Business planning framework - Queensland Health

Office of the Chief Nursing Officerwww.health.qld.gov.au/ocno

Resource manual 4th editionJuly 2008

Business planning framework a tool for nursing workload management

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The Business planning framework: a tool for nursing workload management �s a comprehens�ve resource des�gned to support tra�n�ng �n bus�ness plann�ng for the purpose of manag�ng nurs�ng resources and workload management.

ISBN 978-1-921447-31-0

©Queensland Health, July 2001 Copyr�ght protects th�s publ�cat�on. Except for purposes perm�tted by the Copyright Act, reproduct�on by whatever means �s proh�b�ted w�thout the pr�or wr�tten perm�ss�on of Queensland Health. Inqu�r�es should be addressed to Queensland Health, GPO Box 48, Br�sbane Q 4001.

Second ed�t�on; September 2002 Th�rd ed�t�on, July 2005 Fourth ed�t�on, July 2008

http://qheps.health.qld.gov.au/ocno/content/bus_planning.htm

Business planning framework: a tool for nursing workload management

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ForewordNurs�ng workload management �n Queensland Health �s �n accordance w�th the Business planning framework: Nursing Resources (BPF), wh�ch was developed collaborat�vely by Queensland Health and the Queensland Nurses Union (QNU). The BPF was or�g�nally publ�shed �n 2001. The approach taken by the BPF �s to ach�eve a balance between serv�ce demand and the supply of nurs�ng resources requ�red to meet the �dent�f�ed demand. Use of the BPF for nurs�ng workload management was mandated �n the Nurses (Queensland Health)-Section 170MX Award 2003, Part 5, Section 17.

The part�es �nvolved �n the Nurses Interest Based Barga�n�ng (NIBB) process, represent�ng Queensland Health and the Queensland Nurses Un�on (QNU), agreed that f�ve key pr�or�ty �ssues w�ll ensure a susta�nable nurs�ng workforce �nto the future, as well as underp�nn�ng the successful �mplementat�on of the Nurses (Queensland Health) Cert�f�ed Agreement (EB6) 2006. Part 4, Sect�on 31 of EB6 addresses workload management and acknowledges the need to ensure the �ntegr�ty and appropr�ate appl�cat�on of the ex�st�ng agreed nurs�ng workload management tool (BPF).

S�nce 2006, Nurs�ng Interest Based Barga�n�ng Interest Group (NIBBIG) has been address�ng the f�ve agreed pr�or�ty areas of recru�tment and retent�on, work-l�fe balance, educat�on and tra�n�ng, models of care and workloads. NIBBIG has prov�ded Queensland Health, QNU and the nurs�ng workforce w�th a pos�t�ve opportun�ty to exam�ne and address the underly�ng �ssues that hamper the recru�tment and retent�on of nurses w�th�n Queensland Health.

A jo�nt Queensland Health/QNU work�ng party was establ�shed �n 2006 to address the effect�ve management of nurs�ng workloads and nurs�ng workforce plann�ng through the development of th�s ed�t�on of the Business planning framework: a tool for nursing workload management. The a�m of the BPF �s to prov�de nurses w�th a bus�ness plann�ng process to ass�st �n determ�n�ng appropr�ate nurs�ng staff levels to meet serv�ce requ�rements, �dent�fy strateg�es to ass�st �n manag�ng workloads and evaluate the performance of the nurs�ng serv�ce.

Queensland Health nurses are encouraged to take an act�ve role �n develop�ng, �mplement�ng and evaluat�ng a bus�ness plan and workload management strateg�es relevant to the serv�ces they del�ver. A sound bus�ness framework and workload management strateg�es are essent�al �n del�ver�ng qual�ty care �n today’s compet�t�ve and dynam�c health care env�ronment.

Paul�ne Ross Ch�ef Nurs�ng Off�cer Queensland Health

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Contents Foreword ��

Acknowledgements v

Overv�ew 1

Introduct�on 2

Module 1: Develop a business plan 7

1.1 Introduct�on 8

1.2 Object�ves 8

1.3 What �s bus�ness plann�ng? 8

1.4 What �s a bus�ness plan? 9

1.5 Why develop a bus�ness plan? 9

1.6 How to develop a bus�ness plan 10

Module 2: Develop a service profile 14


2.2 Object�ves 15

2.3 What �s a serv�ce prof�le? 15

2.4 Ident�fy�ng the a�m 16

2.5 Develop�ng object�ves 16

2.6 Descr�b�ng the present serv�ce 17

2.7 Env�ronmental analys�s 18

2.8 Strengths, weaknesses, opportun�t�es and threats analys�s 28

2.9 Agreed serv�ce prof�le 29

Module 3: Costs, reports and budgets 30


3.2 Object�ves 31

3.3 Types of staff�ng costs and common term�nology 32

3.4 Pat�ent acu�ty 33

3.5 Act�v�ty 35

3.6 Reports 36

3.7 Overv�ew of fund�ng model and budgets 42


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Module 4: Resource allocation 46


4.2 Object�ves 47

4.3 Develop�ng the annual operat�ng expense budget for nurs�ng 47

4.4 Strateg�es to address an �mbalance of supply and demand 80

4.5 Mon�tor�ng the use of resources 84

Module 5: Evaluate Performance 85


5.2 Object�ves 86

5.3 Measur�ng performance 86

5.4 Scorecard report�ng 87

5.5 Frequency of measurement 89

5.6 Comparat�ve analys�s 89

5.7 Benchmark�ng 90

5.8 Conclus�on 90

Glossary of terms 91

Bibliography and further reading 93

Appendix A: Example – Proposed Business Plan 97

Appendix B: Example – Agreed Business Plan 103

Appendix C: Sources of Data 112

Appendix D: Queensland Health General Ledger 114

Appendix E: Definitions of Full-Time Equivalents 115

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AcknowledgmentsRev�ew and development of the fourth ed�t�on of the Business planning framework: a tool for nursing workload management (2008), formally the Business planning framework: Nursing Resources, was undertaken by members of the Nurs�ng Workloads Management comm�ttee:

– Lex Ol�ver (Cha�r) D�str�ct D�rector of Nurs�ng, Rockhampton Hosp�tal – Angela Bertram Project Off�cer, Royal Br�sbane and Women’s Hosp�tal – Kate Pearson Nurs�ng D�rector, QEII Hosp�tal – Robyn Fox Nurs�ng D�rector, Royal Br�sbane and Women’s Hosp�tal – Mandy Edwards Ass�stant D�rector of Nurs�ng, Pr�ncess Alexandra Hosp�tal – Mary Wheeldon Nurs�ng D�rector, The Pr�nce Charles Hosp�tal – Glynda Summers D�str�ct D�rector of Nurs�ng, Ca�rns Base Hosp�tal – Kym Barry Profess�onal Off�cer, Queensland Nurses’ Un�on

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OverviewThe des�gn and development of the Queensland Health Business planning framework: Nursing Resources (BPF) was an outcome of the M�n�ster�al Taskforce on Nurs�ng Recru�tment and Retent�on 1999, wh�ch �dent�f�ed that ‘no means ex�sted to effect�vely analyse staff�ng level requ�rements for Queensland Health’ and recommended a ‘bus�ness plann�ng model’ for nurs�ng be developed as a pr�or�ty. Further, the model needed to �nclude measures relat�ng to workloads, sk�ll m�x, and pat�ent acu�ty/complex�ty together w�th the tra�n�ng and development needs of nurses.

