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National Guidelines for Rehabilitation Staffing Levels: A Literature Review
ORIGINAL ARTICLE
National Guidelines for Rehabilitation Staffing Levels: A Literature Review Patricia Erlendson, BScOT, MHA, is an Occupational Therapist whose current position is the professional practice leader for Occupational Therapy at Providence Health Care, Vancouver.
Dr. Robert Modrow, PhD, is an international consultant specializing in the application of gap analysis logic and the design, implementation and evaluation of patientcentred, evidence-based, outcome-focused healthcare systems.
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by Patricia Erlendson and Robert Modrow
ccupational therapists, physiotherapists and speech-language pathologists provide rehabilitation services across the continuum of healthcare, from intensive care units to a patient’s home. Rehabilitation significantly influences patient recovery and quality of life; yet, the optimal staffing level and skill mix required to achieve an improved patient functional status have not been well researched. Neither national nor provincial rehabilitation staffing standards have been established to guide health services management or manpower planning. Consequently, rehabilitation staffing mix and levels vary considerably even among facilities that provide similar services. The Canadian Institute for Health Information (CIHI)1 states that, “The optimal number and mix of healthcare providers in a given region” is unknown.
Canadian rehabilitation managers have expressed interest in rehabilitation staffing guidelines but are hesitant to adopt the American prospective payment model for rehabilitation services. Canadian rehabilitation staffing guidelines should not be based on a for-profit third-party payer’s estimate of patient needs. The patient’s response to therapy measured through improved functional performance must drive rehabilitation staffing guideline development.
National staffing guidelines would serve as a benchmark for health service administrators, rehabilitation professionals and consumers. Costly manpower, short in supply, must be deployed in the most effective manner, but health service administrators need effective mechanisms to identify underserved or over-resourced programs. In addition, rehabilitation providers require tools to lobby for and educate consumers. The Executive Director2 of the Canadian Association of Occupational Therapy states that rehabilitation professionals must show consumers that they are receiving effective and efficient care.
Abstract Canadian rehabilitation staffing guidelines do not exist; consequently, significant service-level differences are found. This article reviews methods of determining rehabilitation staffing and presents factors to consider in developing staffing guidelines. Skill mix, service intensity, patient diagnosis and cost of care should drive staffing benchmarks.
In this literature review, we describe methods currently used to determine rehabilitation staffing levels and their limitations. We also present factors to consider in developing national rehabilitation staffing benchmarks and discuss methods of developing staffing guidelines.
Current Rehabilitation Staffing Practice Rehabilitation staffing guidelines to determine appropriate staffing patterns do not exist in any Canadian healthcare setting. In 1984, the British Columbia Ministry of Health3 recommended that inpatient rehabilitation patients participate in several hours of treatment a day. A crude estimate of the number of rehabilitation staff could be determined from this vague statement, but it clearly does not guide health services decision making. Long-term care guidelines make no provision for rehabilitation services, although the rehabilitation management community in British Columbia
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follows a formula of one therapist to 75 residents. Little information related to the numbers of rehabilitation personnel providing service is publicly reported. The majority of healthcare administrators base rehabilitation staffing decisions on historical staffing practices, which are driven by budget patterns. For example, if a program was funded for 10 therapists in the previous year, funding is provided to maintain that staffing level the following year. Managers are reluctant to “lose” their allocated budget to another cost centre in our competitive budgeting process, and changes in rehabilitation staffing patterns usually occur within a cost centre. Zero-based budgeting has attempted to link budgeted staffing levels to workload indicators, such as number of admissions or length of stay, but not to patient outcome. Managers implementing new services must identify the staff mix and level required to meet patient needs. A frequently used method is to survey colleagues who provide similar services and to benchmark staffing levels to another like program. A savvy manager will benchmark to a better resourced program. An alternative approach is to match staffing levels with expected workload. Managers identify and evaluate workload drivers such as number of admissions, expected number of visits, or length of stay and base staffing on the work to be performed. This process is difficult to carry out, usually because of competition for limited funding.
Limitations of Current Staffing Practice The two processes that are based on current practice maintain the status quo and do not encourage innovative staffing solutions. Unfortunately, competition for money in healthcare does not always ensure that staffing decisions will optimize patients’ functional outcomes, and no evidence exists in the literature to support staffing decisions. Canada is experiencing a critical shortage of physiotherapists and occupational therapists, and our current method usually involves a demand for more therapists, rather then a shift of resources.
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A review of rehabilitation staffing levels reveals interesting differences between sites and provinces. The CIHI1 reported survey information on the number of physiotherapists per 100,000 persons in each province. Data from 1997 indicate a range of 28 per 100,000 in Newfoundland to 64 per 100,000 in British Columbia. The 1999 annual benchmarking report sponsored by the Association of Canadian Teaching Hospitals4 provides some comparative data related to therapy hours in acute care teaching hospitals. The report provided information on total worked hours per weighted case for the therapies. The range of worked hours is between 4.29 to 11.31 hours per weighted case, a significant difference. The differences in health outcomes were not reported. During the last 20 years, work that was traditionally performed by rehabilitation staff in acute hospitals has shifted to the community.1 Significant duplication of work occurs when a patient is transferred to the community, but few steps have been taken to reduce the duplication. Can you imagine the savings in time and energy if we began to trust each other’s ability to assess and document findings, and if the patient’s record actually followed the patient? The shift in work from inpatient services to community services should be accompanied by shifts of rehabilitation resources. The current literature has not documented many transfers of rehabilitation professionals from acute care rehabilitation departments to the community. Backman5 believes that unions, regulatory bodies and staffing patterns have resulted in a lack of flexibility and an inability to meet changing patient needs. Shifting resources from one department or program area to another is difficult. “Turf protection” is endemic in rehabilitation departments. The most effective method of providing services should be determined following an analysis of roles and responsibilities. How often are patients asked the same questions by a seemingly endless series of rehabilitation providers? Do our patients care if the walker is provided by the physiotherapist or occupational therapist? The opportunities to expand the scope of practice of providers
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(e.g., rehabilitation assistants) and to make available more qualified providers are hampered by the rigidity of the healthcare system. Consequently, it is difficult to redistribute rehabilitation therapists to areas or programs that are underserved. Staffing decisions are based on professional regulatory bodies’ by-laws, union contracts and historical budgeting practice. The application of economic theory to cost and outcomes in healthcare may highlight a potential problem in the demand for more therapists. The law of diminishing returns describes a point where increased cost does not improve outcomes and may even have a negative influence.6 The field of rehabilitation has not generated the evidence necessary for determining intensity effectiveness, or methods for balancing cost of service and outcomes. We need to determine which therapeutic activities are contributing to a patient’s functional recovery versus those that do not.
Measuring the Work of Canadian Therapists The present Canadian workload measurement system was developed by the Canadian Physiotherapy Association (CPA) in 1971.7 It was designed to provide information to manage physiotherapy departments. Occupational therapy, physiotherapy and speech-language departments in Canadian public facilities use this system to report workload retrospectively. They have submitted this information to the CIHI for more than 20 years. The Association set workload expectations for physiotherapists in 1984. The guidelines recommend the number of patient attendances and percentage of time therapists should spend on direct care activities in various treatment settings. The guidelines are based on best practice in 1984 and are not linked to patient outcomes. The workload expectations were to determine staffing patterns, levels and mix of staff, appropriate caseloads, assessment of programs and resource distribution.8 The present workload measurement system does not meet current requirements.
Christie,9 a Canadian physiotherapist, described the process she undertook to establish workload expectations in 1998. She reviewed historical caseloads, performed a survey of other similar Canadian facilities and directly questioned the therapists on workload. She then set workload expectations for several diagnostic clusters. She recommends establishing workload expectations for specific patient populations. An effective workload measurement system is required to measure the work performed and manage increasingly demanding workloads. Backman and Fyke5,10 both identify a need for the healthcare system to ensure equitable workloads. An Australian study11 supports the development of workload measurement systems to determine reasonable workload expectations. The authors believe that the high injury rates’ physiotherapists experience during their careers could be reduced with an improved workload management system.
