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http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Q:\Current\Prf\Present\STTI2006\Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Making Choices Under Fiscal Constraints and Uncertainty: Helping Nursing Students Make Clinical Decisions in Resource Constrained
Environments
Thomas Cox PhD, RN
Sigma Theta Tau International
17th International Nursing Research Conference Focusing on Evidence Based Practice
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Overall ObjectivesDescribe the context of forced decision
making in HC settings due to PCIR induced financial instabilities
Describe how to use game theory and simulations to safely expose students to controlled ethical conflicts and resource allocation decisions
Describe a freely available simulation program that helps users experience the nature of conflicts and tradeoffs faced by nurses who choose between services and patients in resource constrained settings
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Learner Objectives
Learner Objective #1: The learner will be able to obtain a simulation program designed to model the way nurses distribute scarce resources among a cohort of patients when demands and resources are uncertain
Learner Objective #2: The learner will be able to help students use the simulation program, collect and analyze data, and help students' evaluate their allocation choices
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Author Background
NursingMathematicsSocial Work
StatisticsHealth and Social Services Planning
Program EvaluationPsychotherapy
Insurance Ratemaking, Reserving and Reinsurance
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Why Is This Necessary?Some health care finance mechanisms shift insurance
risks from health plans to health care providers
“Professional Caregiver Insurance Risk”
Typical insurance risk portfolio transfers:
Capitation agreements
Managed Care
Prospective Payment Systems/DRGs
Prospective nursing unit/division budgets
Managing insurance risks exacerbates extant difficulties managing clinical and financial risks in HCOs
Curriculum focuses on clinically correct decision making – need more work on how to allocate scarce resources
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Professional Caregiver Insurance Risk 1
PCIR occurs when HCPs accept insurance risks in prospective payment systems, leading to:
Portfolio size differentials cause inefficiencies
Higher conflagration risk exposures for HCPs
Inadequacy or inefficiency of payment mechanisms
HCPs lack access to internal/external $ resources
Viscosity in resource transfers – difficult to move assets between units, locations, and patients
Violations of basic insurance/accounting principles
Greater difficulties managing nursing environments
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
PCIR and Clinical Decision Making
Many HCOs reduce supplies, staff, & equipment - BAD
Insurance risk/clinical management requires redundant supplies, staff, and equipment – failure to plan is a different issue than having inadequate resources
Poor planning means that nurses face needless decisions
Student evaluations focus on clinical decisions - time and resource constraints are peripheral
Few tools to develop skills in patient/service trade-offs
Simulated choice making may help improve ability to make and reflect on allocation decisions and processes
Use simulated experiences to review allocation choices, conduct research, and develop theory
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Why Simulations?Nurses need to be able to fluidly shift from the
usual, to the unexpected, to the overwhelming
Simulations are a safe way to expose students to forced choice decision-making outside clinical settings
Safely & efficiently encourage reflectiveness on practice and the assessment of how a nurse can improve their decision-making over time.
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
ConclusionC
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Decision Making Under Uncertainty 1I wanted a fun way to expose students to the problem of
allocating insufficient resources to activities and patients
User cares for 8 patients but it is unlikely that all requested services can be provided
User learns patient’s needs when entering their room
Each patient presents 2 options with regard to 10 services:
Provide some or all services needed immediatelyCannot return during the shift
Cannot ‘make up’ later when services are not performed
Unused time cannot be reclaimed – it is lost service potential
Skip to the next patient – provide no services
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Decision Making Under Uncertainty 2Service demands are randomly generated at run time
Users have to learn to withhold some services to early patients in order to have time left for their last patients
Users cannot learn how to get around the program by learning a pattern of demand - no two runs are the same
Four 2 hour long shifts
Patient’s needs exceed time and resources available
If user exhausts time - some patients needs will go unmet
Reports on allocations of time to services and patients
User & teacher review decisions and discuss implications
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Software DevelopmentVersion 1
FORTRAN in a DOS environment
Clunky
Reviewed by students, colleagues, friends
Future Versions
Visual Basic, Perl, PHP, Python, Java – Web delivery
Freely distributable Open Source code & binaries available under GNU public license
Source code can be altered
FORTRAN compiler is free
(In)formal data collection and research tool
DISCLAIMER: Spaghetti code – no claims to aesthetics
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Future Plans 1Windows and Linux GUI environments
Develop clinically meaningful scenarios
Allow return to patients during shift & options to see information on patients at the start of the shift
Prior assessment of user’s anticipated strategy to compare with user performance during simulation
Embedded audio and video materials on simulated patients, ethics, game theory, tips for managing uncertainty…
Manager’s perspective – assignments of nurses to patients
Include optimization software for staff scheduling and delegation
Develop potential to collect data for future research
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
How to get it?If all else fails, email me at:
[email protected] “tc” underscore “spirit”
Subject Line: “Nursing Simulation Software”
Web Access:
