics for a Medical/Surgical Floor.

Average Census Based on Patient Classification-- Avg. Required Hours

per Patient Day

Percent of Patients in Acuity Level

Year Month AM PM Night Total AM PM Night Total 1 2 3 4

2003 January 14.1 13.8 13.8 13.9 1.8 1.5 0.9 4.1 26.3 26.9 45.0 1.7

February 14.9 14.3 14.1 14.4 1.8 1.5 0.9 4.1 26.2 31.8 38.6 3.3

March 15.3 14.9 14.6 14.9 1.9 1.5 0.9 4.3 19.7 27.5 48.8 3.5

April 18.7 18.4 18.2 18.4 1.8 1.4 0.8 4.1 27.3 26.4 44.3 2.0

May 19.8 19.5 19.3 19.5 2.0 1.6 0.9 4.4 21.7 21.0 52.7 4.3

June 19.2 18.5 18.3 18.7 1.8 1.5 0.9 4.2 23.8 24.9 50.2 1.1



Table 7.3 Average Census, Required Labor Hours, and Acuity Level Statistics for a Medical/Surgical Floor (Cont.)

July 8.7 8.2 7.5 8.1 1.7 1.4 0.8 4.0 18.0 43.4 38.1 0.6

August 8.0 7.5 6.7 7.4 1.6 1.4 0.8 3.7 23.1 44.8 32.1

September 7.4 6.9 6.5 6.9 1.8 1.4 0.8 4.0 15.4 44.6 38.2 1.7

October 6.4 6.1 5.3 5.9 1.8 1.5 0.9 4.1 13.0 39.7 47.3

November 13.5 13.2 12.7 13.1 1.8 1.4 0.8 4.1 28.7 30.4 38.3 2.6

2004 December 13.3 12.6 11.2 12.4 1.6 1.3 0.7 3.7 30.3 43.6 25.7 0.4

2005 January 11.3 11.2 10.1 10.9 1.9 1.5 0.9 4.2 18.9 32.7 45.9 2.5

Statistics

Mean 14.4 13.9 13.4 14.0 1.8 1.5 0.8 4.1 23.3 32.0 42.1 2.4

Minimum 4.5 4.4 4.1 4.3 1.6 1.3 0.7 3.7 12.2 21.0 25.7 0.0

Maximum 22.8 22.2 21.9 22.3 2.0 1.6 0.9 4.5 38.0 44.8 53.7 5.2

St. Deviation 5.3 5.1 5.2 5.2 0.1 0.1 0.0 0.2 6.7 6.7 6.8 1.5



Standard DevelopmentStandard DevelopmentStandard DevelopmentStandard Development

Standards can be internal or external -- choice Standards can be internal or external -- choice of standards used depends on cost and of standards used depends on cost and accuracy targetsaccuracy targets

Internal standards are often more accurateInternal standards are often more accurate– The first step in standard development is The first step in standard development is

identifying and documenting the activities identifying and documenting the activities performed on the unit/department being performed on the unit/department being examinedexamined

– What tools might you use to identify What tools might you use to identify these activities?these activities?



Fixed or Variable?Fixed or Variable?Fixed or Variable?Fixed or Variable? All activities identified should be classified as All activities identified should be classified as

fixed or variablefixed or variable– Fixed -- do not vary by volumeFixed -- do not vary by volume– Variable -- fluctuate with services offeredVariable -- fluctuate with services offered

Classification by direct or indirect care should Classification by direct or indirect care should also be madealso be made– Direct -- centered around the patientDirect -- centered around the patient– Indirect -- Patient care support servicesIndirect -- Patient care support services

Can you think of examples of each?Can you think of examples of each?



Determining Activity TimesDetermining Activity TimesDetermining Activity TimesDetermining Activity Times

Often no need to analyze all activities on the unit, Often no need to analyze all activities on the unit, but the activities chosen should be representative but the activities chosen should be representative of all department activitiesof all department activities

For some departments, it is better to analyze all For some departments, it is better to analyze all activities, especially if service mix and complexity activities, especially if service mix and complexity differs greatlydiffers greatly

What are some tools we can use to determine What are some tools we can use to determine activity times?activity times?



