A manual for implementation

Transcription

1 WHO/HRB/98.2 Distr.: Limited English only Workload indicators of staffing need (WISN) A manual for implementation World Health Organization Division of Human Resources Development and Capacity Building Geneva, Switzerland 1998

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3 WHO/HRB/98.2 Distr.: Limited English only Workload indicators of staffing need (WISN) A manual for implementation Prepared for the World Health Organization by Peter J. Shipp Initiatives Inc. Boston USA World Health Organization Division of Human Resources Development and Capacity Building Geneva, Switzerland 1998

4 Acknowledgements The manual Workload Indicators of Staffing Need (WISN) has been developed and field-tested by the World Health Organization with financial support through the voluntary contribution from the Government of Japan to the Division of Human Resources Development and Capacity Building. Its contribution is greatly appreciated. World Health Organization This document is not issued to the general public, and all rights are reserved by the World Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any means - electronic, mechanical or other - without the prior written permission of WHO. The views expressed in documents by named authors are solely the responsibility of those authors.

5 Table of contents Introduction...1 Section A The WISN method and its uses The need for a new method The basis of the WISN Method Features of the WISN Method How the WISN Method works: differences and ratios Using the WISN Method: identifying priority situations Using the WISN Method: improving the current staffing situation Using the WISN Method: human resource management and planning The constraints and limitations of the Method...19 Section B Steps in design and implementation of the method Starting the process: setting the objectives Choosing the basic design of the procedure to be implemented Setting up the implementation group Procedure for establishing standards of professional performance Mobilizing commitment to the WISN Method Collecting and handling the data Plan and budget for operating the new procedure in regular use Workplan and budget for implementation...35 Section C Technical factors Determining available working time per year Setting Activity Standards Turning Activity Standards into Standard Workloads Using standard workloads and allowance standards to calculate staffing requirements Computerization of the WISN calculations...67 Annex A Staffing requirements for time-specified posts 69 Annex B Instructions for groups which are setting activity standards 71 Section D Examples of WISN activity standards already used for individual staff categories...77

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7 Introduction Introduction This Manual sets out all the activities which are necessary in order to design and implement the WISN Method in a country. The material in this Manual is based on the experience and results of implementing the WISN Method in Papua New Guinea (supported by the Asian Development Bank), in the United Republic of Tanzania (supported by DANIDA through WHO), in Kenya (supported by USAID); in Sri Lanka (supported by the World Bank); and also in six other countries: Bahrain, Egypt, Hong Kong, Oman, Sudan and Turkey which participated in a field trial of an early draft of this Manual (supported by WHO headquarters and the WHO Regional Office for the Eastern Mediterranean). The Manual is divided into four sections: Section A The WISN method and its uses A description of the principles and the main policy/management uses of the method. This section has two main purposes. First, it provides an overall picture or context for those who will design and set up the procedure, so that they can better understand how the different tasks contribute to the overall result. Second, it provides material which can be used to explain to potential users of the results, and to others who will be involved in the implementation, how the method operates and how it can be used to improve their work. Section B Steps in design and implementation of the method How to carry out the implementation of the method. The section describes a step-by-step procedure for designing and installing the WISN Method and how these may be fitted together into an overall work plan for the implementation exercise. Section C Technical factors How to deal with the technical/mathematical aspects of the method. This section covers the setting of activity (time) standards for government health staff, how to translate these into standard (annual) workloads for use in the WISN calculations, the calculation procedures to be used, and the use of computers in performing the calculations and producing tables of results. Section D Examples of WISN activity standards already used for individual staff categories This section lists the Activity Standards which have been used for staff categories and subcategories in countries which have either implemented the WISN Method or which for other reasons have set Activity Standards for their health staff. Because conditions and circumstances vary so much from one country to another, these figures are offered for guidance only. In normal circumstances, a Manual for Implementation like this is of interest and comes into use only when a decision has already been made to undertake an exercise to implement a new procedure. However, the WISN Method is novel, it produces information which has not been available before now, and it is based on a principle (setting activity times or standards for health staff) which has not been used in health services, although it has been widely employed in manufacturing and commercial organizations for many years. The senior staff concerned may well find that they require information about the basis of the method, its operation, its results and their uses before they can come to the initial decision on whether to implement the method. 1

8 Workload indicators of staffing need A manual for implementation Although this document covers all the normal requirements for a Manual of Implementation, it also takes account of this unusual situation where the method is entirely novel. The material in sections A and B is set out so that it can be summarized and/or edited in order to provide decision-makers with the background information on how the WISN Method works and how the results can be used, should this be necessary, in order to help them take the initial decision on whether to implement the method. This material can also be used to prepare presentations for managers, administrators and others who will be the eventual users of the method and its results. 2

