THE STRATEGIC ALIGNMENT OF (RE)DESIGN & HEALTH …€¦ · THE STRATEGIC ALIGNMENT OF (RE)DESIGN &...

THE STRATEGIC ALIGNMENT OF (RE)DESIGN & HEALTH WORKFORCECanadian Centre for Healthcare Facilities

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Nov 27, 2019Shawn Drake, MSc, PhD (c)Managing Partner, Workforce EdgeFounding Chair, Comparative Panel on Health Workforce Mobilization

© 2019 Workforce Edge Consulting Inc. All Rights Reserved. Not for dissemination without explicit written permission.

Objectives / Agenda

1. Enhance visibility to situate staff scheduling and workforce deployment as a strategic priority, to a unique group of stakeholders

2. Share real stories from the frontline of how design impacts:

i. service delivery

ii. the working experience as inter-related with the provision of care

iii. staffing and deployment

iv. cost and sustainability of health services delivery

3. Summarize opportunities and business case for change investment $$ utilizing more effective design

4. Flag an active national “Call for Collaboration” in the domain

2© 2019 Workforce Edge Consulting Inc. All Rights Reserved. Not for dissemination without explicit written permission.

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Active issues within the public policy context

increasing demand The dramatic increase in the aged population over the next decade will continue to increase demand for health services.

shifting demographicsGen Y, Millennials are a majority of the workforce and expect to be connected, mobile, and have a variety of work opportunities.

shrinking workforceCanadian data suggests that RN

vacancies could topple 60,000 FTE in the next few years; although

strides have been made.

cost pressuresRising healthcare costs are being

driven by consumer expectations, and are expected to continue.

significant transformation of health workforce environmentsWe have had the privilege of partnering with health systems for close to 2 decades, dedicated to leading formal transformations.

Addressing the themes above requires continuous improvement and innovation.

qualityData and systems maturity are bringing more visibility and demand for insight, and key performance indicators.

engagementAn innovative sector with resource

challenges, and many opportunities, demands intuitive strategies to

ensure retention.


Strategic lenses application

• Focusing on HHR supply, is not a new phenomenon in sustaining the delivery of health services:

– Romanow Report; Kirby Report; Mazankowski Report; F/T/P Committee on Health Workforce; Canadian Health Workforce Network; Global Health Workforce Alliance; WHO priorities;

– All contribute to a strong vision: “Canada will attract, prepare, deploy and retain highly skilled health care providers to give Canadians access to appropriate, timely, effective care…” (HHR Strategy, Canada, 2011).

• Substantial # of planning models developed and discussions within literature (for overview: Hall & Mejia, 1978; on impact of mobility, Kirkpatrick, et al., 2016; on co-ord w/ higher education, Buchan, 2016; Dussalt, 2017; on finance, Wendt, 2016; on intake and retention, Maioni, 2014; Maioni & Marmor, 2016; on gender, Bourgeault, numerous);

• Sustainability is about more than planning, forecasting, and securing supply, to enter the system:

– “Addressing needs implies more than producing more workers; scaling up can be achieved by improving competences, changing skills mix, and by augmenting productivity” (Dussault, et. al, 2010, 5);

• CNA lever suggestions for policy intervention have focused on advancing:

– Productivity and workforce utilization, absenteeism reduction, increased enrolment into nursing programs, increased retention, and reducing attrition within new nurse graduate entry programs.


Productivity and sustainability

• CNA has projected that if no policy interventions are implemented to secure the forecasted need, Canada will be short almost 60,000 RNs by 2022 (On model, see also: Tomblin Murphy et al., 2012).

• So, if productivity is the key – whether and to what extent can we increase productivity (and do a better job of ensuring health providers are healthy enough to come to work)?

• We need to look beyond filling the funnel and skill mix utilization;

• We need to focus on the practices, processes, workflows, foundations and organization of the deployment functions;

• We have to “optimize” the staff scheduling and workforce deployment environments;

• Afterall, the efficiency and effectiveness of service delivery…depends to a great extent, on the deployment and use of personnel (O'Brien-Pallas, 2002; c.f. Canada, 2011).