Limitations of Current Workload Reporting System An informal survey of managers in British Columbia indicates that they use quality assurance workload data to monitor number of patient attendances and therapist productivity. Many departments continue to follow the CPA workload expectations, even though the work performed by therapists has evolved over the last two decades. Managers report that using the workload data for managerial decisions is difficult. Many rehabilitation practitioners question the reliability and validity of the workload information collected. A survey of Canadian occupational therapy managers12 indicates that the information collected cannot be used for patient costing or manpower planning, as the workload measurement systems are not linked to financial or other management tools. Backman5 reports that healthcare managers in Saskatchewan are concerned about workload measurement systems. Because professional associations developed the guidelines, some managers believe that workload benchmarks for rehabilitation
staff are inflated. Management decision making must be supported by relevant data, and the present workload measurement system must be updated. The information currently collected does not support decisions about utilization or human resources. The following factors limit the use of Canadian workload measurement-system data for developing staffing guidelines: the link between service provided and patient outcome is missing; the system does not measure the work that is not performed; and the system does not determine who should have performed the work. In addition, since workload information is collected retrospectively, its accuracy is questionable.
Rationale for Developing Rehabilitation Staffing Guidelines In the last decade, decision making has been decentralized, moving from provincial health ministries to regional health authorities. Since hospital and community services may now be managed by a regional board, opportunities to improve continuity of care from hospital to home can be acted upon more easily. When public funding of home care began in the 1970s,the proportion of total healthcare dollars allocated to hospitals dropped1 and the number of rehabilitation professionals providing service in the community increased. Today, regional health authorities must help to facilitate this task by ensuring effective distribution of rehabilitation professions within a region and benchmarking staffing levels to national guidelines. Changes in facilities’ organizational structures have also occurred in the last 20 years, and the traditional departmental management structures have been eliminated. Diverse health professionals report to managers who do not have the same professional background. Saskatchewan regulators and professional associations report program management structures that have resulted in rehabilitation professionals not being employed to the full extent of their competencies owing to the organization of work and workload. Senior managers,
who lack knowledge about the scopes of practice of the various rehabilitation professionals, require up-to-date baseline workload measurement tools.5 National staffing guidelines could assist human resource decision making. Lastly, national staffing guidelines for rehabilitation professionals would support secession planning. According to the U.S. Department of Labor,13 half of the occupations that are projected to grow the fastest are in healthcare, and shortages exist in occupational therapy and physiotherapy. The CIHI1 has reported that the number of licensed physiotherapists in Canada increased by 30 percent between the years 1989 and 1997. However, in Saskatchewan, physiotherapy vacancy rates in the last decade remained constant even though the number of physiotherapists increased.5 It is not clear if the other provinces experienced similar vacancy rates even with increased numbers of licensed therapists. Mechanisms for determining the healthcare system’s needs for rehabilitation professionals or the number of educational seats required to meet future demands do not exist.
Factors to Consider in Developing Staffing Guidelines The factors to consider in the development of guidelines include skill mix, intensity of service, patient type and diagnosis. The relationship between patients’ expected functional outcomes and service provision must be explicit. Skill mix: Skill mix addresses the work performed by rehabilitation assistants versus therapists. Rehabilitation assistants, who have less formal training than therapists, perform tasks under the direction of a professional. The position paper on support personnel of the Canadian Association of Occupational Therapists14 (p. 111) states that the “use of support personnel will expand and increase access to occupational therapy services and will allow occupational therapists to utilize effectively their professional skills.” The national bodies of both occupational therapy and physiotherapy are discussing the
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delineation of the roles and responsibilities of this relatively new group of rehabilitation worker. Professionals continue to express concerns related to supervision, liability and educational requirements. National staffing guidelines must incorporate rehabilitation support personnel and ensure that assistants perform their work with an appropriate level of direction and supervision from a qualified professional. The work performed by support personnel must be carefully evaluated as nursing research indicates that skill mix has a greater impact on health outcomes then staffing levels. The proportion of professional nursing care hours to total nursing hours—not total number of nursing hours—is a predictor of medical outcomes, such as decubitus ulcers, medication errors and patient complaints. A skill-mix percentage of registered nurse to nursing care hours greater than 87.5 percent was reported to have no positive impact on care.15 One could assume similar findings in rehabilitation, although there are no published reports of an optimal skill-mix proportion. Further research is required in this area as support personnel must be included in the guidelines. Service intensity: Rehabilitation staffing guidelines must relate the frequency of treatment, or service intensity, to patient outcomes. A significant amount of research in this area is required to guide staffing level decisions, although a few studies do demonstrate a relationship between the amount of therapy received and outcome. Recovery from a hip fracture improves with increased physiotherapy services. A recent study16 linked the achievement of four clinical milestones early in recovery to discharge status. The authors guardedly postulate that increased intensity of physiotherapy in the early post-operative stage has a positive influence on the attainment of these milestones. Later research suggests that the amount of physical therapy patients receive is related to functional improvement. The authors17 show that functional status at discharge can be predicted by an
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improvement in ambulation and the number of minutes of physical therapy a patient receives. A cross-sectional study of veterans admitted with an acute cerebrovascular accident18 shows that improved outcomes are achieved by patients who are hospitalized in facilities that provide post-acute care. Diversity of rehabilitation staff and physicians, and staffing ratios for nurses and physicians, influenced outcome. A comparison of nursing homes in four European countries19 reveals that the Netherlands provides intensive rehabilitation services. Thirtyfive percent of residents admitted to a nursing home are discharged, a rate that is not comparable to any of the other three countries. These studies support a relationship between intensity of rehabilitation services and enhanced outcome, but evidence to demonstrate an optimal level of service is lacking. This is an exciting area for research.
Flynn et al.21 describe the work of a group of American rehabilitation facilities to develop a patient classification system. The authors used a variety of techniques to determine workload including a literature review, work sampling and a nursing survey. Variances in staffing patterns between sites were used to develop benchmarks and continuous quality improvement initiatives. The authors indicate that linking workload with outcomes will be the next phase of their work.
The Functional Independence Measure (FIM) is an outcome tool well supported in the rehabilitation literature. Hamilton and Granger22(p. 500) state that, “Uniformity in assessment of rehabilitation patient’s functional outcome will strengthen the scientific basis of rehabilitation practice.” The authors suggest that the FIM allows interfacility comparisons to determine effectiveness. FIM scores can be reported in terms of change of score per day or per hour of treatment and used to demonstrate efficacy. National Consistent reporting across Canada of FIM rehabilitation score changes related to staffing guidelines intervention will allow need to be mindful interfacility comparisons and provide research data of the relationship on which to build staffing guidelines.
Patient type and diagnosis: The diversity of patients treated by rehabilitation professionals complicates the development of national staffing guidelines. The rehabilitation patient’s specific needs and unique life experiences between outcomes drive rehabilitation goals, outcomes: A and cost of care. Expected treatment plan and intenrecent study to investigate sity of service. However, the intensity of physiocurrent nursing literature does support therapy and occupational therapy and the use of objective measures to mobility outcomes of patients with determine rehabilitation nursing require- orthopedic conditions used the FIM as ments and could perhaps assist other an outcome tool.23 The authors developed rehabilitation providers to determine a predictive model to explain the staffing requirements. variance in mobility. This type of research The Braintree Hospital Rehabilitation could lead to methods of balancing cost Network developed an activity-based of care with patient outcomes. resource allocation system to determine nursing levels. The system categorizes dimensions of care, base times to provide the care, skill required to deliver the care and indirect care activities. Actual patient-care needs determine staffing levels and skill mix and allow managers to deploy staff according to objective data.20
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National rehabilitation staffing guidelines need to be mindful of the relationship between outcomes and cost of care, particularly during periods of cost control. A comparison of outcomes and utilization of hospitals from two regions of the United States24 suggested that the need to decrease costs encouraged the development of benchmarks related to
utilization; however, patient outcomes were disregarded. Readmission rates for the three most common high-cost diagnostic-related groups were studied in relation to length of stay. The authors were able to develop benchmarks that balanced cost with patient outcome. A similar approach should be used to determine staffing guidelines.