9 Section A The WISN method and its uses Section A: The WISN method and its uses This section sets out a description of the principles on which the WISN Method is based, what information it can produce, and how this information can be used by health managers and administrators in order to improve the current health personnel situation, for example, how to deploy the available health staff more effectively, and also how to plan for future improvements in services and in human resource management. Contents 1. The need for a new method The basis of the WISN Method Features of the WISN Method How the WISN Method works: differences and ratios Using the WISN Method: identifying priority situations Using the WISN Method: improving the current staffing situation Using the WISN Method: human resource management and planning The constraints and limitations of the Method The need for a new method For many years there has been a need for a rational method of setting the correct staffing levels in health facilities. In earlier decades, when developing countries first addressed the issues of human resource planning and management in their health services, they used population ratios (numbers of doctors, nurses, etc. per 1,000 population). For a time this was sufficient to tackle the major problem of the period - assessing the overall staffing requirements and the training loads for health services in the country. Later, attention naturally shifted to the more detailed question of the staffing of individual health facilities, and standard staffing schedules were used (fixed patterns of staff for health posts, health centres, district hospitals, etc. in the country). While both these methods were useful in their time, they have serious disadvantages. Population ratios do not distinguish between the employment of health staff in the different services in an area, for example, the numbers of nurses who should be employed in referral hospitals, district hospitals, health centres, health posts, etc. With standard staffing schedules the distribution of the facilities themselves is also a major factor; for example, a district may have well-staffed facilities, but far too few of them. But most important, these methods do not take account of the wide local variations which are found within every country, such as the different levels and patterns of morbidity in different locations, the ease of access to different facilities, the patient attitudes in different parts of the country to the services provided, and the local economic circumstances. All these factors considerably affect the demand for services in an area and at individual facilities, and therefore they affect the staffing levels actually required to meet the demand. The WISN Method frequently shows that staffing requirements vary widely between health facilities of the same type, according to their workloads. Staffing norms based on population ratios or standard staffing schedules are usually set somewhere in the middle of this range. This leads to overstaffing in some facilities and under staffing in 3

10 Workload indicators of staffing need A manual for implementation others. Those facilities which are unable to cope with their workloads (because they have only the staffing norms or standard staffing schedules) apply for more staff, and frequently get an increase because the request is in fact justified. Once this precedent has been established, other facilities also seek staff increases even though their staffing levels are in fact adequate for their workloads. Thus the authority of the norms or standard staffing schedules disappears and their value in personnel management and control is lost. Health administrators have long sought a method of calculating health staffing requirements which does not have these disadvantages. Furthermore, as national health staffing establishments and training volumes have been brought under some degree of control, health administrators have been turning their attention to further issues, for example, the optimal deployment of staff, particularly to rural areas; the equitable deployment of staff in accordance with the demands actually experienced; and the optimal determination of staff categories, particularly with a view to reducing the large number of staff categories found in some countries. In many countries ministries of health are experiencing a double pressure. On the one hand there is a strengthening popular demand for better health services to an ever-increasing population, coupled with a stronger and more detailed interest from the population at large (and particularly in the national news media) in both the performance of the country's health services and the equity of its distribution. On the other hand, resources for health are at best increasing slowly; in most countries they are at a standstill or even reducing. Certainly resources are not keeping pace with the increase in demand. Health administrators must attempt to achieve maximum coverage of services (extending into the rural and remote areas where the unit costs of service delivery are higher) with greater impact (by improving current effectiveness levels), equity in the provision of services (i.e. overall staffing deployment according to demand) and economy of operation (in staff categories, numbers and mix). Until now there has been no technique available which will calculate: the optimal allocation and deployment of current staff geographically, i.e. allocating staff to provinces within a country, districts within a province, areas within a district, and so on, according to the volume of services which are being delivered and the different types of health staff which are required to deliver these services; the optimal allocation and deployment of current staff functionally, i.e. allocating staff between the different types of health facilities or different health services in the country as a whole, in a province, in a district, in an area, etc., according to the volume of services which are being delivered and the different types of health staff which these services call for; the optimal staffing patterns and levels (categories and numbers) in individual health facilities according to local conditions (morbidity, access, attitudes) and not based on national averages (population ratios and standard staffing schedules); the optimal staff categories and their activities, i.e. identifying where combining existing staff categories or creating new categories will achieve maximum health impact with maximum economy. The WISN Method will produce all these types of results. The pressing need now is to ensure that questions of the optimal allocation and deployment of staff can be answered at two levels at the national/provincial level, so that staff can be allocated or distributed to districts equitably; and at district level, so that staff can be deployed to different locations, services and facilities to best effect. In addition there are longer term strategic issues 4