We should remember these!We should remember these!We should remember these!We should remember these!

Work samplingWork sampling– often done by outside sourceoften done by outside source

Time and motion studiesTime and motion studies– expensive and time consuming; not expensive and time consuming; not

common in healthcarecommon in healthcare Estimation- Estimation- low cost and minimal timelow cost and minimal time Historical averaging- Historical averaging- easiest and least $$easiest and least $$ Logging- Logging- excellent, low cost methodexcellent, low cost method



To determine work standards. . .To determine work standards. . .To determine work standards. . .To determine work standards. . .

Divide the total estimate of hours required Divide the total estimate of hours required for a given activity by the total volume to for a given activity by the total volume to determine the workload standard.determine the workload standard.

If Radiology works 1500 hours to produce 3000x-rays, the work standard would be:If Radiology works 1500 hours to produce 3000x-rays, the work standard would be:

1500 hrs.3000 x-rays 1500 hrs.3000 x-rays

= 30 minutes per x-ray= 30 minutes per x-ray



But can we expect 100% from anyone?But can we expect 100% from anyone?But can we expect 100% from anyone?But can we expect 100% from anyone? Many factors prevent 100% staff utilizationMany factors prevent 100% staff utilization

– Controllable-- Controllable-- staff scheduling, avoidable delays, staff scheduling, avoidable delays, scheduling of vacations, scheduling of vacations,

– Uncontrollable-- Uncontrollable-- physician ordering patterns physician ordering patterns (and golf tournaments!), sick leave, market (and golf tournaments!), sick leave, market constraints of labor forceconstraints of labor force

Estimating UtilizationEstimating Utilization– Review historical levels and agree to a targetReview historical levels and agree to a target– Quantify delays and downtime and allow for Quantify delays and downtime and allow for

acceptable levelsacceptable levels– Calculate a weighted average utilizationCalculate a weighted average utilization



Table 7.4 Weighted Average Utilization for a Laboratory Based on Workload Fluctuations by Shift

Shift Percent of Work Load

(A)

Expected Utilization

(Percent) (B)

Weighted Utilization

(A*B)

Morning 45 95 .428

Afternoon 35 85 .298

Evening 7 90 .063

Night 13 85 .111

Total 100 0.900

Weighted Average Utilization Target = 90 %.



Example 7.1A teaching hospital’s laboratory routinely performs nine microscopic procedures. Average monthly volume of each procedure has been determined from the historical data. An earlier time study also revealed the workload standard for each procedure, as shown in Table 7.5.

Variable Activities

Volume (# of procedures per

30-day period)

Workload Standard (hours per procedure)

Standard Hours for 30-day period

Procedure 1 350 .12 42.00

Procedure 2 222 .30 66.60

Procedure 3 185 .45 83.25

Procedure 4 462 .26 120.12

Procedure 5 33 .84 27.72

Procedure 6 12 .88 10.56

Procedure 7 96 .362 34.75

Procedure 8 892 .46 410.32

Procedure 9 26 1.9 49.4

TOTALS 2278 844.72

Table 7.5 Workload Standards for Microscopic Procedures in Laboratory



Solution:

The first step in setting staff levels for a procedure is to discover the number of procedures to be performed (A).

By multiplying the volume for each procedure by the workload standard, a time estimate for each activity is made.

The sum of the standard hours represents the total time needed to perform the procedures (B).

Because this total represents only the direct procedure hours of the technicians, it must be augmented by the indirect (support) hours, which in this example are estimated at 0.21 hours per procedure. Table 7.4 depicts these calculations.