Recommendat�on 29 of the Taskforce Report was formulated to address th�s �ssue and stated that:

Queensland Health funds the development of a Bus�ness Plann�ng Model to prov�de a method of determ�n�ng appropr�ate long term nurs�ng staff�ng levels necessary to meet spec�f�c serv�ce requ�rements.

The BPF, or�g�nally publ�shed �n 2001 has been per�od�cally rev�ewed and updated �n consultat�on w�th key stakeholders. The 2007-2008 (4th) ed�t�on of the BPF takes �nto account feedback rece�ved from key stakeholders, �nclud�ng nurses who have been extens�vely �nvolved w�th �mplementat�on and use of the BPF.

Add�t�onally, the BPF has been �ncorporated �nto the Nurses (Queensland Health) – Sect�on 170MX Award 2003. Part 5, Sect�on 17 of th�s Award requ�res nurs�ng workload management to be �n accordance w�th the BPF and states:

17.1.2 Nurs�ng workload management �n Queensland Health w�ll be �n accordance w�th the Business planning framework: Nursing Resources, as amended from t�me to t�me by agreement between part�es, wh�ch was developed �n consultat�on w�th the Austral�an Nurs�ng Federat�on (Queensland branch) and publ�shed �n July 2001, to address workloads of nurses �n Queensland Health. (Austral�an Industr�al Relat�ons Comm�ss�on, Nurses (Queensland Health) Sect�on 170MX Award 2003)

The rev�ew of the BPF undertaken �n 2007 was �n response to the negot�at�on of the Nurses (Queensland Health) Cert�f�ed Agreement (EB6). The part�es �nvolved �n these negot�at�ons �dent�f�ed a number of pr�or�ty areas of cr�t�cal �mportance to the nurs�ng workforce, �nclud�ng ‘effect�ve management of nurs�ng workloads and nurs�ng workforce plann�ng’. It was agreed that address�ng these pr�or�ty areas would underp�n the successful �mplementat�on of EB6. The object�ve of th�s rev�ew of the BPF �s to del�ver fa�r and reasonable nurs�ng workloads through the �mplementat�on of a transparent and cons�stent workload tool and the �mplementat�on of strateg�es to address nurs�ng workloads.


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IntroductionBus�ness plann�ng �s a systemat�c process for exam�n�ng an organ�sat�on and �ts env�ronment �n order to best allocate resources to meet serv�ce demand. A bus�ness plan (somet�mes referred to an operat�onal plan) �s the work�ng document that art�culates the strateg�es for ach�ev�ng the goals of the serv�ce. It �s through the use of th�s process that nurs�ng resources w�ll be allocated to most appropr�ately manage workloads.

The Business planning framework: a tool for nursing workload management prov�des nurses w�th a bus�ness plann�ng process to ass�st �n determ�n�ng appropr�ate nurs�ng staff levels to meet serv�ce requ�rements and evaluate the performance of the nurs�ng serv�ce. It �s a move away from us�ng h�stor�cal staff�ng establ�shment rat�os to a method based on a demand and supply approach that �s respons�ve to the chang�ng health care del�very env�ronment and the subsequent nurs�ng resource requ�rements.

Th�s approach to nurs�ng resource management focuses on ach�ev�ng a balance between serv�ce demand and the supply of nurs�ng resources necessary to meet �dent�f�ed demand.

Serv�ce demand relates to meet�ng pat�ent care needs and �s establ�shed by cons�der�ng factors such as:

• act�v�ty • acu�ty/complex�ty • performance targets • technology • phys�cal layout and env�ronment of work area • supply �ssues of health profess�onals and support staff • serv�ce qual�ty • pat�ent and staff safety • models of serv�ce del�very • f�nanc�al outcomes • overnment �n�t�at�ves and pol�cy d�rect�on • publ�c/pr�vate �nterface.

Calculat�ng nurs�ng human resource requ�rements (supply) necessary to meet serv�ce needs (demand) �nvolves measur�ng demand �n terms of the total number of requ�red nurs�ng hours.

Factors affect�ng the supply of nurs�ng resources �nclude:

• budgeted full-t�me equ�valents (Append�x E: Def�n�t�ons of FTE) • employment cond�t�ons �nclud�ng leave ent�tlements • supply �ssues of health profess�onals and support staff • recru�tment and retent�on • workforce sk�ll m�x and allocat�on • workforce requ�rements such as tra�n�ng/staff development and performance management • d�rect and �nd�rect pat�ent care hours.

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Match�ng the supply of nurs�ng resources to serv�ce demand �s an �ntegral part of develop�ng a bus�ness plan for any health serv�ce. Th�s manual w�ll ass�st the user to systemat�cally work through the bus�ness plann�ng process, �nclud�ng calculat�ng supply and demand w�th�n that process, and develop�ng and �mplement�ng strateg�es to manage them, wh�ch �n turn supports the management of nurs�ng workloads.

Purpose of the manual

The BPF manual �s a comprehens�ve reference and educat�on resource to ass�st nurses w�th the process of determ�n�ng nurs�ng human resource requ�rements (supply) �n the context of the demands placed on the serv�ce (demand). The outcome of th�s process �s the development of a bus�ness (or operat�onal plan) that relates to the effect�ve management of nurs�ng resources and workloads �n the serv�ce.

Th�s manual has been des�gned pr�mar�ly to address bus�ness plann�ng needs for nurses. However �t has the potent�al to be used as an effect�ve resource by other profess�onal groups. The manual gu�des the user through analys�ng a un�t, serv�ce, or department, determ�n�ng the nurs�ng resources requ�red and evaluat�ng the performance of the nurs�ng serv�ce �n order to develop an ach�evable bus�ness plan.

The a�m of the resource manual �s to ass�st nurses to undertake bus�ness plann�ng for the�r serv�ce and to prov�de educat�on on bus�ness plann�ng and workload management strateg�es.