11 Section A The WISN method and its uses which must be tackled at the national level, concerned with volumes of training and determining the optimal staff categories to employ in the health services. In order to provide useful information to both medical and non-medical administrators at all levels of the health service in these times of economic stringency and staff shortages, the new technique should be: simple to operate, using data which is already collected and available; simple to use, so that the results can contribute to staffing decisions at all levels of the health service; technically acceptable, so that health service managers are prepared to use the results in their decisions; comprehensible, so that the results will be accepted by non-medical managers, e.g. finance, planning, personnel administration; realistic, so that the results will offer practical targets for budgeting and resource allocation. The WISN Method will meet all of these requirements. 2. The basis of the WISN Method The WISN Method is based on the work which is actually undertaken by health staff. Every health facility has its own pattern of workload which may include inpatients, surgical operations, deliveries, outpatients, clinics of various types, health education, home visits, outreach activities, inspection visits, etc. Each type of workload calls for effort (i.e. time) from specific health staff categories. For example, a supervised home delivery requires the time of a midwife or trained traditional birth attendant; a hospital outpatient may require time from a nurse (preparation and recording), a doctor (examination), a laboratory technician (performing tests), a dispenser (filling a prescription), and so on, depending on the medical practices and procedures which are followed in the country. Sometimes treating a case requires time from several different staff categories working together as a team, for example, in performing a surgical operation. For each type of workload (inpatient, outpatient, MCH clinic, etc.) we can set an Activity Standard. This is a unit time for each staff category - how much time on average a case, a prescription, etc. should take each staff category which is involved in it, working to acceptable professional standards. Alternatively we can set a standard rate - how many patients, laboratory tests, etc. can be dealt with to an acceptable standard of performance per hour or per day. This unit time or rate will differ, depending on the type of work (inpatients, outpatients, clinics, home visits, etc.), on the category of staff dealing with the clients (on average ward nurses spend longer per day with hospital inpatients than doctors do) and also on the type of facility (more complex cases are referred to the higher level hospitals where on average they take more staff time per case). This Activity Standard, an activity time or a rate of working (either can be used), can now be converted into the equivalent annual workload, that is, how much of this type of work could be done by one person in a year working to these professional standards and also making due allowance for time spent on vacation, holidays, training, sickness absence, etc. This equivalent annual workload is called the Standard Workload. The amount of each type of work done in a health facility in a year is reported in its annual statistics. Thus applying the Standard Workloads (annual work rates) to these annual statistics will show how many staff in each category are required in order to accomplish this workload to 5

12 Workload indicators of staffing need A manual for implementation acceptable professional standards. This figure is the staffing requirement of the facility calculated according to the WISN Method. The formula is: Workload in the facility (service statistics) Standard workload (for one staff) = Staffing requirement To be useful to decision-makers and managers, this figure of calculated staffing requirement must be compared with the actual staffing level in the facility in order to identify where the shortages and surpluses are, and how big, by staff category, in each health facility. Actual staffing figures must therefore be available for the WISN calculations. Sometimes these staffing figures are not compiled with the annual service statistics, and must be collected as a separate exercise. 3. Features of the WISN Method The WISN Method takes account of the different type or complexity of care offered in different facilities. For example, the treatment of an inpatient in a teaching hospital is usually more complex and time-consuming than it is in a district hospital or a health centre. For this reason the ward nurse spends longer in total each day with a patient in a teaching hospital than the nurse in a district hospital does. This is reflected in the different unit times or rates set for inpatient care in these different facilities. By using these unit times or rates, the calculations will show, for example, that more ward nurses are required in a teaching hospital for the same number of inpatients as compared with a district hospital or health centre. Calculations always show that more doctors are required in the higher level referral hospitals for the same reason each patient takes more doctor time on average. A similar result is obtained with clinic attendances in teaching hospitals as compared with, say, district hospitals. However, where one particular activity is performed in the same way in all health facilities, e.g. immunizations, then the same Activity Standard, i.e. the same unit time or rate (and its annual equivalent the Standard Workload), is used for this activity in all facilities. Thus a number of different Activity Standards may be used for one activity for technical reasons, for example, to allow for more complex cases being treated in some health facilities. However, no adjustment in Activity Standards is made because of location. In the calculations the same Activity Standard for each activity is applied to all facilities of the same type, for example, health centres, throughout the country. This means that the calculated staff requirements in each type of facility are based on the same medical standards throughout the country. This is the basis of the calculated equitable distribution of staff; it is the staff distribution which will offer the same standard of service in health facilities of the same type. The method can be applied to health facilities and services run by voluntary agencies, commercial organizations, private practitioners, etc. provided only that their annual service statistics and their actual staffing levels are available for the calculations. The results can be used to compare on a consistent basis the relative staffing levels in government facilities and all these other facilities. The method can be used by managers and staff in charge in individual facilities (health posts, health centres, hospitals, etc.) if this is preferred. These results will show how the current levels of each staff category employed in the facility compare to the staffing levels which should be employed according to the national Activity (professional) Standards in order to cover the annual workload in the facility. For this use, where managers and staff in charge apply the method themselves, only simple calculations would be possible, and these can be set out on a pro forma; an example used for nursing staff in health centres in Papua New Guinea is shown in Fig.1. The 6