http://drtcbear.servebbs.net:81/STTI2006
http://www.afn.org/~mathstat/STTI2006
Free FORTRAN compiler used for the program
http://gcc.gnu.org/wiki/GFortran
If you improve on it – pass it on to me and others
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
The Open Source Imperative
Please acknowledge my work but you are free to copy and improve the simulations
Contributions, suggestions, and feedback are encouraged and appreciated
I don’t own it – I just wrote it
Any problems: email [email protected]
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
ConclusionNurses face increasingly difficult ethical and
resource allocation choices
Applying game theory, uncertainty assessment, and simulated decision-making may help students understand the ethical quandaries that exist in modern health care systems
Data collection and analysis of simulations across students, schools, and health care systems may help researchers and educators with regard to curriculum needs, continuing education issues & helping nurses deal with increasingly complex and difficult choices
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Additional Slides
Probably Not Part of Formal Presentation
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
History of Games & SimulationsChess – 6th century - simulate battles
Prussia - modern war-gaming - "Neue Kriegsspiel" 19th century - replace Chessboard with maps and terrain and pieces that mimic infantry, artillery and cavalry forces
“Simulation” - John von Neumann and Stanislaw Ulam - 1940s - "Monte Carlo analysis“
20th C - large scale, computerized “War Games,” pilot training simulators, government and corporate simulations
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Game TheoryInterdisciplinary approach to the study of human behavior
Disciplines most involved in game theory are:
Mathematics
Economics
Social and behavioral sciences
Mathematical game theory formally started by mathematician John von Neumann & mathematical economist, Oskar Morgenstern “The Theory of Games and Economic Behavior”
Copyright 2005 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Issues in Game TheoryWhat are 'rational' strategies if outcomes depend on other player’s strategies and incomplete information?
In "games" with mutual gain (loss) is cooperation "rational" or is individual gain more "rational" regardless of the potential for mutual gain (loss)?
If cooperation is possible, when is it appropriate to be self-serving and when is cooperation appropriate?
How do strategies for ongoing relationships differ from single encounter relationships?
Can rules for cooperation be developed from the plays of rational egoists?
What are "rational" economic behaviors for nurses in resource constrained environments?
Make the consequences of decision-making visible
Copyright 2006 Thomas Cox PhD, RN, BA, BSN, MS, MSW, MSN, CPCU
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Rational Decisions & Decision MakersDMs have fixed range of alternatives to choose
from and their choices influence results
Each outcome has numeric value – ‘utility’
Subjective - how much DM desires outcome
Objective - how good outcome is for the DM
Usual assumption:
Rational DMs make decisions that maximize
their expected utility
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Types of Decision Situations1. Decision making under certainty: Does DM
prefer $100 or punch in the nose?
2. Decision making under risk: Will DM bet $100 on the flip of a fair coin?
3. Decision making under uncertainty: Will DM go to a movie or study for pop quiz?
The last situation is much harder than the others, but DT uses same basic framework:
Modelling possible decisions and payoffs, and maximizing DM’s utility
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Terminology
States of nature: Conditions that exist under particular decisions
Uncertainty: knowing the states of nature before hand
Risk: States of nature are unknown but we can assign probabilities
Uncertainty: probabilities cannot be assigned
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Parallels with Other Decision Processes
Investment portfolio management:Investor (nurse) has a fixed amount of money (Time)
to allocate to different investments
Investor (nurse) seeks maximal gain/minimal loss
How should they allocate money (time)?
How do we define ‘good’ or ‘bad’ outcomes?
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
BackgroundHealthcare organizations face considerable uncertainty about
the adequacy and timeliness of reimbursement for health care services they provide
These uncertainties were present earlier but the expansion of financial risk assumptions in managed care, prospective payment systems, and capitation agreements exacerbates the past impact of these effects in the past, more severely impacting HCOs financially and structurally
Nurses routinely make clinical/financial decisions affecting service quantity and quality for cohorts not individual clients
Simulating these processes will help faculty and students evaluate decisions affecting cohorts, better prepare students for workplace challenges, and lead to better evaluations of choices regarding efficiency, effectiveness, and caring
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Professional Caregiver Insurance Risk 2
The Central Limit Theorem explains how insurer risk aggregation and retention reduces overall risk for insurers and policyholders
Insurance risk disaggregation eliminates the social and financial benefit of insurance as a risk management strategy
The loss of insurance benefit increases financial and clinical risks for providers and consumers
No combination of increased management expertise and HC system efficiencies will overcome the inefficiencies introduced by transferring insurance risks to HCPs, but…
http://www.standarderrors.org/Presentations/STTI2006Cox-MakingChoicesUnderFiscalConstraints&Uncertainty.ppt
Professional Caregiver Insurance RiskInsurance, financial, and clinical risks borne by health care providers (PCs) when they accept insurance risks from 'insurers' under capitation, PPS, Managed Care, and fixed operating budgets
Aggregate risk reduction by insurance is eliminated when public/private insurers cede insurance risks to PCs
PCs have higher risk - adversely affecting PCs, marginalized consumers, and marginalized geographic or social regions, due to limited financial & social capital
PCIR fosters HCP insolvencies, consolidations, lower service capacity, and exacerbates resource shortages, leading to rationing of care on nursing units