Developing National Guidelines: Two Approaches Patients who do not have access to rehabilitation services do not achieve an optimal level of function following an illness or accident. A randomized controlled study of stroke patients25 demonstrated the efficacy of community occupational therapy services in Britain. Significant differences in function for clients who received service at home compared to those who were not treated were found using several outcome tools including the Barthel Index and the Carer Burden Index. The average number of visits was six, not a very costly investment for enhanced patient outcome. National guidelines for rehabilitation staffing levels will provide a method to effectively distribute rehabilitation professionals and enhance patient outcomes through improved access to service. Two approaches are described in the nursing and rehabilitation literature to determine staffing needs: developing staffing requirements on diagnosis or doing so on workload indicators.
Diagnosis The first approach is to base guidelines on patient population or diagnosis. Certain patient groups respond more positively then other patient groups to inpatient rehabilitation. This information should have a tremendous influence on the establishment of patient priority setting and the development of rehabilitation staffing guidelines. The preliminary results of the CIHI’s rehabilitation minimum data set project show differences in outcomes achieved for different diagnostic groups. Patients with spinal problems have significantly larger changes in function than do patients with a lower extremity
amputation. Patients with hip and knee replacements had the highest average increases in functional status.1 Further data are required, but the effectiveness of rehabilitation services for various patient populations must be analyzed in the context of determining staffing levels. Rehabilitation staffing guidelines could be developed for specific diagnostic groups; thus, staffing levels would reflect patients’ responsiveness to treatment, and limited resources could be allocated more cost effectively. Cockerill et al.26 recommend determining patient care cost by diagnostic grouping and suggest developing standard protocols for diagnostic subgroups to estimate service levels. Managers could prospectively predict and control resource requests and facilitate case costing. The authors state that the majority of Canadian occupational therapy managers support the development of standard protocols by diagnosis. In an attempt to categorize patients with a stroke diagnosis, Stineman and Granger27 established severity-adjusted functional outcome benchmarks, based on the Uniform Data Set. The authors developed a conceptual framework of typical patterns of functional recovery. Patients are classified by stroke impairments such as severe, mid-range or mild disabilities and are subdivided into FIM functionrelated groups. The outcomes of patients with similar impairments and degrees of disability can then be compared. Stratifying patients by functional categories may assist to determine the patient’s prognosis, admission criteria for inpatient rehabilitation and optimal human resource allocation. On the other hand, research indicates that diagnosis alone cannot determine staffing requirements. The treatment emphasis for patients with the same diagnosis shows a relationship between the discharge destination and the type of occupational therapy service a client with a stroke receives.28 Physiotherapy research supports the relationship between unique patient characteristics and outcome within the same diagnostic cluster. A study of clients with knee impairments
found that differences in outcomes were related to factors beyond the control of the patient or therapist. The authors recommend that the treatment approach must accommodate these factors.29 Rogers et al.30 describe the effectiveness of a behavioural rehabilitation program in improving the performance of morning care activities of nursing home residents with dementia. This group of patients is traditionally viewed as not responsive to the rehabilitation process. Prior to the implementation of rehabilitation guidelines based on diagnostic categories, the effectiveness of rehabilitation for specific diagnostic groups and categories must be thoroughly researched.
Workload A second approach to developing guidelines is one based on workload. The nursing profession has developed several staffing models based on workload. Their traditional approach to staffing decisions is based on census. Budreau et al.31 discuss the use of other workload indicators to determine staffing requirements. The authors report wide variations in staffing and skill mix between similar units in acute care facilities. They suggest that this is a result of changes in care patterns and recognition by some units of the other factors affecting workload and staffing. In addition to census, activity on the unit must be incorporated (e.g., number of admissions and discharges) to determine a suitable staffing level. A case-weighting methodology in a speech-language practice was used to predict the length of service and treatment frequency to estimate the cost of care. Therapists weighted each client in the areas of severity, recovery stage and level of service intensity. The weighting system provided objective information to balance and set caseload priorities among therapists. Gaps in service and the staffing requirements to meet the gap could be determined as well.32 When applied to physiotherapy services, the case-weighting approach achieved results similar to those for speech-language pathologists.33
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A case-weighting system developed by occupational therapists in the community to distribute workload was based on complexity and severity. The therapists agreed to an appropriate total case weight for each therapist. Gaps in service could be identified and used to determine the number of positions required to meet the community’s occupational therapy needs.34 A procedure-based workload measurement system developed by Sunnybrook Health Science Centre’s Occupational Therapy Department35 is similar to most nursing workload systems. Standard times per occupational therapy procedure were established to support resource allocation decisions.
Benchmarks in Healthcare Variations in rehabilitation staffing levels across Canada are significant and problematic. National rehabilitation staffing guidelines would encourage interfacility comparisons, but health services administrators must be prepared to learn from benchmark variances and act on the data. Healthcare research using benchmarks has uncovered differences in treatment and patient outcomes, and the authors recommend action be taken to act on the variances. The Veteran’s Administration in the United States36 has initiated a national outcomes project to compare rehabilitation services provided for veterans with visual impairments. The authors believe that the study will reveal differences in outcomes that will guide service planning in the future. A case-mix adjustment model to classify patients following a stroke found variations in outcomes between Veteran’s Affairs units.37 The differences in clinical outcomes are identified as opportunities to develop a best-practices stroke rehabilitation model. Health services administrators and rehabilitation professionals who use benchmarks must be prepared to analyze critically variances in patient outcomes and rehabilitation service delivery and implement corrective action.
Recommendations
Conclusion
To ensure access to services and improve patient outcomes, national staffing guidelines for rehabilitation professionals, which are credible to professionals, health services managers and consumers, should be developed. The guidelines must be explicit with respect to the relationship between intensity of service, skill mix, point of care and patient’s functional gain. They must be kept current to reflect changes of patient care patterns and manpower availability.
Because of the many factors to be considered, setting rehabilitation staffing guidelines is a complex task. Markham and Birch40 state that the assessment of human resource needs must include supply levels, population healthcare needs and society’s willingness to pay for the service. The guidelines must be accepted by health service managers, rehabilitation professionals and the Canadian citizens who fund healthcare.
National guidelines must include rehabilitation support personnel. Research to determine the effectiveness of these workers should include cost, patient outcomes and acceptance by patients. Concerns about job loss, liability, decreased professionalism and scopes of practice need to be addressed.
Minnick and Pabst41 discuss the limited use of staffing systems in nursing and theorize a lack of trust in the systems over the time-honoured “golden gut”.† The changes that have occurred in the management of rehabilitation services have eliminated the golden gut. They underscore the need for staffing level guidelines.
Imm and Venneman38 project the number of allied health professions required for the state of Wisconsin on a ratio between healthcare provider and population. This is the accepted practice to determine physician resources and may be a starting point for Canada’s rehabilitation professionals. Survey information to determine the number of rehabilitation providers and the work they are performing is a necessary first step. National staffing guidelines must be based on data; a large database is required to determine trends and develop outcome knowledge. A database requires a uniform approach, and attitudes within the rehabilitation community must be overcome. A survey of physical therapists who participated in a standardized data collection project indicated a lack of acceptance of operational definitions, and negative attitudes about automation, paperwork and training. Reluctance to adhere to a standardized method influences the quality of data collected.39 The Canadian rehabilitation community must determine how patient outcome will be measured and begin to develop evidence-based staffing models.
† Refers to the use of qualitative data over quantitative data to make staffing decisions; using your gut feelings.