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Content

The resource manual cons�sts of f�ve modules that �nclude recommended references. Queensland Health documents referred to �n the manual are ava�lable v�a the Queensland Health Electron�c Publ�sh�ng Serv�ce (QHEPS).

Module 1

Introduces the concept of develop�ng a bus�ness/operat�onal plan.

Module 2

Descr�bes how to develop a serv�ce prof�le, �nclud�ng a�m, object�ves and env�ronmental analys�s.

Module 3

Descr�bes types of costs, reports and budgets that are relevant to the development of a nurs�ng budget.

Module 4

Expla�ns the steps �nvolved �n develop�ng a nurs�ng operat�ng expense budget based on the allocat�on of nurs�ng hours (supply) to ach�eve a balance w�th serv�ce requ�rements (demand), and outl�nes strateg�es for manag�ng �mbalances between supply and demand.

Module 5

D�scusses the evaluat�on of performance of the serv�ce by analys�ng the balance between serv�ce demand and resource allocat�on (supply).

Appl�cat�on of the BPF �s supported by a number of tools des�gned to ass�st nurses and nurse managers to determ�ne nurs�ng requ�rements appropr�ate for the workload ant�c�pated �n the work un�t. Queensland Health staff can access tools on QHEPS v�a the Off�ce of the Ch�ef Nurs�ng Off�cer webs�te at http://qheps.health.qld.gov.au/ocno/home.htm

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Principles of the business planning framework

The BPF �s underp�nned by three pr�nc�ples that are to be �ntegrated �nto �ts appl�cat�on. These pr�nc�ples are:

1. The pat�ent/cl�ent2. The staff3. The organ�sat�on.

Principle 1: The patient/client

The BPF supports the prov�s�on of pat�ent/cl�ent focused health care through:

• apply�ng models of cl�n�cal care and cl�n�cal pract�ce that are ev�dence based and support �ntegrat�on

• meet�ng agreed outcomes and health �mprovement targets • promot�on of the prem�ses underp�nn�ng del�very of safe, qual�ty health care by

Queensland Health namely:

Principle 2: The staff

Nurs�ng staff plan and manage resources, ensur�ng:

• the supply of nurs�ng staff �s balanced w�th serv�ce demand to effect�vely manage nurs�ng workloads

• �ntegrat�on of: – workforce plann�ng – workplace flex�b�l�ty – ev�dence based pract�ce – clearly �dent�f�ed requ�red competenc�es – appropr�ate tra�n�ng • systems are �n place for manag�ng safe, equ�table workloads.

Principle 3: The organisation

The BPF �ncorporates the pr�nc�ples assoc�ated w�th Queensland Health’s current strateg�c d�rect�on through:

• strong comm�tted leadersh�p that w�ll support the ach�evement of organ�sat�onal goals • opt�mal use of resources to ach�eve qual�ty outcomes • �ntegrat�on of systems to ass�st dec�s�on mak�ng • health serv�ce managers prov�d�ng access to t�mely, accurate and rel�able data to enable

plann�ng and mon�tor�ng of serv�ces and costs.

Access�ble Safe Effect�ve Respons�ve Eff�c�ent Appropr�ate Susta�nable


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The Business planning framework

The BPF cons�sts of three stages:

Stage 1 Develop a serv�ce prof�le (demand)Stage 2 Resource allocat�on (supply)Stage 3 Evaluate performance (analys�s of the balance between demand for resources to

resources allocated). The overall a�m of the process �s to ach�eve a balance of serv�ce demand w�th resource allocat�on. Through th�s framework, nurses are prov�ded w�th the means to develop a flex�ble, respons�ve bus�ness/operat�onal plan that �s relevant to a part�cular serv�ce, un�t or department.

Each stage of the process should not be cons�dered �n �solat�on, or as separate from the des�red outcome of develop�ng a bus�ness/operat�onal plan.

The pr�nc�ples of the framework can be appl�ed to a var�ety of health care serv�ces �n rural, remote, tert�ary, reg�onal and commun�ty sett�ngs where nurses are employed by Queensland Health.

The framework �s dep�cted �n the d�agram below.• Aims

• Objectives

• Environmental analysis

• SWOT analysis

• Activity

• Acuity/complexity

• Other factor

• Routine monitoring of performance against the plan

• Scorecard reporting

• Analysis of the balance of demand for services/activity with resources allocated

Balance:

• Service demand

• Activity


• Other factors

With: Resource allocation (Supply)

3. Evaluate Performance

1. Develop a Service Profile(Demand)

2. Resource Allocation (Supply)

Balance of Service Demand and Resource

Allocation

Service Demand

Resource Allocation (Supply)

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Module 1: Develop a business plan

1.1 Introduction

1.2 Objectives

1.3 What is business planning?

1.4 What is a business plan?

1.5 Why develop a business plan?

1.6 How to develop a business plan





Allocation

Service Demand



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1.1 IntroductionBus�ness plann�ng �s a systemat�c process for exam�n�ng an organ�sat�on and �ts env�ronment �n order to allocate resources to meet serv�ce demand �n the most appropr�ate way. Th�s module �ntroduces the concept of bus�ness plann�ng, �ts relevance to Queensland Health’s strateg�c d�rect�on and �ncludes a br�ef overv�ew of the process �nvolved �n develop�ng a bus�ness plan.

1.2 ObjectivesOn complet�on of th�s module, the reader/workshop part�c�pant w�ll be able to:

1. Determ�ne how the local serv�ce agreement �s al�gned w�th the Queensland Health strateg�c d�rect�on.

2. Analyse and summar�se how the local health serv�ce meets the relevant goals of Queensland Health.

3. Ident�fy those who need to part�c�pate �n the development of a bus�ness/ operat�onal plan for the health serv�ce.

4. Descr�be the sect�ons of a bus�ness plan.

1.3 What is business planning?Bus�ness plann�ng �s the process of determ�n�ng act�ons to support strateg�c d�rect�on. It should be undertaken for the development of e�ther a new planned or ex�st�ng serv�ce. Throughout the process, the total operat�on of the planned or ex�st�ng health serv�ce �s cr�t�cally exam�ned. Health care organ�sat�ons ex�st �n a complex and chang�ng env�ronment. Undertak�ng plann�ng w�ll ass�st �n adapt�ng to these changes.

Bus�ness plann�ng can be v�ewed as a three-part process.

1. Aims

The bus�ness plann�ng process should beg�n w�th �dent�fy�ng the a�ms and object�ves of the serv�ce.

2. Analysis

The second stage �s where a systemat�c analys�s of the serv�ce and �ts env�ronment �s undertaken, �nclud�ng an evaluat�on of the prev�ous year’s �mplementat�on. Th�s stage encompasses the cr�t�cal measur�ng of whether resource allocat�on (supply) meets current and future serv�ce demands.