13 Section A The WISN method and its uses pro forma specifies what figures must be entered on the sheet (the workloads and current staffing levels) and lays out the calculations (involving only simple arithmetic) in such a way that they can be accomplished by clerical staff with very little training. Alternatively these simple calculations can be done by the staff at district level, where the service statistics for individual facilities are held. On the other hand, the calculations are particularly appropriate for computers in the sense that they can be set up (programmed) on such machines by computer operators (rather than the more sophisticated computer programmers) using the standard facilities provided in widely available computer packages (spreadsheets or databases). Thus the WISN calculations could be performed on a central computer which can be programmed to produce the results for each health facility, together with district, regional and national summary tables. This centralized approach is certainly best where annual statistics for individual facilities are already sent to and held at the centre, and its advantages may make it worthwhile to have these annual statistics sent to the centre where this is not already done. In larger countries these calculations could be carried out at regional level, with the results sent on to the centre for consolidation into national tables. The method uses whatever service statistics are currently available rather than calling for special data-collection systems to be set up, which is usually both time-consuming and expensive. Thus using the WISN Method will extract extra information from the statistics which are already collected at present and so offers an increased benefit from the current expenditure of resources in collecting these regular statistics. The method is flexible in that it can take advantage of any later improvement in these statistics, for example, wider coverage or greater detail, and thereby produce more comprehensive or detailed WISN results. It can also highlight where changes in the statistics would have the greatest effect in improving the quality of the WISN information provided. 7

14 Workload indicators of staffing need A manual for implementation Figure 1 Pro forma used for nursing staff in health centres in Papua New Guinea Note: Use annual figures for the most recent complete year (Jan-Dec) Province: Southern Highlands HC Nipa Year: 1986 District: Nipa Workload Calculation Recommended nursing officers Workload Calculation Recommended CHWs Admissions Admissions / 600 = / 300 = 4.30 Outpatients** Admissions / = / = 2.77 Total clinic Attendances*** Admissions / 700 = / = 2.31 Supervised births 275 / 150 = 1.83 Total 9.38 Total 8.59 Nursing officers ACTUAL 7 / Total 8.59 = ISN 0.81 Community health workers ACTUAL 11 / Total 9.38 = ISN 1.17 * CHWs = Community health workers including nurse aides, aid-post orderlies and orderlies working in the centre. ** Outpatients do not include clinic attendances. *** Total clinic attendances = new attendances and reattendances at antenatal, family-planning and child health clinics. Some essential work activities never appear in the annual statistics, for example, record keeping, administration, supervision, staff management, etc. Full allowance for the workload caused by these activities is made in the calculations. 8

