Monday, May 31, 2010

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

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