3. Action

In th�s stage of the bus�ness plann�ng process, act�ons to ach�eve the a�ms of the serv�ce are developed, dec�s�ons are made regard�ng the allocat�on of resources and evaluat�on measures are determ�ned.

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1.4 What is a business plan?A bus�ness plan (somet�mes referred to as an operat�onal plan), �s the work�ng document that art�culates the strateg�es for ach�ev�ng the goals of the un�t. It �s a statement of what the serv�ce, un�t or department expects to ach�eve over a set per�od as a step towards fulf�ll�ng �ts strateg�c plan.

In Queensland Health, there �s a connect�on and �nterdependency between d�fferent plann�ng processes. These �nclude whole of government pr�or�t�es, the Queensland Health Strategic Plan, and the Queensland Statewide Services Plan. The Queensland Health Strategic Plan �s developed for a set per�od of t�me and art�culates the v�s�on, m�ss�on, strateg�c �ntent, object�ves, �n�t�at�ves and outputs to be ach�eved by Queensland Health over a per�od of f�ve to 10 years.

Health serv�ce plann�ng then needs to def�ne what and how serv�ces w�ll be prov�ded. The relevant corporate and Health Serv�ce D�str�ct (HSD) pr�or�t�es and strateg�es need to be reflected �n the serv�ce level bus�ness plans and as per the serv�ce agreement. The outputs of the HSD w�ll be ach�eved by the var�ous bus�ness un�ts �n the d�str�ct.

A bus�ness plan usually has a one year t�meframe based on the f�nanc�al year. Adjustments to the plan may be requ�red as key factors such as pat�ent/cl�ent act�v�ty and nurs�ng supply change over the t�me per�od.

1.5 Why develop a business plan?Nurs�ng �s the most v�s�ble serv�ce �n health care organ�sat�ons and as such, requ�res a s�gn�f�cant proport�on of budgetary allocat�on. The bus�ness plan prov�des a sound bas�s for project�ng the requ�red nurs�ng resources.

There are many factors �mpact�ng on the nurs�ng resources needed to del�ver serv�ces. These requ�re careful and thorough cons�derat�on. The number of nurs�ng hours requ�red �n one organ�sat�on w�ll not necessar�ly be transferable to another organ�sat�on, as there are a number of key var�ables wh�ch �mpact on the workloads of nurses. It �s �mportant to determ�ne the key var�ables that have a s�gn�f�cant �mpact on nurs�ng workloads. Effect�ve staff�ng levels need to be developed from both a serv�ce and whole of organ�sat�on perspect�ve.

Part�c�pat�on �n the development of a bus�ness plan for the work area w�ll ass�st nurses to act�vely engage �n dec�s�on mak�ng �n regard to resource ut�l�sat�on. Nurses are then �nvolved �n how the�r workloads are managed �n the�r work area.

Benefitsofabusinessplan

• Ass�sts the nurse to plan for the del�very of serv�ces. • Clearly def�nes the goals/object�ves (�n l�ne w�th the strateg�c plan) to g�ve purpose and

d�rect�on to the work of the team members w�th�n the serv�ces. • Ident�f�es tasks and pr�or�t�es. • Determ�nes the resources requ�red to del�ver serv�ces. • Prov�des gu�dance w�th the mon�tor�ng and evaluat�on of serv�ce performance.


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1.6 How to develop a business plan

In develop�ng a bus�ness plan, consultat�on w�th stakeholders needs to occur. Involv�ng the serv�ce staff �n the plann�ng process has the advantage of ass�st�ng the staff to see the serv�ce as a whole. There w�ll potent�ally be a better understand�ng of the concepts, as well as greater ownersh�p and comm�tment to the plan. The follow�ng po�nts are �mportant cons�derat�ons when develop�ng a bus�ness plan.

Whoyouneed

Use a small group of stakeholders to develop the bus�ness plan (stakeholders be�ng people who w�ll be �nfluenced by the plan). Wh�le the major�ty of the group would usually be members of the serv�ce, external people may also part�c�pate, for example:

• a person w�th expert�se �n bus�ness plann�ng • a member of the sen�or management staff.

Whatyouneed

Documents

Relevant key �nformat�on conta�ned �n the follow�ng documents w�ll ass�st �n the plann�ng process.

• The current Queensland Health Strateg�c Plan • D�str�ct performance reports/scorecards • D�str�ct serv�ce agreement • Other relevant pol�cy/plann�ng documents �nclud�ng past bus�ness plans • Qual�ty reports • F�nanc�al and act�v�ty reports

Time

It �s �mportant to comm�t suff�c�ent t�me to undertake the process.

Activity

1. Rev�ew the current Queensland Health Strategic Plan and Statewide Health Services Plan.

2. Rev�ew the current Serv�ce Agreement for your D�str�ct. 3. Note how the serv�ce agreement �s al�gned w�th the goals of the strateg�c plan. 4. Summar�se how your bus�ness un�t/organ�sat�on/serv�ce meets the relevant

goals of the strateg�c plan. 5. Cons�der who needs to part�c�pate �n the development of a bus�ness plan for

your serv�ce.

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Structure of a business plan

The bus�ness plan �s a formal document and as such needs to be reta�ned as a reference for future plann�ng. Ta�lor the plan accord�ng to the preferences of the users.

Size and format

The s�ze of the bus�ness plan w�ll depend on the s�ze and complex�ty of the serv�ce. It shouldn’t be too long or �t won’t be read or used as �ntended.

Content

The plan needs to conta�n suff�c�ent �nformat�on for the users to understand how �t �s used to �n the del�very of serv�ces. The plan should be �nformed by the follow�ng sect�ons. Each of these sect�ons w�ll be further d�scussed �n the later modules.


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In th�s manual, each of these sect�ons �nform�ng the bus�ness plan �s addressed �n deta�l through �nd�v�dual modules. A br�ef descr�pt�on of the contents of each of these sect�ons �s presented �n the follow�ng table.

1. Introduction (see Module 1)

Th�s sect�on prov�des a br�ef h�story of the serv�ce �nclud�ng past act�v�ty and ach�evements.

2. Serviceprofile(see Module 2)

a. A�ms/object�ves The a�ms and object�ves of the serv�ce should be stated.

b. Present serv�ce.

Th�s sect�on needs to have a more deta�led descr�pt�on of the current state of the serv�ce. It may �nclude reference to past comm�tments that were unable to be ach�eved and pr�or�t�es for future serv�ce development.