15 Section A The WISN method and its uses This approach is perfectly general and can be used for all health staff. However there is an easier and better way of calculating the requirements of hospital ward staff (mainly nurses). It is not easy to add up the durations of all individual contacts between nurse and inpatient to give the average amount of time a nurse (or other category of ward staff) should give to each inpatient during a 24- hour period. Rather the nurses are asked to specify the number of inpatients (occupied beds) for which a nurse on duty should be responsible, e.g. one registered nurse per 16 occupied beds, one nurse aide per eight occupied beds. These figures can vary according to the shift (morning, afternoon, night) and the type of ward (medical, paediatric, etc.) One major advantage of this approach is that it is much easier for nurses to estimate how many inpatients they can cover adequately when they are on duty than it is for them to add up the total average time which should be spent with each patient totalled over three shifts during a 24-hour period. And the results are found to be more accurate as well. The general WISN Method as applied to nurses (setting Activity Standards in terms of contact time rather than inpatients covered) is based on a similar principle to the many methods currently used for calculating immediate nurse staffing requirements for a particular ward. These methods divide the inpatients into a number of dependency levels and specify the nursing effort (time) required by inpatients at each level, usually derived from work study observations. These are more detailed and sophisticated calculations which require detailed statistics (numbers of inpatients at each dependency level) and produce detailed results, e.g. how many nurses of each type are required in Ward 4 tomorrow morning? The general WISN Method can also be applied to non-medical staff, e.g. administration, office staff and support staff (laundry, kitchens, cleaners, drivers, etc.) Some of these calculations are based on the service statistics, for example, for laundry and kitchen staff, but the remainder are based on other data, e.g. the number of cleaning staff depends on the size of the facility, the number of personnel administration staff depends on the number of staff employed, and so on. In using annual statistics, the method calculates the average staffing levels required throughout the year in order to cope with the recorded workload, even though the work is frequently seasonal with higher workloads in some months than in others. In doing this the method corresponds to the practicalities of the situation in that the staff employed in a facility are expected to cope with the workloads as they arise, in the heavy months as well as the light. There is no regular procedure for posting extra staff to facilities in their busier months. However, it would be possible to extend the WISN Method to calculate what the seasonal staffing levels should be at different times of the year, if ever these results should have a practical use for managers and administrators. The practical use of the method by operational managers also requires figures for current staffing in each of the health facilities covered by the WISN calculations. Sometimes these figures are not readily available at the centre and a special data collection exercise must be undertaken to obtain them from the district offices. The WISN Method is based on setting unit times or rates of working for the different activities which are undertaken by different staff categories. These unit times or rates are in effect quality standards. Specifying 15 minutes per antenatal examination by a doctor, or specifying one registered nurse on duty during the afternoon shift per 12 occupied beds in a hospital ward, implies certain standards of health care quality and therefore certain codes of professional practice and standards of professional performance. There can be a significant practical advantage in addressing the question of what unit times or rates (Activity Standards) to use for each staff category employed in the health service. The nursing cadre frequently has a written code of professional practice, that is, Activity Standards, which can 9

16 Workload indicators of staffing need A manual for implementation be translated into Standard (Annual) Workloads for each nursing category. On the other hand, many other cadres have no similar document, and setting Activity Standards for staff categories within these cadres (for the purpose of the WISN Method) can be made the first step in setting explicit national standards for staff performance and also producing written codes of professional practice for these other cadres. Sometimes the national standards of performance and professional practice which are officially set in a country are much higher than current practice and would therefore require staffing levels in health facilities which are very much higher than the current numbers employed. While these high standards of health care quality are very desirable, it may in practice be impossible within the next few years for the country to achieve them, that is, to recruit, train and pay sufficient staff to achieve them. They could be considered as longer-term staffing and health care quality targets. The WISN Method can assist in the planning to achieve these longer-term targets (see point 7 below). However, the results produced by the WISN Method are also intended for immediate use by managers and administrators in order to improve the current operation of health services. The Activity Standards which are set for staff in a WISN exercise (and hence their Standard Workloads) should not be too far from the current average conditions in the country. Otherwise, the results (the calculated health workforce requirements) will be too high to be considered as realistic staffing targets for individual facilities, districts, provinces and the country as a whole. Such exaggerated results will not be of practical use in dealing with current problems and so will not get any serious consideration from managers and administrators, who are mainly concerned to improve the current situation. Activity Standards which are set only somewhat higher than the current average professional practice in the country could be used to calculate interim or temporary staffing targets; these figures would correspond to an improved standard of performance and professional practice which could be achieved in the medium-term future in the light of the current circumstances of the country. If the standards of performance and professional practice are set too high by comparison with the current situation, they produce figures for staffing requirements which are far too high to be useful to managers and administrators. However, the method also produces from the same data comparative figures of workload pressures, for instance, which facilities are under the greatest pressure and therefore most in need of support; these results remain valid however realistic or otherwise the standards of performance and practice used in the calculations may be. It should be noted that the WISN Method calculates the staffing levels required to provide health services according to certain professional standards in the country. If a facility has these staffing levels, it does not necessarily mean that the staff there are working to these standards that is a matter for the supervisors concerned. Rather, what the calculation says is that in this situation there are sufficient staff resources in the facility to provide the volume of health services which are shown in its annual statistics according to the professional standards laid down for these services. The method can also be used as part of the annual budgeting process. The salary and staff establishment component of budget submissions can be compared with the corresponding calculations of staffing requirements, for instance, the number of staff required to deliver existing services to acceptable professional standards, in order to evaluate and/or justify existing posts as well as any requests for new ones. If required, this calculation can be done for individual staff categories and for individual health facilities. 10