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References and Notes 1. Canadian Institute for Health Information. Healthcare in Canada 2000: a first annual report. [Web page] 2001. Available from: www.cihi.ca [Accessed May 1, 2001]. 2. Von Zweck C. Health system performance indicators: our key to accountability for our publicly funded health services. Occupational Therapy Nov 2001;3:5–6. 3. British Columbia Ministry of Health, Hospital Programs Division. Policy manual: the Ministry; October 31, 1984. 4. Association of Canadian Teaching Hospitals. Hay Group. Benchmarking comparison of Canadian teaching hospitals. Ottawa: the Association; 1999. 5. Backman A. Job satisfaction, retention, recruitment and skill mix for a sustainable healthcare system: report to the deputy minister of health for Saskatchewan. Saskatoon: Health Services Utilization and Research Commission; 2000. 6. Hogan A. Methodological issues in linking costs and health outcomes in research on differing care delivery systems. Medical Care 1997;35(Suppl):NS96–NS105. 7. Calder D, Jarvis S. Physiotherapy caseload guidelines: summary of a report prepared for the Canadian Physiotherapy Association. Physiotherapy Canada 1986;38:43–47. 8. Canadian Physiotherapy Association. Caseload guidelines. Ottawa: the Association; 1984. 9. Christie H. Physiotherapy caseload guidelines. Physiotherapy Canada 1999;51:186–190. 10. Fyke K. Caring for Medicare: sustaining a quality system. Saskatchewan: Commission on Medicare; 2001. 11. Cromie J, Robertson V, Best M. Occupational health and safety in physiotherapy: guidelines for practice. Australian Journal of Physiotherapy 2001;47:43–51. 12. Cockerill R, Scott E, Wright M. Responding to workload measurement needs. Canadian Journal of Occupational Therapy 1994;61:219–221.
13. United States Department of Labor, Bureau of Labor Statistics. Career guides to industries, 2001. [Web page]. Available from: http://stats.bls.gov/oco/cg/cgs035.htm [Accessed April 25, 2001]. 14. Canadian Association of Occupational Therapists. Position statement on support personnel in occupational therapy services. Canadian Journal of Occupational Therapists 1998;65:111-112. 15. Blegen M, Goode C, Reed L. Nurse staffing and patient outcomes. Nursing Research 1998;47:43–50. 16. Guccione A, Fagerson T, Anderson J. Regaining functional independence in the acute care setting following hip fracture. Physical Therapy 1996;76:818–826. 17. Roach K, Ally D, Finnerty B, Watkins D, Litwin B, JanzHoover B, et al. The relationship between duration of physical therapy services in the acute care setting and change in functional status in patients with lower-extremity orthopedic problems. Physical Therapy 1998;78:19–24. 18. Hoenig H, Sloane R, Horner R, Zolkewitz M, Reker D. Differences in rehabilitation services and outcomes among stroke patients cared for in veterans hospitals. Health Services Research 2001;35:1293–1318. 19. Meijer A, Campen C, Kerkstra A. A comparative study of the financing, provision and quality of care in nursing homes. The approach of four European countries: Belgium, Denmark, Germany and the Netherlands. Journal of Advanced Nursing 2000;32:554–561.
34. Fortune T, Ryan S. Applying clinical reasoning: a caseload management system for community OT. British Journal of Occupational Therapy 1996;59:207–211. 35. Wright M, Scott E, Cockerill R. Surviving the management game: workload measurement systems in a cost conscious environment. Canadian Journal of Occupational Therapy 1993;60:23–28.
38. Imm I, Venneman M. Supplementing state and national healthcare workforce planning: a regional effort. Journal of Allied Health 1998;27:77–82. 39. Russek L, Wooden M, Ekedahl S, Bush A. Attitudes toward standardized data collection. Physical Therapy 1997;77:714–729.
36. De L’Aune W, Welsh R, Williams M. A national outcomes assessment of the rehabilitation of adults with visual impairments. Journal of Visual Impairment & Blindness 2000;94:281–292.
40. Markham B, Birch S. Back to the future: a framework for
37. Reker D, O’Donnell J, Hamilton B. Stroke rehabilitation outcome variation in Veterans Affairs rehabilitation units: accounting for case-mix. Archives of Physical Medicine Rehabilitation 1998;79:751–757.
41. Minnick A, Pabst M. Improving the ability to detect the
estimating healthcare human resource requirements. Canadian Journal of Nursing Administration 1997;10:7–23.
impact of labor on patient outcomes. Journal of Nursing Administration 1998;28:17-21.
AVAILABLE ON-LINE IN JUNE 2003
Toward Standard Definitions for Waiting Times
20. Crockett M, DiBlasi M, Flaherty P, Sampson K. Activitybased resource allocation: a system for predicting nursing costs. Rehabilitation Nursing 1997;22:293–298.
by Claudia A. Sanmartin and the Steering Committee of the Western Canada Waiting List Project
21. Flynn E, Heinzer M, Radwanski M. A collaborative assessment of workload and patient care needs in four rehabilitation facilities. Rehabilitation Nursing 1999;24:103–108.
Abstract
22. Hamilton B, Granger C. Disability outcomes following inpatient rehabilitation for stroke. Physical Therapy 1994;74:494–502. 23. Kirk-Sanchez N, Roach K. Relationship between duration of therapy services in a comprehensive rehabilitation program and mobility at discharge in patients with orthopedic problems. Physical Therapy 2000;81:888–895. 24. Lagoe R, Noetscher C. Combined benchmarking of hospital outcomes and utilization. Nursing Economic$ 2000;18:63–75. 25. Walker MF, Gladman JRF, Lincoln NB, Siemonsma P, Whiteley T. Occupational therapy for stroke patients not admitted to hospital. Lancet 1999;354:278–281. 26. Cockerill R, Scott E, Wright M. Interest among occupational therapy managers in measuring workload for case costing. American Journal of Occupational Therapy 1996;50:447–451. 27. Stineman M, Granger C. Outcome, efficiency, and timetrend pattern analyses for stroke rehabilitation. American Journal of Physical Medicine Rehabilitation 1998;77:193–201. 28. Brodie J, Holm M, Tomlin G. Cerebrovascular accident: relationship of demographic, diagnostic, and occupational therapy antecedents to rehabilitation outcomes. American Journal of Occupational Therapy 1994;48:906–912. 29. Jette D, Jette A. Physical therapy and health outcomes in patients with knee impairments. Physical Therapy 1996;76:1178–1187. 30. Rogers J, Holm M, Burgio L, Granieri E, Hsu C, Hardin J, et al. Improving morning care routines of nursing home residents with dementia. Journal of American Geriatrics Society 1999;47:1049–1057. 31. Budreau G, Balakrishnan R, Titler M, Hafner M. Caregiverpatient ratio: capturing census and staffing variability. Nursing Economic$ 1999;17:317–329. 32. Papathanasiou I, Heron C. Case weighting in a speech and language therapy service. International Journal of Language and Communication Disorders 1998;33:176–179. 33. Papathanasiou I, Lyon-Maris S. Outcome measurements and case weighting in physiotherapy services for people with learning disabilities. Physiotherapy 1997;84:633–638.
There are no standard or universally accepted definitions of waiting times for a broad range of health services and procedures. The Western Canada Waiting List Project, like other similar projects, has recognized the need to establish such standard definitions to improve the accuracy and comparability of waiting time information across procedures and jurisdictions and of information provided to patients. This article proposes standard definitions of waiting times for surgery and magnetic resonance imaging.
Consolidation of Surgical Services within a Health Region: A Case Study by Olive H. Triska, Kathy Trepanier, Judith Evans, Robert Bear, Stewart M. Hamilton, Kathleen Ness and L. Duncan Saunders
Abstract This article is an historical case study of the effects of consolidating surgical services in Alberta’s Capital Health Authority from 1994 to 2001. The consolidation resulted in the region’s two largest hospitals offering primarily high intensity inpatient surgical care, while three other hospitals offered low-intensity day surgery and short-stay procedures only. Over time, refinements of the initial model were required. Lessons learned from the initiative are also presented.
