Classifying the Patient Load

“My caseload is too heavy right now… one more patients and I’ll drop from exhaustion”.

Several authors have described methods for rating and tracking the workload associated with the patients therapists are seeing. In general, the usefulness and validity of diagnosis or diagnosis related groups (DRGs) has been questioned.

Some have focused on the staff's perception of what “load” individual patients represent. For example, patients with great number of co-morbidities and/or psycho-social barriers may be rated higher than patients with single diagnoses and few or no psycho-social barriers. Alternatively, in acute care a clinician may rate a patient that requires two or more clinicians to provide care as higher than a patient that can be treated by a single clinician.

There is a certain amount of value to clinicians rating their workload but a critical flaw in the above process is that the valuation may not be related to clinician's decisions to safely, effectively, and efficiently treat the patient. For example, a physical therapist may identify deconditioning as a treatment goal to be addressed, but if the physical therapist continues to treat the patient in acute care long after meeting the necessary functional status to support discharge, the continued services are wasteful “overproduction”. To correct this, the therapist's rating of the “load” of the patient should reflect the treatment goal of minimizing length of stay and safely discharging the patient to a lower-costing level of care.

With a focus on the more important metrics of performance, the decisions to increase resources to a program or service area should be met with positive improvements in patient outcomes, shorter length of stay, fewer preventable readmissions, lower job stress, acceptable levels of workload reported, higher rating of workplace satisfaction, and lower rates of adverse events to both patients and staff.

If managers approach the issues of resource allocation too narrowly it is easy to second guess the decision. Let take an alternative look at the issue next.

Lets assume that the combined workload statistics are being reported at 75% for patient care (combined direct and indirect patient care time) for a team of 6 therapists working a total of 5 FTE. The new manager feels that 85% is a more acceptable goal and therefore, on average, each clinician have available capacity of 10%. So, when a part-time (0.5 FTE) clinician quits their job the manager decides that the clinician does not need to be replaced as the remaining 5 clinicians should have the ability to absorb the caseload.

But things don’t go so well for that manager or the program.

The average workload for patient care remains essentially the same at 76%. Another clinician announces their resignation and a third is known to be in discussion with a similar program at another hospital where the “workload will be more tolerable”. The units that these therapists work on have reported a slight increase in patient falls and two pressure ulcer have developed on patients, an occurrence that was unheard of before recently. Worst of all, both physicians and nurses are complaining that the therapist are less responsive to patient needs and want something done. Despite the time requirement, the manager arranges workshops on team building and time management. The added time only further takes away from patient care and the staff become even more cynical and stressed.

Conversely, this is how it could have gone.

The new manager decides that the 75% value is important to address. Indeed, it could be higher but as a new manager she will not make assumptions on why it is lower than expected. The manager gets detailed information from staff on perceptions of workload, job stress, time spent on professional development, staff absenteeism, patient adverse events, length of stay and past staff turnover for the program. As some of the necessary information comes from staff, she even provides some extra resources, temporarily replacing the vacant 0.5 FTE with a full time casual staff member.

The first surprise is that with the additional staff member… and despite the additional requests for information from staff… workload statistics quickly go to 82%! Now, the first manager would question “How can this be? The workload is spread over more resources so workload, no average, should have gone down, not up”. The answer is that high workload had been negatively affecting the team’s performance. Even though the reported workload was 75%, that actual requirements for patients was much higher; too much work was simply not done.

In the meanwhile, physicians and nursing staff are impressed by how responsive all the therapists have become and are starting to feel that the therapists are more part of the “team” then ever. Over the next 6 months, the manager increases the therapist complement to 5.5 FTE permanently and is still tweaking it at times over this level as she continues to see improvement in LOS and lower readmission rates. Workload stress is going down. Staff morale is rising. The manager develops an interdisciplinary collaborative team and slowly they are working to “widen the zone" in which staff can perform optimally.

IPoC - Pull

Working for a health care organization that is trying to transform itself, one thing they are trying to implement is an Integrated Plan of Care (IPoC) for new in-patients to the hospital. This practice has been implemented a the Mayo Clinics as well a number of other hospitals across North America.

One important feature of their implementation is using the idea of "Pull" to draw in the other health care providers in a timely, efficient, and effective basis to both make the outcome of the hospitalization likely, but also to control the costs (such as reducing the length of stay).

Unfortunately, most hospitals still function from a "Push" perspective. They model, analyze, and predict what resources are most likely to be needed and budget for them on this basis. In the end there is usually too few resource most of the time. There is little, if any, flexibility to ensure the timeliness, efficiency, and effectiveness of the service delivery.

What do you do if you implement an Integrated Plan of Care and there are no professional staff to meet the needs identified? Is the organization really ready to move from a Push perspective to a Pull one?