17 Section A The WISN method and its uses 4. How the WISN Method works: differences and ratios From the actual staffing level in a particular facility and its calculated staffing requirement according to the WISN Method, two separate figures are calculated. The difference, i.e. actual - calculated. This shows the level of shortage or surplus. For example, if the actual number of nurses in a facility is six and the calculated requirement to meet the current volume of work according to the Standard Workload is eight, then there is a shortage of two nurses in the facility to meet acceptable professional standards of service delivery. The six nurses in post are working under some pressure to cope with the nursing workload in the facility, which is actually enough for eight nurses. Or if the actual number of midwives in a facility is 10 and the calculated staffing requirement according to the Standard Workload is eight, then the facility employs two midwives more than it requires in order to meet its midwifery workload to acceptable professional standards. (This is not to say that two midwives are idle in the facility, but rather that the facility can deliver a higher quality of service, for instance, more midwifery services and care to patients, than other facilities which do not have such a surplus.) There is a very important point here. When we use the WISN Method to calculate staffing requirements, these figures are not based on some theoretical need for staff according to the health status or morbidity statistics in the population, or according to desirable staffing patterns in health facilities. With these more theoretical methods, a calculated staff shortage (e.g. less staff in post than the standard staffing pattern calls for), says nothing at all about the work pressures in the facility. But staff requirements calculated by the WISN Method are based on the work which is actually being done in the health facilities, for instance, the number of patients who are actually being treated and the number of clients who are actually being served in the facilities. In these cases a calculated shortage of staff in a facility actually does mean pressure of work on those employed in the facility, which almost invariably leads to a reduction in professional standards. A figure measuring this pressure of work is given by the ratio. The ratio, i.e. actual/calculated. This ratio is called the Workload Indicator of Staffing Need (WISN) and gives its name to the method as a whole. If the WISN ratio is 1.00, i.e. actual staff = calculated staffing requirement, then the current staff is just sufficient to meet the workload according to the professional standards which have been set. If the WISN is less than 1.00, then the current staff is not sufficient to meet these standards. Continuing with the example above, if a facility has six nurses but is calculated to need eight, then the WISN for this category is 6/8 = 0.75 or 75%, and only 75% of the required staff are available or only 75% of the standards can be achieved. If the WISN is greater than 1.00, then there are more than enough staff to meet the standards set. For example, the facility mentioned above has 10 midwives but is calculated to need only eight; the WISN for this category is 10/8 = 1.25 or 125%, and there is an excess of 25% in the midwives above the number needed to achieve the standards set. The WISN ratio is one of the novel features of this method. It shows the degree of pressure which each staff category is under in coping with the annual workload it is actually dealing with in the facility. 11

18 Workload indicators of staffing need A manual for implementation 5. Using the WISN Method: identifying priority situations The two figures the difference and the ratio (WISN) are used in combination and each has its own function. The difference between the two figures shows how big the imbalance (shortage or excess) is, and where it is. It shows which facilities have a shortage in a particular staff category and which facilities have an excess (as compared with calculated requirements) in the same staff category. It is used for planning where any new staff should be posted and also for determining how staff can be redeployed between facilities (to the extent that this is possible), in both cases with the aim of achieving a more equitable distribution of staff and overall a more cost-effective service. The ratio (WISN) shows where the workload pressure is the greatest and where it is the least, and so where it is most urgent to take action in order to adjust staffing levels. It is used for identifying which facilities should have priority when considering staffing changes (both increases or reductions). For example, compare the following two situations: a shortage of three nurses in a health centre where there are seven nurses but there should be 10 to cope with the workload. WISN = 7/10 = 0.7, i.e. 70% of staff requirements available, 30% understaffed; a shortage of 10 nurses in a hospital where there are 90 nurses but there should be 100 to cope with the workload. WISN = 90/100 = 0.9, 90% of staff requirements available, 10% understaffed. The nurses in the health centre are under much greater work pressure (30% understaffed) and therefore merit more urgent attention than the nurses in the hospital (10% understaffed). Unfortunately the larger shortage (of 10 nurses in the hospital) would usually command attention over the smaller shortage (of three nurses in the health centre), particularly when the larger figure is backed by the authority of the hospital director or matron. These calculations offer an objective method of prioritising situations of staff shortage, that is, identifying where the need is greatest and so offering assistance in making decisions on staff deployment, for example, where best to post new staff. The same calculations can also be used to prioritise situations of staffing excess as well, that is, identifying those places where staff can most easily be spared. For example, consider the following two situations: an excess of four nurses in a health centre where there are 12 nurses employed but the calculations show that only eight are needed to cope with the workload. WISN = 12/8 = 1.5, i.e. 150% of staff requirements available, or 50% excess; an excess of 20 nurses in a hospital where there are 120 nurses employed but the calculations show that only 100 are needed to cope with the workload. WISN = 120/100 = 1.2, i.e. 120% of staff requirements available, or 20% excess. In most instances the manager or administrator concerned would consider reducing the number of nurses in the hospital ("They have well over 100 nurses, they will not notice a reduction so much... ) rather than in the health centre. However, the four extra nurses in the health centre give a much greater degree of overstaffing (50% excess) and therefore some of these staff should be 12