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National Guidelines for Rehabilitation Staffing Levels: A Literature Review Patricia Erlendson, BScOT, MHA, is an Occupational Therapist whose current position is the professional practice leader for Occupational Therapy at Providence Health Care, Vancouver.
Dr. Robert Modrow, PhD, is an international consultant specializing in the application of gap analysis logic and the design, implementation and evaluation of patientcentred, evidence-based, outcome-focused healthcare systems.
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by Patricia Erlendson and Robert Modrow
ccupational therapists, physiotherapists and speech-language pathologists provide rehabilitation services across the continuum of healthcare, from intensive care units to a patient’s home. Rehabilitation significantly influences patient recovery and quality of life; yet, the optimal staffing level and skill mix required to achieve an improved patient functional status have not been well researched. Neither national nor provincial rehabilitation staffing standards have been established to guide health services management or manpower planning. Consequently, rehabilitation staffing mix and levels vary considerably even among facilities that provide similar services. The Canadian Institute for Health Information (CIHI)1 states that, “The optimal number and mix of healthcare providers in a given region” is unknown.
Canadian rehabilitation managers have expressed interest in rehabilitation staffing guidelines but are hesitant to adopt the American prospective payment model for rehabilitation services. Canadian rehabilitation staffing guidelines should not be based on a for-profit third-party payer’s estimate of patient needs. The patient’s response to therapy measured through improved functional performance must drive rehabilitation staffing guideline development.
National staffing guidelines would serve as a benchmark for health service administrators, rehabilitation professionals and consumers. Costly manpower, short in supply, must be deployed in the most effective manner, but health service administrators need effective mechanisms to identify underserved or over-resourced programs. In addition, rehabilitation providers require tools to lobby for and educate consumers. The Executive Director2 of the Canadian Association of Occupational Therapy states that rehabilitation professionals must show consumers that they are receiving effective and efficient care.
Abstract Canadian rehabilitation staffing guidelines do not exist; consequently, significant service-level differences are found. This article reviews methods of determining rehabilitation staffing and presents factors to consider in developing staffing guidelines. Skill mix, service intensity, patient diagnosis and cost of care should drive staffing benchmarks.
In this literature review, we describe methods currently used to determine rehabilitation staffing levels and their limitations. We also present factors to consider in developing national rehabilitation staffing benchmarks and discuss methods of developing staffing guidelines.
Current Rehabilitation Staffing Practice Rehabilitation staffing guidelines to determine appropriate staffing patterns do not exist in any Canadian healthcare setting. In 1984, the British Columbia Ministry of Health3 recommended that inpatient rehabilitation patients participate in several hours of treatment a day. A crude estimate of the number of rehabilitation staff could be determined from this vague statement, but it clearly does not guide health services decision making. Long-term care guidelines make no provision for rehabilitation services, although the rehabilitation management community in British Columbia
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follows a formula of one therapist to 75 residents. Little information related to the numbers of rehabilitation personnel providing service is publicly reported. The majority of healthcare administrators base rehabilitation staffing decisions on historical staffing practices, which are driven by budget patterns. For example, if a program was funded for 10 therapists in the previous year, funding is provided to maintain that staffing level the following year. Managers are reluctant to “lose” their allocated budget to another cost centre in our competitive budgeting process, and changes in rehabilitation staffing patterns usually occur within a cost centre. Zero-based budgeting has attempted to link budgeted staffing levels to workload indicators, such as number of admissions or length of stay, but not to patient outcome. Managers implementing new services must identify the staff mix and level required to meet patient needs. A frequently used method is to survey colleagues who provide similar services and to benchmark staffing levels to another like program. A savvy manager will benchmark to a better resourced program. An alternative approach is to match staffing levels with expected workload. Managers identify and evaluate workload drivers such as number of admissions, expected number of visits, or length of stay and base staffing on the work to be performed. This process is difficult to carry out, usually because of competition for limited funding.
Limitations of Current Staffing Practice The two processes that are based on current practice maintain the status quo and do not encourage innovative staffing solutions. Unfortunately, competition for money in healthcare does not always ensure that staffing decisions will optimize patients’ functional outcomes, and no evidence exists in the literature to support staffing decisions. Canada is experiencing a critical shortage of physiotherapists and occupational therapists, and our current method usually involves a demand for more therapists, rather then a shift of resources.
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A review of rehabilitation staffing levels reveals interesting differences between sites and provinces. The CIHI1 reported survey information on the number of physiotherapists per 100,000 persons in each province. Data from 1997 indicate a range of 28 per 100,000 in Newfoundland to 64 per 100,000 in British Columbia. The 1999 annual benchmarking report sponsored by the Association of Canadian Teaching Hospitals4 provides some comparative data related to therapy hours in acute care teaching hospitals. The report provided information on total worked hours per weighted case for the therapies. The range of worked hours is between 4.29 to 11.31 hours per weighted case, a significant difference. The differences in health outcomes were not reported. During the last 20 years, work that was traditionally performed by rehabilitation staff in acute hospitals has shifted to the community.1 Significant duplication of work occurs when a patient is transferred to the community, but few steps have been taken to reduce the duplication. Can you imagine the savings in time and energy if we began to trust each other’s ability to assess and document findings, and if the patient’s record actually followed the patient? The shift in work from inpatient services to community services should be accompanied by shifts of rehabilitation resources. The current literature has not documented many transfers of rehabilitation professionals from acute care rehabilitation departments to the community. Backman5 believes that unions, regulatory bodies and staffing patterns have resulted in a lack of flexibility and an inability to meet changing patient needs. Shifting resources from one department or program area to another is difficult. “Turf protection” is endemic in rehabilitation departments. The most effective method of providing services should be determined following an analysis of roles and responsibilities. How often are patients asked the same questions by a seemingly endless series of rehabilitation providers? Do our patients care if the walker is provided by the physiotherapist or occupational therapist? The opportunities to expand the scope of practice of providers
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(e.g., rehabilitation assistants) and to make available more qualified providers are hampered by the rigidity of the healthcare system. Consequently, it is difficult to redistribute rehabilitation therapists to areas or programs that are underserved. Staffing decisions are based on professional regulatory bodies’ by-laws, union contracts and historical budgeting practice. The application of economic theory to cost and outcomes in healthcare may highlight a potential problem in the demand for more therapists. The law of diminishing returns describes a point where increased cost does not improve outcomes and may even have a negative influence.6 The field of rehabilitation has not generated the evidence necessary for determining intensity effectiveness, or methods for balancing cost of service and outcomes. We need to determine which therapeutic activities are contributing to a patient’s functional recovery versus those that do not.
Measuring the Work of Canadian Therapists The present Canadian workload measurement system was developed by the Canadian Physiotherapy Association (CPA) in 1971.7 It was designed to provide information to manage physiotherapy departments. Occupational therapy, physiotherapy and speech-language departments in Canadian public facilities use this system to report workload retrospectively. They have submitted this information to the CIHI for more than 20 years. The Association set workload expectations for physiotherapists in 1984. The guidelines recommend the number of patient attendances and percentage of time therapists should spend on direct care activities in various treatment settings. The guidelines are based on best practice in 1984 and are not linked to patient outcomes. The workload expectations were to determine staffing patterns, levels and mix of staff, appropriate caseloads, assessment of programs and resource distribution.8 The present workload measurement system does not meet current requirements.
Christie,9 a Canadian physiotherapist, described the process she undertook to establish workload expectations in 1998. She reviewed historical caseloads, performed a survey of other similar Canadian facilities and directly questioned the therapists on workload. She then set workload expectations for several diagnostic clusters. She recommends establishing workload expectations for specific patient populations. An effective workload measurement system is required to measure the work performed and manage increasingly demanding workloads. Backman and Fyke5,10 both identify a need for the healthcare system to ensure equitable workloads. An Australian study11 supports the development of workload measurement systems to determine reasonable workload expectations. The authors believe that the high injury rates’ physiotherapists experience during their careers could be reduced with an improved workload management system.