3. Environmentalanalysis(see Module 2)

The extent of analys�s of the external and �nternal env�ronment �s dependent on the serv�ce for wh�ch the plan �s be�ng developed. For example, a serv�ce that �s for the ent�re state w�ll be more complex than a serv�ce for a small, def�ned populat�on.

4. Strengths,weaknesses,opportunities,threat(SWOT)analysis (see Module 2)

The SWOT analys�s �s the assessment of factors �n the external and �nternal env�ronment �nto the categor�es of strength, weakness, opportun�ty or threat, �nclud�ng �nformat�on from the evaluat�on of prev�ous plans.

5. Resource requirements/allocation (see Modules 3 and 4)

Th�s sect�on w�ll descr�be the resources that are requ�red to del�ver the serv�ces and the allocat�on or d�str�but�on of these.

6. Performance measures/evaluation (see Module 5)

Th�s sect�on deta�ls the measures that w�ll be used to mon�tor and control the outcomes of the bus�ness plan. To measure progress aga�nst object�ves the Bus�ness Plan needs to be regularly rev�ewed. Rev�s�on of the plan can also occur �n l�ne w�th changes �n the external and �nternal env�ronments.

Table 1.1: Bus�ness plann�ng: A br�ef descr�pt�on of the content �n each sect�on

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For examples of completed bus�ness plans, see Append�ces A and B.

Th�s module has �ntroduced you to the concept of a bus�ness plan and assoc�ated processes and the relevance to the corporate strateg�c d�rect�on of Queensland Health.

Module 2 w�ll descr�be how to develop a serv�ce prof�le (establ�sh�ng demand), �nclud�ng def�n�ng the a�m and object�ves of the serv�ce and how to undertake an env�ronmental analys�s.

The Business planning framework: a tool for nursing workload management �s �llustrated below.

• Aims

• Objectives

• Environmental analysis

• SWOT analysis

• Activity


• Other factor

• Routine monitoring of performance against the plan

• Scorecard reporting

• Analysis of the balance of demand for services/activity with resources allocated

Balance:

• Service demand

• Activity


• Other factors

With: Resource allocation (Supply)


Allocation

Service Demand






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Module2:Developaserviceprofile

2.1 Introduction

2.2 Objectives

2.3 What is a service profile?

2.4 Identifying the aim

2.5 Developing objectives

2.6 Describing the present service

2.7 Environmental analysis

2.8 Strength, weakness, opportunity, threat analysis





Allocation

Service Demand


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2.1 IntroductionDevelop�ng a serv�ce prof�le (demand) �s the next stage �n the development of a bus�ness plan. Module 2 w�ll outl�ne how to �dent�fy the a�m, develop the object�ves and descr�be the serv�ce. Add�t�onally, a comprehens�ve descr�pt�on of external and �nternal env�ronmental factors that may �mpact on the serv�ce �s �ncluded. The process of explor�ng env�ronmental factors and group�ng them �nto categor�es of strengths, weaknesses, opportun�t�es or threats �s also expla�ned.

The �n�t�al serv�ce prof�le developed by a cost centre �s part of the process to �nform the �n�t�al budget b�d or ‘proposed serv�ce prof�le’. Follow�ng d�scuss�on and negot�at�on, an agreed budget for the new f�nanc�al year �s f�nal�sed. Once the agreed budget �s f�nal�sed and the level of serv�ce agreed, the serv�ce prof�le should be rev�ewed and amended per�od�cally to reflect the budget allocat�on. The f�nal document �s recogn�sed as the ‘agreed serv�ce prof�le’. It �s �mportant to remember that the serv�ce prof�le �s only one step �n the development of a bus�ness plan.

Module 3 w�ll art�culate a staged approach to expla�n�ng the appl�cat�on of var�ous report�ng mechan�sms necessary to establ�sh the cost of serv�ces requ�red.

2.2 Objectives On complet�on of th�s module, the reader/workshop part�c�pant w�ll be able to:

1. Ident�fy the budget process for the�r d�str�ct/organ�sat�on

2. Develop a proposed serv�ce prof�le for the new f�nanc�al year b�d

3. Outl�ne the a�ms and object�ves of the serv�ce

4. Descr�be the current serv�ce �nclud�ng recent ach�evements and pr�or�ty areas for serv�ce development

5. Summar�se the �nternal and external env�ronmental factors �mpact�ng on the serv�ce

6. Class�fy the env�ronmental factors accord�ng to the categor�es of Strength, Weakness, Opportun�ty and Threat (SWOT)

7. F�nal�se an agreed serv�ce prof�le that reflects the agreed, negot�ated annual operat�ng budget and act�v�ty level for the f�nanc�al year

2.3 What is a service profile?Develop�ng a serv�ce prof�le �s the f�rst step �n the bus�ness plann�ng process. Th�s �ncludes descr�b�ng the role and funct�on of the serv�ce by:

• stat�ng the a�m of the serv�ce • def�n�ng the object�ves of the serv�ce • systemat�cally analys�ng the �nternal and external env�ronment • complet�ng a SWOT (strength, weakness, opportun�ty, threat) analys�s.


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In develop�ng the serv�ce prof�le, �t �s �mportant to reflect on how your serv�ce �s al�gned w�th the corporate strateg�c d�rect�on of Queensland Health. What goals of the corporate plan �s your serv�ce meet�ng? Are you del�ver�ng core serv�ces or serv�ces other than core serv�ces? It �s �mportant to ensure that the act�v�t�es undertaken by the serv�ce are address�ng the goals and strateg�es of Queensland Health so that resources are used appropr�ately.

2.4 Identifying the aimQueensland Health has a strateg�c plan stat�ng the m�ss�on statement and key outcomes to be ach�eved dur�ng the des�gnated t�meframe. The current m�ss�on statement for Queensland Health �s ‘Creating dependable health care and better health for all Queenslanders’. When develop�ng a bus�ness plan at a local serv�ce level, the a�m of the serv�ce needs to be clearly �dent�f�ed. Th�s a�m must be cons�stent w�th the d�rect�on of Queensland Health.

State the a�m of your serv�ce �n a succ�nct, broad sentence, descr�b�ng how your serv�ce contr�butes to ach�ev�ng the goals of Queensland Health.

The follow�ng a�m �s an example appl�cable to a card�ac serv�ce:

To prov�de hol�st�c care for card�ology pat�ents, ut�l�s�ng a coord�nated mult�d�sc�pl�nary approach, result�ng �n opt�mal pat�ent outcomes.

The a�m of the serv�ce should be �n l�ne w�th that of the Queensland Health current strateg�c d�rect�on.

