Friday, November 26, 2010

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.

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