A focus on the optimization of the workforce is required

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Workforce Planning

WorkforceOptimization


Policy goals:

• Productivity• Engagement• Absenteeism• Utilization • Others

(See: Drake, 2019, 2020; Drake & Geva-May, 2020; Drake & Smith, 2020, forthcoming)

Impact of achieving objectives:

• Increasing RN productivity by 1% would reduce projected shortfall by up to 50%

• Reducing absenteeism averages from 14 to 7 days for three years, equates to adding 7K RNs to the workforce (CNA, 2009)


There can also be tremendous, unintended, imbalance

• Often at the unit level there is a significant imbalance in achieving baseline staffing. In many healthsystems the tools and methods to plan and achieve baseline staffing in a proactive manner are absent;

• Many health systems rely on electronic scheduling systems which do not have the required functionalityand/or their configuration, and use is poor;

• Taken together these factors exacerbate and magnify the very problems a scheduling function wasintended to fix. This disengages the workforce, hits productivity, and drives resource waste;

• In many contexts we still find units and programs who “work short” much of the time, but:

– Overrun on their budgets;– Are not meeting the direct patient care hours intended;– Incur the building of substantial vacation banks which are a considerable liability for the province; and who– Unsurprisingly, experiencing high turnover and absenteeism rates.

• Even more unfortunate, is that in the same units we still find over-staffing, on random shifts;

• We need to work to help find ways to avoid the waste and to move the health system out of a feast orfamine situation into a much more stable and optimized environment.


“Overs and Unders” contribute to hallway medicine, and waste


Cost of imbalance / labour can be staggering

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$228.1 Billion

2016 Total Canadian Healthcare Expenditure

$264 Billion

2019 Total Canadian Healthcare

Expenditure

11.6% of

GDP

Estimated % of Healthcare expenditure

29.5% Hospitals

16%Drugs

15.3% Physician Services


Cost of imbalance / labour can be staggering (cont.)

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$86.4 Billion

Hospital Operations

60%Spent on Labour

>$50 Billion

National Hospital Labour Expenditure

200,000 Additional long-term care beds

40,000Estimated # of

Care Aides needed

$64 Billion

$7 Billion

Recurring labour spend

Capital Investment Needed


FACILITY PLANNING & (RE)DESIGN Has a role to play in workforce optimization and improving the scheduling and deployment environments


• Two areas relatively unexplored within the staff scheduling transformation domain however are:

(1) the impacts of physical design on staff scheduling success; and

(2) how physical space can contribute to facilitate the effective deployment of the healthcare workforce and achieving these policy goals.

Ability to deploy in a manner that supports efficient and effective productivity, is theintersection of health facility design and workforce optimization i.e., the improvement of the staff scheduling environment.

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Intersection


Links from workspace to workforce are established

• The healthcare workspace affects staff morale, satisfaction, retention and overall productivity;

• Many elements of workspace to workforce are well established in the literature and in practice;

– Pods with even numbers of beds to enable staffing ratios– Proximity of pods to enable staffing up or down, or deviations in the planned skill mix– Proximity of pods and units to enable floating of staff or highly acute patient assignments to highly skilled staff;– Glass rooms;– Situation of work stations, carts, pharmacy supplies;– Even number of rooms in corridors and so on.

• Many of these are well dug into and well documented i.e., trade-offs between single and shared roomssuch as panoptic surveillance as fall prevention; additional steps for staff; patient isolation v. privacy;

• Others argue that space impacts are undefined, “There is scant and ambiguous evidence relating to theimpact on patient safety and staff and patient experiences…” (Maben et. al, 2015);

• We need to focus onthe physical environment, which is underexamined—its layout, makeup and objectsare strong indicators of a workforce’s productivity, health and safety i.e., “environmental psychology”(Vischer, 2008, 175; Vischer & Wifi, 2017).


FRONTLINE PERSPECTIVES Comparative Experiences and Data, Reinforces the Links


Eyes On/NIR

“I can’t see you!”---

“I could do more to help!”

1 RN each shift = 4.2 FTE p/a @RN rate of 41.78 p/h

342K minimum repeatable spend p/a

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Attributes

• Rooms accommodate 4 beds, have heavy, solid doors with little to no visibility;

• In addition to isolations, there can be requirements to have “eyes on” for highly acute patients. A number of trachead intubation patients on the units; RT is mobile;

• Original unit space was too small for growing demand; no options to extend bed-count on same floor; sister unit opened on another floor which was chosen as the rooms accommodate pods of 6 as opposed to 4.

