Wednesday, September 1, 2010

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.

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