2.5 Developing objectivesThe object�ves of the serv�ce need to flow from the a�m. They are statements �nd�cat�ng the key outputs for the serv�ce to ach�eve and therefore form a bas�s for assess�ng the performance of the organ�sat�on. The object�ves of the serv�ce w�ll need to be al�gned to corporate goals. In develop�ng object�ves, cons�der past non-ach�evements of the serv�ce and �ncorporate any new act�v�t�es or programs that need to be undertaken. Ensure the stated object�ves are:

• easy to understand • spec�f�c • real�st�c and ach�evable • t�me or�ented • outcome focused • measurable • pr�or�t�sed.

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Two examples of serv�ce object�ves are:

1. Prov�de pre/post care for pat�ents undergo�ng �ntervent�onal/d�agnost�c procedures �n the card�ac catheter laboratory over the next 12 months.

2. Implement the rev�ewed card�ac pat�ent educat�on program w�th�n s�x months.

Object�ves of the serv�ce must rema�n �n l�ne w�th the a�m of the serv�ce and the current Queensland Health Strategic Plan.

2.6 Describing the present serviceNow descr�be the present serv�ce (or the serv�ce be�ng planned). Th�s �ncludes:

• serv�ce locat�on (geograph�cal and phys�cal) • serv�ce boundar�es (geograph�cal) • recogn�sed type of serv�ce (eg. a card�ac serv�ce) • funct�ons of the serv�ce • current role del�neat�on/Clinical Service Capability (Framework).

Reference to past comm�tments that were not ach�eved and pr�or�t�es for future development m�ght also be �ncluded �f they are cons�dered valuable �n the context of the bus�ness plan.

Activity

1. What �s the a�m of your serv�ce? 2. What are the object�ves of your serv�ce? 3. Descr�be your serv�ce, �nclud�ng locat�on, type and level. What s�gn�f�cant

ach�evements were made �n the last 12 months? 4. L�st the current pr�or�t�es for serv�ce development (th�s may change once you

have undertaken an env�ronmental and SWOT analys�s).


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2.7 Environmental analysisInternal and external env�ronmental factors can affect the funct�ons of the serv�ce. The �mpact, or potent�al �mpact, of any of these factors on the serv�ce, and therefore nurs�ng workloads, can be �dent�f�ed by systemat�cally analys�ng the serv�ce env�ronment. Understand�ng the env�ronmental factors affect�ng the serv�ce ass�sts when mak�ng a comparat�ve analys�s w�th other serv�ces and benchmark�ng.

2.7.1 Internal factors

Internal factors are those the serv�ce can potent�ally �nfluence. There �s a comprehens�ve l�st of �nternal env�ronmental factors that can �mpact on the serv�ce, and these have been categor�sed under four head�ngs:

1. Structural

2. Human resource management

3. Informat�on technology management

4. Performance.

1. Structural–theenvironmentinwhichtheservicesaretobedelivered.

Location and size

– Descr�be the phys�cal env�ronment �n wh�ch the serv�ce ex�sts. - What factors can �mpact on the amount of nurs�ng resources requ�red? For example,

remote areas where transport �s d�ff�cult to obta�n can delay the d�scharge of pat�ents; the s�ze of the local�ty serv�ces can affect commun�ty and outreach serv�ces (travell�ng d�stances and t�me).

Design of facility

– The des�gn of the fac�l�ty can �mpact on nurs�ng costs. Geograph�cally �solated un�ts may �ncur h�gher f�xed nurs�ng costs by requ�r�ng a m�n�mum staff�ng level that �s far greater than pat�ent care requ�rements.

Services within facility

– What serv�ces are located w�th�n the fac�l�ty?

Organisation and unit structural design

– Does the d�str�ct/un�t structural des�gn support the serv�ce to be del�vered? – The larger organ�sat�ons w�th�n Queensland Health may have matr�x structures where

staff have respons�b�l�t�es to both operat�onal and profess�onal leaders. Th�s can create confl�cts of �nterests �n dec�s�on mak�ng.

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Cost centre structure

The structure of the serv�ce may compr�se one or more un�ts/cost centres.

– Do the number, s�ze and type of cost centres meet the current need for report�ng? Are there too many or too few cost centres?

– Do these reflect the needs of the serv�ce and serv�ce managers?

Structure of the service

– What �s the structure of the serv�ce? – What teams are �nvolved �n serv�ce del�very? – What are the roles, respons�b�l�t�es and accountab�l�t�es of team members? – What are the report�ng relat�onsh�ps of team members?

Nursing structure

– What are the number, roles and funct�ons of all categor�es of nurs�ng staff? – What are the accountab�l�t�es of nurs�ng staff? – What �mpact does the nurs�ng structure have on the cl�n�cal and non-cl�n�cal workload? – Model of care/serv�ce opt�ons.

A ‘model of care’ can be descr�bed as a as a mult�faceted concept that broadly def�nes the way health serv�ces are del�vered at un�t, d�v�s�on or whole of serv�ce level. An example of a model of care �s the Queensland Health Integrated Mental Health serv�ce.

Current model of care

– Is the current model of care al�gned to the health care requ�rements of the local commun�ty?

– What are the outcomes for pat�ents/cl�ents? – Is there good ev�dence to support the current model of care? - Does the ex�st�ng structure support the model of care?

Alternative models of care

– Are there other models of care preferred �n terms of econom�c effect�veness and pat�ent/ cl�ent outcomes?


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2. Human resource management

Leadership and management

– Descr�be the env�ronment �n wh�ch the serv�ce ex�sts.

Leaders are needed to ach�eve the object�ves and d�rect�on set of a work un�t or serv�ce. Leadersh�p relates to the ab�l�ty to mot�vate and gu�de others �n a spec�f�c d�rect�on. Management encompasses leadersh�p but also �ncludes the tasks of plann�ng, organ�s�ng, controll�ng and commun�cat�ng �n a manner that �nfluences and makes opt�mum use of resources.

In order to opt�m�se outcomes, leaders and managers of the whole serv�ce (and �nd�v�dual un�ts w�th�n the serv�ce) need to cons�der and be al�gned to:

– What are the sk�lls of the leaders/managers �n the organ�sat�on? – Do they have the level of knowledge requ�red to ach�eve the outcomes? – Who �s accountable for the serv�ce?

Organisational culture

Leadersh�p also �nfluences organ�sat�onal culture. Leaders need to assess the level of trust, commun�cat�on, devolvement and comm�tment to change that ex�sts w�th�n the�r serv�ce.

Core staff working in the service – categories, scope of practice, skills

Th�s refers to those staff members e�ther d�rectly employed to work �n the serv�ce or rostered to work �n the serv�ce. The�r pr�mary roles and respons�b�l�t�es are w�th�n the serv�ce.