Limitations of Current Workload Reporting System An informal survey of managers in British Columbia indicates that they use quality assurance workload data to monitor number of patient attendances and therapist productivity. Many departments continue to follow the CPA workload expectations, even though the work performed by therapists has evolved over the last two decades. Managers report that using the workload data for managerial decisions is difficult. Many rehabilitation practitioners question the reliability and validity of the workload information collected. A survey of Canadian occupational therapy managers12 indicates that the information collected cannot be used for patient costing or manpower planning, as the workload measurement systems are not linked to financial or other management tools. Backman5 reports that healthcare managers in Saskatchewan are concerned about workload measurement systems. Because professional associations developed the guidelines, some managers believe that workload benchmarks for rehabilitation
staff are inflated. Management decision making must be supported by relevant data, and the present workload measurement system must be updated. The information currently collected does not support decisions about utilization or human resources. The following factors limit the use of Canadian workload measurement-system data for developing staffing guidelines: the link between service provided and patient outcome is missing; the system does not measure the work that is not performed; and the system does not determine who should have performed the work. In addition, since workload information is collected retrospectively, its accuracy is questionable.
Rationale for Developing Rehabilitation Staffing Guidelines In the last decade, decision making has been decentralized, moving from provincial health ministries to regional health authorities. Since hospital and community services may now be managed by a regional board, opportunities to improve continuity of care from hospital to home can be acted upon more easily. When public funding of home care began in the 1970s,the proportion of total healthcare dollars allocated to hospitals dropped1 and the number of rehabilitation professionals providing service in the community increased. Today, regional health authorities must help to facilitate this task by ensuring effective distribution of rehabilitation professions within a region and benchmarking staffing levels to national guidelines. Changes in facilities’ organizational structures have also occurred in the last 20 years, and the traditional departmental management structures have been eliminated. Diverse health professionals report to managers who do not have the same professional background. Saskatchewan regulators and professional associations report program management structures that have resulted in rehabilitation professionals not being employed to the full extent of their competencies owing to the organization of work and workload. Senior managers,
who lack knowledge about the scopes of practice of the various rehabilitation professionals, require up-to-date baseline workload measurement tools.5 National staffing guidelines could assist human resource decision making. Lastly, national staffing guidelines for rehabilitation professionals would support secession planning. According to the U.S. Department of Labor,13 half of the occupations that are projected to grow the fastest are in healthcare, and shortages exist in occupational therapy and physiotherapy. The CIHI1 has reported that the number of licensed physiotherapists in Canada increased by 30 percent between the years 1989 and 1997. However, in Saskatchewan, physiotherapy vacancy rates in the last decade remained constant even though the number of physiotherapists increased.5 It is not clear if the other provinces experienced similar vacancy rates even with increased numbers of licensed therapists. Mechanisms for determining the healthcare system’s needs for rehabilitation professionals or the number of educational seats required to meet future demands do not exist.
Factors to Consider in Developing Staffing Guidelines The factors to consider in the development of guidelines include skill mix, intensity of service, patient type and diagnosis. The relationship between patients’ expected functional outcomes and service provision must be explicit. Skill mix: Skill mix addresses the work performed by rehabilitation assistants versus therapists. Rehabilitation assistants, who have less formal training than therapists, perform tasks under the direction of a professional. The position paper on support personnel of the Canadian Association of Occupational Therapists14 (p. 111) states that the “use of support personnel will expand and increase access to occupational therapy services and will allow occupational therapists to utilize effectively their professional skills.” The national bodies of both occupational therapy and physiotherapy are discussing the
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delineation of the roles and responsibilities of this relatively new group of rehabilitation worker. Professionals continue to express concerns related to supervision, liability and educational requirements. National staffing guidelines must incorporate rehabilitation support personnel and ensure that assistants perform their work with an appropriate level of direction and supervision from a qualified professional. The work performed by support personnel must be carefully evaluated as nursing research indicates that skill mix has a greater impact on health outcomes then staffing levels. The proportion of professional nursing care hours to total nursing hours—not total number of nursing hours—is a predictor of medical outcomes, such as decubitus ulcers, medication errors and patient complaints. A skill-mix percentage of registered nurse to nursing care hours greater than 87.5 percent was reported to have no positive impact on care.15 One could assume similar findings in rehabilitation, although there are no published reports of an optimal skill-mix proportion. Further research is required in this area as support personnel must be included in the guidelines. Service intensity: Rehabilitation staffing guidelines must relate the frequency of treatment, or service intensity, to patient outcomes. A significant amount of research in this area is required to guide staffing level decisions, although a few studies do demonstrate a relationship between the amount of therapy received and outcome. Recovery from a hip fracture improves with increased physiotherapy services. A recent study16 linked the achievement of four clinical milestones early in recovery to discharge status. The authors guardedly postulate that increased intensity of physiotherapy in the early post-operative stage has a positive influence on the attainment of these milestones. Later research suggests that the amount of physical therapy patients receive is related to functional improvement. The authors17 show that functional status at discharge can be predicted by an
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improvement in ambulation and the number of minutes of physical therapy a patient receives. A cross-sectional study of veterans admitted with an acute cerebrovascular accident18 shows that improved outcomes are achieved by patients who are hospitalized in facilities that provide post-acute care. Diversity of rehabilitation staff and physicians, and staffing ratios for nurses and physicians, influenced outcome. A comparison of nursing homes in four European countries19 reveals that the Netherlands provides intensive rehabilitation services. Thirtyfive percent of residents admitted to a nursing home are discharged, a rate that is not comparable to any of the other three countries. These studies support a relationship between intensity of rehabilitation services and enhanced outcome, but evidence to demonstrate an optimal level of service is lacking. This is an exciting area for research.
Flynn et al.21 describe the work of a group of American rehabilitation facilities to develop a patient classification system. The authors used a variety of techniques to determine workload including a literature review, work sampling and a nursing survey. Variances in staffing patterns between sites were used to develop benchmarks and continuous quality improvement initiatives. The authors indicate that linking workload with outcomes will be the next phase of their work.
The Functional Independence Measure (FIM) is an outcome tool well supported in the rehabilitation literature. Hamilton and Granger22(p. 500) state that, “Uniformity in assessment of rehabilitation patient’s functional outcome will strengthen the scientific basis of rehabilitation practice.” The authors suggest that the FIM allows interfacility comparisons to determine effectiveness. FIM scores can be reported in terms of change of score per day or per hour of treatment and used to demonstrate efficacy. National Consistent reporting across Canada of FIM rehabilitation score changes related to staffing guidelines intervention will allow need to be mindful interfacility comparisons and provide research data of the relationship on which to build staffing guidelines.
Patient type and diagnosis: The diversity of patients treated by rehabilitation professionals complicates the development of national staffing guidelines. The rehabilitation patient’s specific needs and unique life experiences between outcomes drive rehabilitation goals, outcomes: A and cost of care. Expected treatment plan and intenrecent study to investigate sity of service. However, the intensity of physiocurrent nursing literature does support therapy and occupational therapy and the use of objective measures to mobility outcomes of patients with determine rehabilitation nursing require- orthopedic conditions used the FIM as ments and could perhaps assist other an outcome tool.23 The authors developed rehabilitation providers to determine a predictive model to explain the staffing requirements. variance in mobility. This type of research The Braintree Hospital Rehabilitation could lead to methods of balancing cost Network developed an activity-based of care with patient outcomes. resource allocation system to determine nursing levels. The system categorizes dimensions of care, base times to provide the care, skill required to deliver the care and indirect care activities. Actual patient-care needs determine staffing levels and skill mix and allow managers to deploy staff according to objective data.20
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National rehabilitation staffing guidelines need to be mindful of the relationship between outcomes and cost of care, particularly during periods of cost control. A comparison of outcomes and utilization of hospitals from two regions of the United States24 suggested that the need to decrease costs encouraged the development of benchmarks related to
utilization; however, patient outcomes were disregarded. Readmission rates for the three most common high-cost diagnostic-related groups were studied in relation to length of stay. The authors were able to develop benchmarks that balanced cost with patient outcome. A similar approach should be used to determine staffing guidelines.