19 Section A The WISN method and its uses considered for transfer before reducing the 20 extra nurses in the hospital (20% excess). If the health centre gave up two nurses and reduced its staffing to 10, then: Actual staff = 10 Calculated requirement = 8 WISN = 10/8 = 1.25, i.e. 125% of staffing requirements available, or 25% excess. This reduction of two nurses would bring the excess of the health centre nurses (25%) to be roughly the same as the excess of the hospital nurses (20%). Thus if any nurses are to be moved in order to relieve shortages elsewhere then, from the viewpoint of equity, moving two nurses from the health centre should be considered before moving any nurses from the much larger number in the hospital. These examples show how the combination of difference and ratio (WISN) offers an objective basis for making what are always difficult decisions of staff allocation, deployment, posting and transfer. These examples also show that the method can be used to compare directly the staffing situations and workload pressures in different types of health facility (e.g. nurses in a health centre and in a hospital), even where the staff category concerned may be engaged in different activities in these facilities. 6. Using the WISN Method: improving the current staffing situation The examples above show how the difference between the actual staffing levels and the calculated staffing requirements in one health facility denotes the shortage or excess of staff in the facility according to the actual workloads and the professional standards laid down in the country. The ratio between actual and calculated staffing levels (WISN) shows whether these staff are working under pressure in coping with these workloads and how much pressure there is on them, that is, to what extent the professional standards can be upheld in the facility. For example, in one country employing the WISN Method two categories of nurse (nursing officers and nursing aides) are employed in health centres. Nursing officers deal with inpatients, outpatients, clinic attendances and deliveries; nursing aides deal with inpatients and outpatients only. In one health centre the results of WISN calculations for one year were as shown in Table 1. Table 1 Results for nursing staff in one health centre Actual staff Required staff WISN ratio Difference Nursing officers Nursing aides From these results the health centre manager concluded: a) the shortage of two nursing officers balances the excess of two nursing aides; the total nurse staffing of the health centre is correct but it is incorrectly allocated between the categories according to their tasks (job descriptions); 13

20 Workload indicators of staffing need A manual for implementation b) it is likely that wherever possible some of the tasks of the overburdened nursing officers in relation to inpatients and outpatients are being undertaken by the nursing aides (with an excess of staff), who also attend these patients. Similar calculations can be done for all staff categories in each health facility in a district, a province and the country as a whole. By comparing the calculation results (ratios and differences) for a group of such facilities, a manager can identify whether there are any staffing inequities between the facilities and, moreover, what can be done to improve the situation. In particular, the manager can determine: a) which staff categories in which facilities are under pressure, how much pressure they are under, and how big the staffing deficit is at each facility; b) which facilities have staff in excess of their workload requirements, and how big the excess is at eachfacility; c) what staff movements (transfers) would bring about a more equitable distribution of staff in the group of facilities; d) which facilities should be considered first in these possible staff movements; e) how many extra staff are required to bring the total staffing in the group of facilities up to the level which corresponds to acceptable professional standards; f) where any new staff should be posted in order to achieve maximum impact on the quality of services provided. A further example from the same country shows a summary of the results for nursing staff in four health centres in the same district. These include those given above in Table 1, which are shown as health centre A in the following Table. Table 2 Example of a district summary Nursing officers Health centre Actual staff Staff reqd. WISN ratio Short/ surpl. Actual staff Nursing aides Staff reqd WISN ratio Short/ surpl. A B C D District totals