– What are the categor�es of core staff work�ng �n the serv�ce? – What are the numbers/FTE, role and funct�ons of: • med�cal staff • all�ed health staff • nurs�ng staff – reg�stered nurses (management and cl�n�cal), enrolled nurses,

ass�stants �n nurs�ng • adm�n�strat�ve staff • operat�onal staff. – What �s the current scope of pract�ce of the cl�n�cal staff? – What potent�al �s there to advance the scope of pract�ce? – What opportun�t�es are there for staff to develop further sk�lls? For example, through

educat�on, rotat�on through work areas, and secondment to other serv�ces. – How many of the staff are pract�s�ng at the follow�ng levels: • nov�ce • advanced beg�nner • competent • prof�c�ent • expert – Do the competency levels of the staff match pat�ent/cl�ent needs?

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Support staff

Th�s refers to staff who are not d�rectly employed by the serv�ce, and not rostered exclus�vely to the serv�ce. They have roles and respons�b�l�t�es across mult�ple serv�ces that may �mpact on serv�ce del�very. For example:

• all�ed health • cler�cal/adm�n�strat�ve • bus�ness support • operat�onal • volunteers • spec�al�st nurses or rov�ng CNCs. – What are the numbers, hours of work, sk�lls and dut�es of these staff? – What dut�es/act�v�t�es �n the serv�ce do these staff perform that �mpact on the workload

of nurses? For example, support personnel may perform bed clean�ng; however th�s may be l�m�ted to 0800 – 1700, Monday to Fr�day only. Cler�cal staff prov�de ward recept�on and ma�n recept�on work between the hours of 0800 – 1630 Monday to Fr�day. In smaller organ�sat�ons, the phones may be sw�tched through to the ward from 16.30.

– Are nurses perform�ng any other tasks that could be done by other categor�es of staff?

Teaching and training/development commitments/needs

– What �s the teach�ng role of the serv�ce? – What agreements w�th un�vers�t�es are �n place or under development? – What �s the �mpact of these agreements? For example: • costs • opportun�t�es for fund�ng – What cl�n�cal placements are requ�red? – What structures/processes are �n place to support the teach�ng requ�rements/

comm�tments? – What t�me allocat�on �s requ�red for act�v�t�es such as: • or�entat�on of new staff • or�entat�on of rel�ef staff • mandatory credent�al�ng • opt�onal credent�al�ng. – What t�me has been allocated prev�ously? Was th�s t�me suff�c�ent? – Are needs l�kely to change?


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Other indirect patient/client care commitments

– What management/adm�n�strat�ve respons�b�l�t�es do team members have? For example: • portfol�o work (such as NO2 spec�al projects) • qual�ty �mprovement act�v�t�es, accred�tat�on • research.

3.Informationtechnology/management

Information technology (clinical and management)

– What level of �nformat�on technology �s �n place? – What �s the access to systems? – How rel�able are the systems eg. are nurs�ng staff requ�red to �nput �nformat�on after

per�ods of downt�me – What plans are there for future developments �n IT systems?

Information management

– What �nformat�on sources and systems are �n place? – Is there suff�c�ent �nformat�on prov�ded? – What access �s there to th�s �nformat�on? – Who collects/suppl�es the �nformat�on? – How t�mely and accurate �s the �nformat�on from these systems? – Do staff know how to use the �nformat�on?

4. Performance

Deta�led �nformat�on to ass�st w�th the assessment of the organ�sat�on’s past performance �s conta�ned w�th�n Modules 3 and 4.

Cons�der the performance of your serv�ce for eff�c�ency, effect�veness and economy. Th�s requ�res you to rev�ew:

• f�nanc�al performance aga�nst budget • performance aga�nst des�red outcomes.

In rev�ew�ng these �tems, major areas to focus on are complex�ty of care requ�rements, act�v�ty and f�nanc�al and serv�ce qual�ty.

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Comparativeanalysis

It can be helpful to compare key performance factors w�th a s�m�lar serv�ce focus�ng part�cularly on the resources used by other serv�ces. Ideal serv�ces for comparat�ve purposes are those w�th a s�m�lar pat�ent/cl�ent complex�ty and act�v�ty level.

• Patient/client complexity/acuity

Pat�ents and cl�ents d�ffer �n the amount and complex�ty of resources requ�red to care for them. Casem�x �s the term used to descr�be the d�fferent categor�es of pat�ents.

The term ‘acu�ty’ �s used to descr�be the sever�ty of �llness of a pat�ent/cl�ent. The h�gher the acu�ty, the greater the amount/complex�ty of resources requ�red to care for them.

– For hosp�tal un�ts, what are the major d�agnos�s related groups (DRGs) of your pat�ents?

– For commun�ty based serv�ces, what �s the complex�ty of the care needs of your cl�ents?

– For the serv�ces relat�ng to the bus�ness plan process, what are the nurs�ng care needs (measured �n hours and m�nutes of care per day) of the most s�gn�f�cant DRGs (for example, Top 20 DRGs)? The nurs�ng care requ�rements for groups of pat�ents can be used as an �nd�rect measure of pat�ent acu�ty/ complex�ty. Such �nformat�on can be obta�ned from a Pat�ent Dependency System �f one �s used.

• Patient/client activity

Key act�v�ty data for your serv�ce should be rev�ewed. Act�v�ty areas to cons�der are l�sted �n the follow�ng table.

Table 2.1: Activity factors

Note – these are some of the major act�v�ty areas that need to be exam�ned by the serv�ce. However, w�th�n �nd�v�dual un�ts there may be other types of act�v�ty that need to be rev�ewed. Cons�der:

– What were the trends �n the act�v�ty areas l�sted above over the last two to three years? – Is any s�gn�f�cant change ant�c�pated?

Module 3 conta�ns more �nformat�on on �nterpret�ng reports and forecast�ng.

• Number of separat�ons• We�ghted separat�ons• Total occup�ed beds• Average occupancy• Occas�ons of serv�ce• Emergency department presentat�ons• Numbers per tr�age category• Number of operat�ons

• Number of day surgery cases• Outpat�ents occas�ons of serv�ce• Number of b�rths• Retr�evals• Back-transfers• Home v�s�ts• Number of group sess�ons, numbers of

attendees at group sess�ons


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• F�nanc�al outcomes – What were the f�nanc�al outcomes; over-budget, under-budget, trends �n costs?

• Qual�ty of serv�ce – current/preferred/evaluat�on methods – What qual�ty measures are currently �n place? –What �s the current performance of the organ�sat�on as measured aga�nst cl�n�cal,

f�nanc�al and employee �nd�cators? – Is current performance acceptable?