Developing National Guidelines: Two Approaches Patients who do not have access to rehabilitation services do not achieve an optimal level of function following an illness or accident. A randomized controlled study of stroke patients25 demonstrated the efficacy of community occupational therapy services in Britain. Significant differences in function for clients who received service at home compared to those who were not treated were found using several outcome tools including the Barthel Index and the Carer Burden Index. The average number of visits was six, not a very costly investment for enhanced patient outcome. National guidelines for rehabilitation staffing levels will provide a method to effectively distribute rehabilitation professionals and enhance patient outcomes through improved access to service. Two approaches are described in the nursing and rehabilitation literature to determine staffing needs: developing staffing requirements on diagnosis or doing so on workload indicators.
Diagnosis The first approach is to base guidelines on patient population or diagnosis. Certain patient groups respond more positively then other patient groups to inpatient rehabilitation. This information should have a tremendous influence on the establishment of patient priority setting and the development of rehabilitation staffing guidelines. The preliminary results of the CIHI’s rehabilitation minimum data set project show differences in outcomes achieved for different diagnostic groups. Patients with spinal problems have significantly larger changes in function than do patients with a lower extremity
amputation. Patients with hip and knee replacements had the highest average increases in functional status.1 Further data are required, but the effectiveness of rehabilitation services for various patient populations must be analyzed in the context of determining staffing levels. Rehabilitation staffing guidelines could be developed for specific diagnostic groups; thus, staffing levels would reflect patients’ responsiveness to treatment, and limited resources could be allocated more cost effectively. Cockerill et al.26 recommend determining patient care cost by diagnostic grouping and suggest developing standard protocols for diagnostic subgroups to estimate service levels. Managers could prospectively predict and control resource requests and facilitate case costing. The authors state that the majority of Canadian occupational therapy managers support the development of standard protocols by diagnosis. In an attempt to categorize patients with a stroke diagnosis, Stineman and Granger27 established severity-adjusted functional outcome benchmarks, based on the Uniform Data Set. The authors developed a conceptual framework of typical patterns of functional recovery. Patients are classified by stroke impairments such as severe, mid-range or mild disabilities and are subdivided into FIM functionrelated groups. The outcomes of patients with similar impairments and degrees of disability can then be compared. Stratifying patients by functional categories may assist to determine the patient’s prognosis, admission criteria for inpatient rehabilitation and optimal human resource allocation. On the other hand, research indicates that diagnosis alone cannot determine staffing requirements. The treatment emphasis for patients with the same diagnosis shows a relationship between the discharge destination and the type of occupational therapy service a client with a stroke receives.28 Physiotherapy research supports the relationship between unique patient characteristics and outcome within the same diagnostic cluster. A study of clients with knee impairments
found that differences in outcomes were related to factors beyond the control of the patient or therapist. The authors recommend that the treatment approach must accommodate these factors.29 Rogers et al.30 describe the effectiveness of a behavioural rehabilitation program in improving the performance of morning care activities of nursing home residents with dementia. This group of patients is traditionally viewed as not responsive to the rehabilitation process. Prior to the implementation of rehabilitation guidelines based on diagnostic categories, the effectiveness of rehabilitation for specific diagnostic groups and categories must be thoroughly researched.
Workload A second approach to developing guidelines is one based on workload. The nursing profession has developed several staffing models based on workload. Their traditional approach to staffing decisions is based on census. Budreau et al.31 discuss the use of other workload indicators to determine staffing requirements. The authors report wide variations in staffing and skill mix between similar units in acute care facilities. They suggest that this is a result of changes in care patterns and recognition by some units of the other factors affecting workload and staffing. In addition to census, activity on the unit must be incorporated (e.g., number of admissions and discharges) to determine a suitable staffing level. A case-weighting methodology in a speech-language practice was used to predict the length of service and treatment frequency to estimate the cost of care. Therapists weighted each client in the areas of severity, recovery stage and level of service intensity. The weighting system provided objective information to balance and set caseload priorities among therapists. Gaps in service and the staffing requirements to meet the gap could be determined as well.32 When applied to physiotherapy services, the case-weighting approach achieved results similar to those for speech-language pathologists.33
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A case-weighting system developed by occupational therapists in the community to distribute workload was based on complexity and severity. The therapists agreed to an appropriate total case weight for each therapist. Gaps in service could be identified and used to determine the number of positions required to meet the community’s occupational therapy needs.34 A procedure-based workload measurement system developed by Sunnybrook Health Science Centre’s Occupational Therapy Department35 is similar to most nursing workload systems. Standard times per occupational therapy procedure were established to support resource allocation decisions.
Benchmarks in Healthcare Variations in rehabilitation staffing levels across Canada are significant and problematic. National rehabilitation staffing guidelines would encourage interfacility comparisons, but health services administrators must be prepared to learn from benchmark variances and act on the data. Healthcare research using benchmarks has uncovered differences in treatment and patient outcomes, and the authors recommend action be taken to act on the variances. The Veteran’s Administration in the United States36 has initiated a national outcomes project to compare rehabilitation services provided for veterans with visual impairments. The authors believe that the study will reveal differences in outcomes that will guide service planning in the future. A case-mix adjustment model to classify patients following a stroke found variations in outcomes between Veteran’s Affairs units.37 The differences in clinical outcomes are identified as opportunities to develop a best-practices stroke rehabilitation model. Health services administrators and rehabilitation professionals who use benchmarks must be prepared to analyze critically variances in patient outcomes and rehabilitation service delivery and implement corrective action.
Recommendations
Conclusion
To ensure access to services and improve patient outcomes, national staffing guidelines for rehabilitation professionals, which are credible to professionals, health services managers and consumers, should be developed. The guidelines must be explicit with respect to the relationship between intensity of service, skill mix, point of care and patient’s functional gain. They must be kept current to reflect changes of patient care patterns and manpower availability.
Because of the many factors to be considered, setting rehabilitation staffing guidelines is a complex task. Markham and Birch40 state that the assessment of human resource needs must include supply levels, population healthcare needs and society’s willingness to pay for the service. The guidelines must be accepted by health service managers, rehabilitation professionals and the Canadian citizens who fund healthcare.
National guidelines must include rehabilitation support personnel. Research to determine the effectiveness of these workers should include cost, patient outcomes and acceptance by patients. Concerns about job loss, liability, decreased professionalism and scopes of practice need to be addressed.
Minnick and Pabst41 discuss the limited use of staffing systems in nursing and theorize a lack of trust in the systems over the time-honoured “golden gut”.† The changes that have occurred in the management of rehabilitation services have eliminated the golden gut. They underscore the need for staffing level guidelines.
Imm and Venneman38 project the number of allied health professions required for the state of Wisconsin on a ratio between healthcare provider and population. This is the accepted practice to determine physician resources and may be a starting point for Canada’s rehabilitation professionals. Survey information to determine the number of rehabilitation providers and the work they are performing is a necessary first step. National staffing guidelines must be based on data; a large database is required to determine trends and develop outcome knowledge. A database requires a uniform approach, and attitudes within the rehabilitation community must be overcome. A survey of physical therapists who participated in a standardized data collection project indicated a lack of acceptance of operational definitions, and negative attitudes about automation, paperwork and training. Reluctance to adhere to a standardized method influences the quality of data collected.39 The Canadian rehabilitation community must determine how patient outcome will be measured and begin to develop evidence-based staffing models.
† Refers to the use of qualitative data over quantitative data to make staffing decisions; using your gut feelings.