PTWonk

Transformation

I recently read an article titled “Transformational Leadership and Organizational Culture: The Situational Strength Perspective” by Masood et al (2006). Masood and his co-authors provide a framework for understanding the interrelationship between leadership (transformative or non-transformative), culture (hierarchical, market, clan-based, or adhocracy), and context (weak versus strong situations).

In applying this to healthcare organizations that I have worked for in the past and currently, such organizations are typically hierarchical in structure, lead by non-transformative leaders, and present a strong situational context which, on the whole, impedes transforming changes to occur within the organization.

(Note, I do not mean to imply that some leaders do not have transformation qualities, but simply that those qualities are not allowed to be expressed within the organization except in a tight, controlled manner reflective of the hierarchical structure).

In order for transformational change to be most successful, leaders need to not only have transformational qualities (good visioning, rhetorical, and impression management skills, and ability to use these skills to develop strong emotional bonds with followers) but they also need to work within a situational context that allows these qualities to flourish. Similarly, clan and adhocracy cultures are more adept at recognizing opportunities for change, accept ambiguity, and have the energy and motivation to elevate issues to a higher level and produce not just action but results.

To implement “transformation” within a hierarchical organization we often asking leaders and front-line staff to “buck-the-system” which goes against the grain of everything they may have been told (or experienced) the organization values and rewards. This contradiction is simply too much for many leaders and most staff and the transformation effort is destined to fail.

Lastly, implementing transformation is not about achieving the deliverables in a project plan. True transformation starts with leadership and culture and leads to production (i.e., the manner in which work is performed). Transformation, once in place, is ongoing, never ending.

It’s the people – not the processes and policies and products – that highlight a transformative organization. If you are talking about transforming patient care within your organization, ask yourself if you have focused on the people first.

An Issue with Caseload and Workload Guidelines

A Fundamental Issue of Caseload Guidelines

An issue that I have come to accept is that caseload guidelines based on an economic model of “supply and demand” are fundamentally flawed. The reason for this is that an economic model is all about the efficient supply and consumption of resources under the constraint of scarcity.

Within the current context of health care scarcity leads to rationing of supply
which results in neither efficient nor effective health service delivery. In other words, the resulting services are not ideal and, in fact, we often struggle to provide optimal services within this context. Conversely, workload and caseload guidelines are often based on an ideal situation.

Unless new caseload guidelines can fundamentally connect effective workload management to positive patient outcomes and cost containment, guidelines will be justifiably ignored by publicly funded health care administrators where available budget is the predominant factor that is considered.

Hollis (1994) reported the fundamental question in caseload management is “…how many people are needed to provide a quality service?” Yet, the question of defining, measuring, and analyzing the quality has largely remained not investigated.

Alternatively, if there was some guarantee that the funding (supply of clinical positions) would be maintained to meet the needs of patients or a guarantee that we would adjust the number of practicing clinicians, then we have achieved something.

The reality is that if all the patients are not seen without delay and there is no constraint on the resources, therapists are always forced to prioritize patients or interventions or both, and the outcomes that would achieved if supply equaled resources are not achieved.

Scarcity of resources creates a number of concerns in healthcare. Clinicians will feel pressured by multiple sources to meet demands for which there are not enough resources. There will be either too many patients or too many needs to be addressed. Out of a sense of professionalism and dedication, clinicians will forgo breaks, lunch periods, and perform unpaid overtime to meet the needs of patients. Organizations may make decisions to ignore certain patient populations rather than spreading resources too thin.

Clinicians will be forced to prioritize patients and interventions, making decisions to delay interventions, create wait lists, or provide sub-optimal services based on what we may see as the most beneficial interventions for the patient, such as providing sub-optimal duration, intensity or frequency of treatment.

Scarcity does not always create the efficiencies that one might expect. As caseload increase, clinicians become less effective. High caseloads have an inherent degree of “waste” that cannot be avoided, making clinicians less efficient.

Our response to this scarcity creates risks. Patients may suffer by not receiving interventions, receiving interventions, but in a delayed manner, or not receiving sufficient intervention to meet treatment goals. Patients are at a higher risk of adverse events such as falls. Patients are less compliant with interventions because staff or stressed for time to communicate effectively. Clinicians are stressed morally and ethically, leading to inefficiencies and ineffective interventions. The organization is at risk of lawsuits due to its inability to support effective and safe practices. And, the organization is at risk of actually creating a more costly health care system by making misguided decisions around staffing levels and the workload expectations of clinicians.

Reported versus Actual

I recently have been reviewing articles on occupational stress, workload, and job performance. Overall, my reading has enlightened me. The issue is far more complex than I had thought. I was saddened that I was unable to find any articles that had studied the rehabilitation professions on these topics. I was surprised to see one article authored by a former prof from my MBA days.

One article struck a cord. It focused on addressing the qualitative elements of performance, not just the quantitative ones. The most important piece of information that stuck with me can be stated as "Don't Confuse the Product with Productivity".