Table 7.6 Calculation of Staffing Requirements for Microscopic Procedures

Total volume of activities (tests) (A) 2278

Total direct procedure hours (B) 844.72

Indirect support hours (C) = .21 x (A)(assume 0.21 hours per procedure)

478.38

Subtotal variable hours required (D) = (B) + (C) 1323.10

Department utilization target (E) [from above] 90.00%

Total variable hours required (normalized) (F) = (D)/(E) 1470.11

Constant hours (G) (30 days at 12.28 hours per calendar day in this example)

368.40

Total target worked hours required (H) = (F) + (G) 1838.51

Total target FTEs required (I) = (H) divided by 173.33 (hours per FTE per month-- (40 hrs./wk. x 52 wks)/12 months)

10.61 FTEs

Vacation/holiday/sick FTE allowance (J) = (I) x 9.8% (percentage varies by hospital department)

1.04 FTEs

Total Required Paid FTEs (K) = (I) + (J) 11.65 FTEs



Minutes of Care Required = (Average Census)*(Average Required Minutes per Patient)

Determination of the FTEs required to staff a nursing unit requires several steps. First, the minutes of required care is determined using the following formula:

Determination of FTEs for Nurse Staffing.

This equation then should be divided by the number of minutes available to work per nurse per day (equals 8 hours/day * 60 minutes/hour, or 480 minutes available) to determine the number of unadjusted FTEs. Thus, in second step, unadjusted FTEs are calculated using the next formula:

Dayper Nurseper Work toAvailable Minutes

Required Care of Minutes TotalFTEsUnadjusted



However, this method of calculation assumes 100 percent utilization of the staff, an assumption that is clearly unrealistic for the reasons mentioned earlier. Suppose that the administration has established a utilization standard of 0.75; that is, 75 percent of each employee’s time will be spent in unproductive activities, or activities unrelated to direct patient care. The number of minutes available to work per nurse per day (example, 480 minutes) must be adjusted by the utilization standard; hence in the third step, core level FTEs is determined with this formula:


)(*)tan(

)(*)Re(

MinutesWorkAvailabledardSnUtilizatio

CensusAveragePatientperMinutesquiredAverageFTEsLevelCore



The nursing manger would like to determine the number of nursing staff needed for the medical/surgical unit. Table 7.2 and Table 7.3 provide census and acuity information for a medical/surgical floor.

Solution:Table 7.2 provides information on the daily census

for January, 2005. Table 7.3 aggregates the monthly data to provide the average census over a 25-month period. Notice that the mean values presented in Table 7.2, are the same as those found in the January, 2005 row in Table 7.3. It is important to realize that the core staffing levels in this example are found through a retrospective analysis of average monthly census and required hours per patient day.

Example 7.2:



Mean 14.4 13.9 13.4 14.0 1.8 1.5 0.8 4.1 23.3 32.0 42.1 2.4

Minimum 4.5 4.4 4.1 4.3 1.6 1.3 0.7 3.7 12.2 21.0 25.7 0.0

Maximum 22.8 22.2 21.9 22.3 2.0 1.6 0.9 4.5 38.0 44.8 53.7 5.2

Std. Deviation 5.3 5.1 5.2 5.2 0.1 0.1 0.0 0.2 6.7 6.7 6.8 1.5

Table 7.3 Average Census, Required Labor Hours, and Acuity Level Statistics for a Medical/Surgical Floor.

Average Census Based on Patient Classification-- Avg. Required Hours

per Patient Day

Percent of Patients in Acuity Level

AM PM Night Total AM PM Night Total 1 2 3 4



The first step of the staffing calculation is to find the total number of minutes of care required, using formula:

Minutes of Care Required = (Average Census)*(Average Required Minutes per Patient).

Minutes of Care Required = (14 * 4.1)*60 minutes = 3444 minutes.

The second step uses next formula to divide the number of minutes available to work per nurse per day (480 minutes) to determine the number of unadjusted FTEs required.

Solution:

0.7480

1.4*14FTEsUnadjusted

The third step determines the core level FTEs, using formula:

6.9480*75.0

1.4*14FTEsLevelCore



Coverage Factor.