21 Section A The WISN method and its uses From these figures the district medical officer concluded: a) the district has about the correct number of nursing officers in its health centres, but they are not optimally distributed. It would be very desirable, if it were possible, to transfer two nursing officers from health centres C and/or D to health centre A; b) the district has a net shortage of five nursing aides in its health centres, but even so the situation could be improved by transferring up to two of these staff from health centre A. The highest priority for employing extra nursing aides is at health centre C; although both C and D are three nursing aides short, those in C are under the greater pressure (only 73% of nursing aides in post) as compared with D (83% of nursing aides in post). In fact the pressure on nursing aides in D (83% staffing, three short) is about the same as in B (86% staffing, although only one short), because B is much smaller. The results show: how the workload pressure in each facility can be compared with the average of the group; where the staff shortages or workload pressures are greatest for the different staff categories; and therefore where new staff in each category should best be posted or where staff transfers would improve the overall situation. In other words, these results are used to identify staffing inequities between facilities and moreover they can also be used to determine what specific actions can be taken in order to achieve equity in the situation. This will work even if there is an overall staff shortage in a group of facilities. For example, the most equitable distribution of the 39 nursing aides shown in Table 2 can be calculated using the WISN Method. The results are shown in Table 3, which sets out the actual situation (repeated from Table 2) and also the calculated equitable distribution of these staff among the four facilities. Table 3 Equitable distribution of nursing aides Actual situation Health centre Actual staff Staff reqd. WISN ratio Short/ surpl. Equit staff Equitable distribution Staff reqd Equit WISN Staff movements A B C D District totals The calculated staff requirements in the four facilities remain the same, since this is based on the workloads at each of them. The ratio between the calculated equitable staffing and the calculated staffing requirement (called the Equitable WISN) lies between 0.83 and 0.91 for the different facilities; this is the most equitable distribution of these staff that can be achieved in this situation. The final column of the Table shows that it can be achieved by transferring three staff from health 15

22 Workload indicators of staffing need A manual for implementation centre A, two of these to health centre C and one to health centre D. The calculation shows what is the most equitable distribution of the available staff which would enable all facilities in a group to work under an equal degree of pressure. The same approach can be used to review the workload pressures and the corresponding staffing levels within a large facility, for example, the allocation of nurses to wards or departments in a large hospital. This would identify instances of over- and under-staffing and determine what would be an equitable distribution of staff. This is worthwhile only where there are large staff categories in a health facility. These calculations can be extended to compare staffing levels and workload pressures in several different types of health facility in a district, for example, health posts, health centres, hospitals, MCH clinics, etc. The results will show: a) which staff categories in all these facilities are under the greatest pressure and therefore are most in need of support; b) what transfers of staff within the district would give a more equitable distribution of staff between the facilities and a greater health impact if the same staff category is employed in several different types of facility. Some shortage categories are employed in only one facility, for example, X-ray staff or laboratory staff may be employed only in the district hospital, and no transfers within the district are possible. The calculations show which of these staff categories is under the most severe work pressure and therefore which requests for extra staff should be pushed the hardest. The calculations also supply a mathematical justification for such requests. Another powerful feature of the method is that the results for each staff category can be aggregated at different levels of the health service to produce the total in post, total calculated requirement, total shortage/excess and average WISN (workload pressure). Thus the results can be produced for each health centre in a district, together with the district totals and average, as shown in Table 2. Then these district totals and averages can be listed for each of the districts in a region, together with the regional totals and averages. Finally these regional totals and averages can be listed for each of the regions in the country, together with the national totals and averages. Such aggregated results can also be produced for each type of health facility (health posts, hospitals, MCH clinics, etc.) or each category of staff (doctors, nurses, pharmacy staff, etc.) throughout the country. Additionally, the results for all types of health facility in a district can be combined to produce a comprehensive picture of the health staffing in a district, for instance, the total in post, total calculated requirement, total shortage/excess and average WISN (workload pressure). These figures can also be aggregated to produce similar comprehensive pictures of the health staffing for each region and for the country as a whole. Such aggregations are very powerful tools for human resource management in a district, a region or in the country as a whole. However, such aggregations can give really accurate results only if the figures are comprehensive, that is, they cover all the relevant health facilities which should contribute to the tables. If an aggregation is based on statistics from only a proportion of the health facilities which should be covered, then the results can give useful information on WISN ratios (workload pressures) in the country, depending on how representative are the health facilities which are covered by the figures. However, such calculations can give only an estimate of the real staffing requirements (by correcting for the missing facilities), and hence only an estimate of the real recruitment rates and training volumes which would meet these requirements. Of course, if 16