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.

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.

Non-Patient Activity

My current attention has move towards addressing workload and optimal staffing models. Currently I'm developing a framework for determining the optimal staffing levels for Allied Health (okay,... my bias in on PT). My approach is novel (based on my literature review). One issue I would like to bring up now is "non patient care" activity. For Canadian PTs in acute care... particularly those familiar with the Workload Measurement System developed by CIHI and our respective national associations some 30+ years ago... you probably are familiar with what non-patient care activities (NPCA) pertain to.

In general, NPCAs are those tasks that support service delivery but cannot be linked to a specific patient or group of patients. This might include developing policies, procedures, and guidelines. In some cases it will continuing professional development (education) activities such as attending Grand Rounds, inservices,etc. It also includes time becoming oriented to ones role, addressing team issues, etc.

Over the past decade due to the lack of investment in rehabilitation, particularly in light of the growing body of evidence of the effectiveness of rehabilitation interventions, many organization have adjusted to having more patients and fewer therapists by increasing the expectation on clinicians to spend a greater portion of their workday in patient care activities, particularly direct patient care. In some case, organizations are no longer tracking non-patient care activities at all. I have heard managers voice an expectation that clinicians should be spending 100% of their time in direct and indirect patient care. But, I have yet to see or hear a report that these decisions have been beneficial to patient care. At a minimum, the effect on clinicians has been clearly negative. And, from an organizational perspective, the resulting longer patient lengths of stay and higher other health care costs have been overlooked.

It is ESSENTIAL that clinicians have time for activities such as continuing professional development, professional socialization, mentorship and coaching, and reflection on practice... and NO, these are NOT activities that should be pursued on the staff member's own time. These activities clearly impact the ability of the organization to deliver on its promises to patients and the community and it is unacceptable for the organization to not take responsibility for them.

My personal experience is that clinical effectiveness and staff member satisfaction are closely associated with the organization's ability to support non-patient care activities. When well supported, the bottom line ($) of health care is improved.

If organizations want to get a little more "work" out of their staff members, they should focus on reducing the waste associated with service delivery. Some sources of this waste of time are waiting for patients, wasting time moving between patient that could be avoided, waiting for information (such a the physician that neglects to write an order), or waiting for assistance when patient care requires multiple staff member to provide it safely.

Any focus on non-patient care activities... particularly when I work with an organization that does not have a single therapist not spending 80+% of their time in patient care activities... is misguided, and in my view, foolish.

PT Wonk