One other adjustment must be made to make sure that the core staffing levels are as accurate as possible. The above calculation assumes that employees will be available to work 365 days per year, without vacations, sick days, or holidays. To adjust for these factors, we must calculate a coverage factor.

An example of the coverage factor adjustment is found in Table 7.5. The first step in its determination is subtracting weekend days per year and benefit days from the required coverage days per year (365 in most any health care organization), to arrive at a total of available days per FTE (line 5).

By dividing the total number of required days per year by the total available days, we obtain a coverage factor. This coverage factor is then multiplied by the unit FTE requirements to calculate the total unit FTE requirements.




Table 7.7 The Effect of Shift Alternatives on Staffing – The Coverage Factor

Assumptions 5/40 or 2/12 & 2/8 Plans

4/40 or 4/36 Plans

(1) Required Coverage Days per Year 365 365

(2) Weekend Days per Year 104 156

(3) Benefit Days*Vacation*Sick Days*Holidays*Other

10771

10771

(4) Total Allowance Days of FTE (2) + (3) 129 181

(5) Total Available Days of FTE (1) - (4) 236 184

(6) Coverage Factor (1)÷(5) 1.55 1.98

Shift Alternatives Unit FTE Requirement Coverage Factor Total Unit FTE Requirements

5/40 9.6 1.55 15

4/40 9.6 1.98 19

4/36 9.6 1.98 19

2/12 & 2/8 9.6 1.55 15



Elasticity LimitsMiddle Zone

+ \ - 10%

Lower Zone

Low Census--Days Off(LCI = 16%)

Float StaffNecessary(HCI = 16%)

Upper Zone

27LowerLimit

33UpperLimit

30Means.d = 3

WSI = 68%

Figure 7.2 Distribution of Daily Workload on a Nursing Unit

Can the core level staff handle the unit’s activities?



External Work StandardsExternal Work StandardsExternal Work StandardsExternal Work Standards

Two Types:Two Types:– Industry StandardsIndustry Standards– Professional StandardsProfessional Standards

Must be careful to adjust these factors for case-Must be careful to adjust these factors for case-mix and skill-mixmix and skill-mix

Per se standards have been argued to lead to Per se standards have been argued to lead to staffing standards that are inaccuratestaffing standards that are inaccurate



Exhibit 7.6 Factors to be Considered in Deciding on Staffing Levels

Size and design of facilityAverage length of stayNon-nursing responsibilitiesNursing responsibilitiesIntensity/acuity levels of patientsReliability of patient classification systemClinical expertise of available staffOrganized system of patient educationStaff mixResearch and data management responsibilitiesPatient transport responsibilitiesPhysician practice patternsFacility census patterns



It is important to recognize that no standard is absolute. Some room must be left for flexibility in staffing. Figure 7.3 demonstrates how statistical analysis can reveal whether the staff is meeting the standards. Figure 7.3: Workload Standard Tolerance

Ranges

Time

Workload Standard

U

S

L

n Tests

ToleranceLimits

Unit: ________ Acuity Level: _________

External Work StandardsExternal Work StandardsExternal Work StandardsExternal Work Standards



Staffing and productivityStaffing and productivityStaffing and productivityStaffing and productivity

Departmental productivity (the ratio of required hours to number of hours actually worked) is a measure of staff utilization

Appropriateness of employee skillsMatching of skills to job descriptions

Worker satisfaction and work organization, retention, recruitment, and transfers also impact productivity



Staffing problems impacting Staffing problems impacting productivity of workforceproductivity of workforce

Staffing problems impacting Staffing problems impacting productivity of workforceproductivity of workforce

Work load volume fluctuations--MD vacations impact ER staff productivity

Work load scheduling--should eliminate fluctuations as much as possible

Skill Mix--does it match work needs?

Staffing patterns-- can staff meet demand fluctuations?



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Chapter 7: Quantitatve Methods in Health Care Management Yasar A. Ozcan 1 Chapter 7. Staffing.

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Transcript of Chapter 7: Quantitatve Methods in Health Care Management Yasar A. Ozcan 1 Chapter 7. Staffing.