Impacts on Service Delivery

• Given lack of visibility “blocked” rooms for isolation require 1:1 RN:Patient ratios; regardless of bed v. room isolation practice and more effective cohorts, visibility still plays a significant role;

• Beyond isolation, “eyes on” scenarios linked to visibility issues command 1:1 ratio; where 2:1 ratios could be an option;

• Inability for RT on unit, triggers anxiety; drives charge calling for “eyes on” domino;

Impacts on Staff

• Chaos at a moments notice; working “short”; hands tied in help team members coping with much heavier loads;

• Re-deployment off of the unit to follow patients; absorption of ER resources to follow patients “up” due to capacity to admit.

Impacts to Scheduling and Deployment

• Working consistently at 1:1 ratios when 2:1 ratios are possible;

• Increased short-call disrupting staff on days off; exhaustion; premium pay i.e., OT;

• Cannot have the ideal being the attached-RT given critical mass is physically severed.


Long Hallways

“Where is everybody?---

“Hey, my feet hurt!”

4-hours per day overlap = 0.75 FTE@RN rate of 41.78 p/h = 61K

Accommodated worker = 2.1 FTE HCA to support accommodated nurses@HCA rate of 23.60 p/h = 97K


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Attributes

• Rectangle shaped unit;

• Nursing station located in the back of the floor;

• Long hallways initially seen as a bonus given some rehab work performed on the unit, yet complex care required and population presenting with various levels of acuity;


• Forces staff to work in a circular motion and disrupts nurse prioritizing care to particular patients;

• Inability to see team members;

• Difficulty locating colleagues;

• Carts placed end of hallways causing additional effort;

• Location of nursing station presents a lack of presence of clerk at entrance of floor/unit. Causes disorientation to visitors. Domino effect distracting care providers;

Impacts on Staff

• Constant “jogging” on the floor; exhaustion; anxiety


• Forced aging care providers protest resulting to work 8 hour instead of 12 hour shifts; splinters the care team having some on 8s and some on 12s; causes 4-hour overlaps which are unavoidable; drives two accommodated workers to be paired with “buddies”


Intensive Care Set-ups/Separations

“Hey, I don’t work on that side”---

“We can’t double down, even when we should”

2 RN each shift = 8.4 FTE p/a

@RN rate of 41.78 p/h


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Attributes

• NICU w/ two large pods w/ substantial physical barrier splitting unit;

• Physical barriers in level 3 intensive care with level 2 capacity;

• ICU, with partial glass and curtains for single rooms, and curvature/abutment affecting cohorts, ability to retain line of sight.


• Drives issues of continuity in assignment; Impacts clinical education and development of junior resources; thereby impacting staffing levels;

• Disrupts natural ability to cohort patients; Triggers movements;

• Impacts ability to double down, or even triple down (given acuity and flow issues in and out of step-down beds).

Impacts on Staff

• Hard to switch between patients and families constantly;

• Groupism; enclaves; bad feelings of staff; stress for charge nurses

• Disagreements over baselines, workload requests ad-hoc, constant validation required by manager, finance for staffing load.


• Difficulty is establishing stable baselines; hits vacation approval driving banks risk and pay-out; Hard to create a relief strategy.


Workforce Planning


Call for collaboration

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Health Workforce Mobilization

• Creates a platform for a focused national dialogue;

• Contributes to the advancement of meaningful system improvement;

• Supports health leaders in developing capacity and core competence.

Health Strategic Review Team

• Focus areas identified;

• Review capacity;

• Extensive breadth;

• Tangible operational outputs i.e., leading practices and pitfalls


Summary thoughts on this intersection of design and scheduling

• Hospital design – must be patient and family centered – and must also be employee centered if we want to keep our staff engaged and being the best that they can be;

• The changing landscape of healthcare is also reflected in the changing patient population, whose acuity has been steadily increasing;

• Current facilities are often outdated, and organizations must spend additional resources to staff safely, due to an inability to maximize utilization and flex to changing care needs;

• This requires a robust business case;

• Changing patient needs require flexible design to adjust staffing to optimize staff and ensure appropriate staffing with limited resources;

• A key consideration is also the ability to share relief;

• And please, when designing facilities (a) plan for a scheduling office; and (b) don’t put it in the basement…


Thank you!

Merci Beaucoup!


THE STRATEGIC ALIGNMENT OF (RE)DESIGN & HEALTH …€¦ · THE STRATEGIC ALIGNMENT OF (RE)DESIGN &...

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