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References and Notes 1. Canadian Institute for Health Information. Healthcare in Canada 2000: a first annual report. [Web page] 2001. Available from: www.cihi.ca [Accessed May 1, 2001]. 2. Von Zweck C. Health system performance indicators: our key to accountability for our publicly funded health services. Occupational Therapy Nov 2001;3:5–6. 3. British Columbia Ministry of Health, Hospital Programs Division. Policy manual: the Ministry; October 31, 1984. 4. Association of Canadian Teaching Hospitals. Hay Group. Benchmarking comparison of Canadian teaching hospitals. Ottawa: the Association; 1999. 5. Backman A. Job satisfaction, retention, recruitment and skill mix for a sustainable healthcare system: report to the deputy minister of health for Saskatchewan. Saskatoon: Health Services Utilization and Research Commission; 2000. 6. Hogan A. Methodological issues in linking costs and health outcomes in research on differing care delivery systems. Medical Care 1997;35(Suppl):NS96–NS105. 7. Calder D, Jarvis S. Physiotherapy caseload guidelines: summary of a report prepared for the Canadian Physiotherapy Association. Physiotherapy Canada 1986;38:43–47. 8. Canadian Physiotherapy Association. Caseload guidelines. Ottawa: the Association; 1984. 9. Christie H. Physiotherapy caseload guidelines. Physiotherapy Canada 1999;51:186–190. 10. Fyke K. Caring for Medicare: sustaining a quality system. Saskatchewan: Commission on Medicare; 2001. 11. Cromie J, Robertson V, Best M. Occupational health and safety in physiotherapy: guidelines for practice. Australian Journal of Physiotherapy 2001;47:43–51. 12. Cockerill R, Scott E, Wright M. Responding to workload measurement needs. Canadian Journal of Occupational Therapy 1994;61:219–221.
13. United States Department of Labor, Bureau of Labor Statistics. Career guides to industries, 2001. [Web page]. Available from: http://stats.bls.gov/oco/cg/cgs035.htm [Accessed April 25, 2001]. 14. Canadian Association of Occupational Therapists. Position statement on support personnel in occupational therapy services. Canadian Journal of Occupational Therapists 1998;65:111-112. 15. Blegen M, Goode C, Reed L. Nurse staffing and patient outcomes. Nursing Research 1998;47:43–50. 16. Guccione A, Fagerson T, Anderson J. Regaining functional independence in the acute care setting following hip fracture. Physical Therapy 1996;76:818–826. 17. Roach K, Ally D, Finnerty B, Watkins D, Litwin B, JanzHoover B, et al. The relationship between duration of physical therapy services in the acute care setting and change in functional status in patients with lower-extremity orthopedic problems. Physical Therapy 1998;78:19–24. 18. Hoenig H, Sloane R, Horner R, Zolkewitz M, Reker D. Differences in rehabilitation services and outcomes among stroke patients cared for in veterans hospitals. Health Services Research 2001;35:1293–1318. 19. Meijer A, Campen C, Kerkstra A. A comparative study of the financing, provision and quality of care in nursing homes. The approach of four European countries: Belgium, Denmark, Germany and the Netherlands. Journal of Advanced Nursing 2000;32:554–561.
34. Fortune T, Ryan S. Applying clinical reasoning: a caseload management system for community OT. British Journal of Occupational Therapy 1996;59:207–211. 35. Wright M, Scott E, Cockerill R. Surviving the management game: workload measurement systems in a cost conscious environment. Canadian Journal of Occupational Therapy 1993;60:23–28.
38. Imm I, Venneman M. Supplementing state and national healthcare workforce planning: a regional effort. Journal of Allied Health 1998;27:77–82. 39. Russek L, Wooden M, Ekedahl S, Bush A. Attitudes toward standardized data collection. Physical Therapy 1997;77:714–729.
36. De L’Aune W, Welsh R, Williams M. A national outcomes assessment of the rehabilitation of adults with visual impairments. Journal of Visual Impairment & Blindness 2000;94:281–292.
40. Markham B, Birch S. Back to the future: a framework for
37. Reker D, O’Donnell J, Hamilton B. Stroke rehabilitation outcome variation in Veterans Affairs rehabilitation units: accounting for case-mix. Archives of Physical Medicine Rehabilitation 1998;79:751–757.
41. Minnick A, Pabst M. Improving the ability to detect the
estimating healthcare human resource requirements. Canadian Journal of Nursing Administration 1997;10:7–23.
impact of labor on patient outcomes. Journal of Nursing Administration 1998;28:17-21.
AVAILABLE ON-LINE IN JUNE 2003
Toward Standard Definitions for Waiting Times
20. Crockett M, DiBlasi M, Flaherty P, Sampson K. Activitybased resource allocation: a system for predicting nursing costs. Rehabilitation Nursing 1997;22:293–298.
by Claudia A. Sanmartin and the Steering Committee of the Western Canada Waiting List Project
21. Flynn E, Heinzer M, Radwanski M. A collaborative assessment of workload and patient care needs in four rehabilitation facilities. Rehabilitation Nursing 1999;24:103–108.
Abstract
22. Hamilton B, Granger C. Disability outcomes following inpatient rehabilitation for stroke. Physical Therapy 1994;74:494–502. 23. Kirk-Sanchez N, Roach K. Relationship between duration of therapy services in a comprehensive rehabilitation program and mobility at discharge in patients with orthopedic problems. Physical Therapy 2000;81:888–895. 24. Lagoe R, Noetscher C. Combined benchmarking of hospital outcomes and utilization. Nursing Economic$ 2000;18:63–75. 25. Walker MF, Gladman JRF, Lincoln NB, Siemonsma P, Whiteley T. Occupational therapy for stroke patients not admitted to hospital. Lancet 1999;354:278–281. 26. Cockerill R, Scott E, Wright M. Interest among occupational therapy managers in measuring workload for case costing. American Journal of Occupational Therapy 1996;50:447–451. 27. Stineman M, Granger C. Outcome, efficiency, and timetrend pattern analyses for stroke rehabilitation. American Journal of Physical Medicine Rehabilitation 1998;77:193–201. 28. Brodie J, Holm M, Tomlin G. Cerebrovascular accident: relationship of demographic, diagnostic, and occupational therapy antecedents to rehabilitation outcomes. American Journal of Occupational Therapy 1994;48:906–912. 29. Jette D, Jette A. Physical therapy and health outcomes in patients with knee impairments. Physical Therapy 1996;76:1178–1187. 30. Rogers J, Holm M, Burgio L, Granieri E, Hsu C, Hardin J, et al. Improving morning care routines of nursing home residents with dementia. Journal of American Geriatrics Society 1999;47:1049–1057. 31. Budreau G, Balakrishnan R, Titler M, Hafner M. Caregiverpatient ratio: capturing census and staffing variability. Nursing Economic$ 1999;17:317–329. 32. Papathanasiou I, Heron C. Case weighting in a speech and language therapy service. International Journal of Language and Communication Disorders 1998;33:176–179. 33. Papathanasiou I, Lyon-Maris S. Outcome measurements and case weighting in physiotherapy services for people with learning disabilities. Physiotherapy 1997;84:633–638.
There are no standard or universally accepted definitions of waiting times for a broad range of health services and procedures. The Western Canada Waiting List Project, like other similar projects, has recognized the need to establish such standard definitions to improve the accuracy and comparability of waiting time information across procedures and jurisdictions and of information provided to patients. This article proposes standard definitions of waiting times for surgery and magnetic resonance imaging.
Consolidation of Surgical Services within a Health Region: A Case Study by Olive H. Triska, Kathy Trepanier, Judith Evans, Robert Bear, Stewart M. Hamilton, Kathleen Ness and L. Duncan Saunders
Abstract This article is an historical case study of the effects of consolidating surgical services in Alberta’s Capital Health Authority from 1994 to 2001. The consolidation resulted in the region’s two largest hospitals offering primarily high intensity inpatient surgical care, while three other hospitals offered low-intensity day surgery and short-stay procedures only. Over time, refinements of the initial model were required. Lessons learned from the initiative are also presented.
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