What some managers don't realize is that when workload is excessive a number of factors come into play that don't simply result in the prioritization of caseload and patient care, but that the actual delivery of services changes. The non-stressed therapist and the overworked therapist might report the same workload, but the actual services delivered to the patient (not to mention, the quality of those services) is different.

A manager with a frame of reference only focused on workload reported (e.g., direct and in-direct patient care stats) fails to appreciate that outcomes suffer whenever workload exceeds resources for anything but the shortest period of time.

Scaling Up

Recently I submitted a proposal for some personnel changes to a healthcare organization. The proposal was extensively researched. Despite the cost of the new positions, there would be a 3 to 14 fold return in improved capacity of the organization depending on the program area. Overall, the proposal is extremely compelling and anyone reading it would question how an organization could not make the decision to support it. But of course, then there comes the million dollar question.

Since there is no room in the budget for a million dollar investment in new staff, the inevitable questions arise. Is there any other way to achieve this outcome? Is there any other way to convince the senior leadership and finance department? Are there any ways to minimize associated risks? Because of the improved capacity, the new positions could be funded by bed closures and the improved capacity would more than offset the reduced capacity associated with the closures.

Eventually, as I listed the numerous ways to move forward on the proposal, one option that received some acceptance was to implement the changes in just one program area, thereby scaling the proposal down significantly, but all along I expressed that this is not the direction I would take the proposal. I am quite confident that in a showdown, the vast majority of the proposal would be approved as anything otherwise would be confound logic to an extreme. Most importantly, I explained, the solution would not be found in scaling the proposal down. This was received with a certain degree of bewilderment.

“What possibility could be wrong with starting on a small scale?” I was asked. My answer: “You still have the same problems inherent in the current decision if you try to scale back up.” In other words, the decision to allocate a million dollars would be just as hard to make after a successful small scale implementation… which everyone seems to agree would be the end result… as it would be for executive management to make now. So why not ask executive management to make the decision now?

What this experience to me reinforced is that despite other’s perspectives of the big picture, certain mindsets are hard to change. Currently there is a mindset that any request for more funding in a time of financial constraint would be politically incorrect. In my mind, I would rather trust the executive management to see the big picture and (hopefully) make the right decision.

Caseload Guidelines

Sorry for the length... the following is a portion of a draft paper on caseload guidelines and workload management. ...............

An issue that I have come to accept is that caseload guidelines based on an economic model of “supply and demand” are fundamentally flawed for one reason: the guidelines never produce the results that are desired. The reason for this is that an economic model is all about the efficient supply and consumption of resources under the constraint of scarcity. So you publish new guidelines and the next economic slump occurs resulting in cutbacks in resources… what has been achieved. If there was some guarantee that the funding (supply of clinical positions) would be maintained to meet the needs of patients, then we have achieved something.

In the end, all the patients are not seen without delay, clinicians always are forced to prioritize patients or interventions or both, and the outcomes that would achieved if supply equaled resources are not achievable.

As an advocate for clinicians, we are foolish to believe that caseload guidelines will result in better working conditions, more satisfied patients, and better health outcomes and controls of healthcare costs.

Scarcity of resources creates a number of concerns in healthcare. Clinicians will feel pressured by multiple sources to meet demands for which there are not enough resources. There will be either too many patients or too many needs to be addressed. Out of a sense of professionalism and dedication, clinicians will forgo breaks, lunch periods, and perform unpaid overtime to meet the needs of patients. Organizations may make decisions to ignore certain patient populations rather than spreading resources too thin.

Clinicians will be forced to prioritize patients and interventions, making decisions to delay interventions, create waitlists, or provide sub-optimal services based on what we may see as the most beneficial interventions for the patient, such as providing sub-optimal duration, intensity or frequency of treatment.

Scarcity does not always create the efficiencies that one might expect. As caseload increase, clinicians become less effective. High caseload have an inherent degree of “waste” that cannot be avoided, making clinicians less efficient.

With scarcity creates risks. Patients may suffer by not receiving interventions, receiving interventions, but in a delayed manner, or not receiving sufficient intervention to meet treatment goals. Patients are at a higher risk of adverse events such as falls. Patients are less compliant with interventions because staff or stressed for time to communicate effectively. Clinicians are stressed morally and ethically, leading to inefficiencies and ineffective interventions. The organization is at risk of lawsuits due to its inability to support effective and safe practices. And, the organization is at risk of actually creating a more costly healthcare system by making misguided decisions around staffing levels and the workload expectations of clinicians.

What is needed is not another set of caseload guidelines that cannot be implemented due to lack of resources or funding.

What is needed is a way for patients, clinicians, and the organization to recognize the risks that are created by scarcity and make rational decisions around optimizing the care that can be provided. It would be Pollyanna to believe that equation of supply = demand will be realized, but we must ensure that we all agree on the principles that will guide the use of resources to achieve the outcomes desired by all.

The Physio Wonk