2.7.2 External factors

The external env�ronment cons�sts of cond�t�ons and forces that are usually beyond the control of the serv�ce. These can be categor�sed under f�ve head�ngs.

1. Pol�cy/legal factors

2. Econom�c factors

3. Soc�al factors

4. Technolog�cal factors

5. Research and ev�dence based pract�ce.

The follow�ng external env�ronmental factors can �mpact on the un�t or serv�ce.

1. Policy/legalfactors

Commonwealth direction/policies/funding

Current Commonwealth d�rect�on and pol�c�es usually �nclude the sett�ng of Nat�onal Health Pr�or�t�es. These are often areas of health care that w�ll rece�ve add�t�onal fund�ng.

Activity

L�st the �nternal �mpacts that are �nfluenc�ng your serv�ce under the follow�ng major head�ngs:

1. Structure 2. Human resource management 3. Informat�on technology/management 4. Performance.

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Queensland Health direction/policies/initiatives

For �nformat�on on these see:

– The current Queensland Health Strategic Plan and Queensland Statewide Health Services Plan

– Serv�ce agreements, wh�ch outl�ne the funds allocated to the HSD and the correspond�ng serv�ce and corporate respons�b�l�t�es

– Other Queensland Health pol�c�es, plans and proposed plans. Note that some pol�c�es w�ll have greater �mpact on nurs�ng resourc�ng, eg. ‘Fam�ly Fr�endly’ prov�s�ons

– Cap�tal works programs – Other relevant corporate documents.

Legislation

Examples of leg�slat�on that are relevant to health serv�ces �nclude:

– Health Services Act 1991 – Workplace Relations Act 1997 – Nursing Act 1992 – Health (Drugs and Poisons) Regulation 1996.

Licensing organisations

– How do the requ�rements of the nurs�ng, med�cal and all�ed health reg�strat�on boards �mpact?

Professional groups – Do groups such as the Austral�an College of Operat�ng Room Nurses (ACORN) or the

Austral�an College of M�dw�ves Inc. (ACMI) mandate standards of pract�ce and/or tra�n�ng �mpact�ng on nurs�ng resources?

Industrial groups/issues

– Examples are award cond�t�ons, enterpr�se barga�n�ng agreements, or var�at�ons across the cont�nuum of care.

Education imperatives

– What educat�onal �mperat�ves are �mpact�ng on the serv�ce? For example, �s there a h�gh level of demand for tert�ary/TAFE cl�n�cal placements (for any of the health profess�ons) w�th�n the organ�sat�on?


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2. Economic factors

International/national economy

The state of the �nternat�onal and nat�onal economy w�ll �nfluence fund�ng pol�c�es and expend�ture patterns. For example, the cost of suppl�es �mported from overseas can be affected by the exchange rate.

Public/private interface

– Are there serv�ces s�m�lar to yours prov�ded by a local pr�vate hosp�tal? – Does th�s have an �mpact on your act�v�ty levels? – What �s the �mpact of the Queensland co-locat�on pol�cy?

Private health care providers – general practitioners, midwives, allied health, domiciliary nursing agencies?

–`What are the role, type and level of serv�ces currently prov�ded by these groups? – Are there plans for th�s to change?

Capital works

– What future cap�tal works are planned?

3. Social factors

Demographics

The demograph�cs of the populat�on be�ng serv�ced w�ll determ�ne the types of health serv�ces requ�red. For example:

– Is �t a young or age�ng populat�on? – What �s the growth rate of the populat�on (by age groups)? – What �s the�r soc�o-econom�c prof�le? – Are the health needs of the commun�ty matched w�th the nat�onal and state pr�or�t�es for

health outcomes?

Cultural

– How d�verse �s the populat�on? – Is there a h�gh proport�on of Ind�genous or ethn�c persons?

Morbidity/mortality

– What are the local morb�d�ty/mortal�ty and d�sease trends of your populat�on base? – Do local �ndustr�es �mpact on the serv�ce?

The demograph�cs of the populat�on be�ng serv�ced can �nfluence the resources requ�red. For example, a large non-Engl�sh speak�ng populat�on w�ll requ�re the use of �nterpreter serv�ces. Organ�s�ng these serv�ces consumes resources and the actual t�me taken to g�ve nurs�ng care may be �ncreased by hav�ng to use �nterpreters.

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Community expectations

– What does the local commun�ty expect from �ts health serv�ces? – Are these expectat�ons real�st�c and/or del�verable? – What �s the�r level of awareness of the health serv�ces they requ�re and that are prov�ded? – What �nvolvement does the commun�ty have �n local health serv�ce plann�ng?

Workforce issues

– Are there enough nurses w�th the sk�lls requ�red for your health serv�ce? – What other workforce recru�tment and retent�on �ssues are there? – Are there d�ff�cult�es w�th attract�ng med�cal staff that �mpact on the workload of the

nurs�ng staff? – What �s the ut�l�sat�on of casual staff? – Is there a chang�ng workforce prof�le, eg. age�ng workforce? – What are the l�nks to the d�rect�on of D�str�ct and Area Health Serv�ce workforce

plann�ng?

4. Technological factors

– What �s the �mpact of technology on the serv�ce? For example, e-commerce, �nternet, advances �n med�cal equ�pment capab�l�ty, telemed�c�ne, WAN?

5. Research and evidence based practice

What research developments are �mpact�ng, or w�ll �mpact on serv�ces? For example:

– Are you requ�red to take part �n data collect�on? – What research act�v�t�es/projects �s your serv�ce plann�ng to undertake? – Is th�s affect�ng your workload? – To what extent have you �ncorporated ev�dence based pract�ce �n your serv�ce? – What resources are ava�lable to support research?

Activity

L�st the external env�ronmental factors that are �nfluenc�ng your serv�ce under the follow�ng head�ngs:

1. Pol�cy/legal 2. Econom�c 3. Soc�al 4. Technolog�cal 5. Research and ev�dence based pract�ce.


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Reviewofenvironmentalanalysis

The env�ronmental analys�s serves as a gu�de for determ�n�ng the long-term d�rect�on of the serv�ce. As such, �t �s not always necessary to undertake a comprehens�ve analys�s each year. However, the analys�s needs to be rev�ewed annually to:

• make adjustments as s�gn�f�cant changes �n the env�ronment occur • serve as a bas�s for rev�ew of where the serv�ce status.

2.8 Strengths, weaknesses, opportunities and threats analysis Once the factors �mpact�ng on the serv�ce have been �dent�f�ed, these can be assessed under the categor�es of strength, weakness, opportun�ty or threat. Th�s �s referred to as a SWOT analys�s.

Strength

A strength �s a d�st�nct�ve competence of the serv�ce.

Weakness

A weakness �s a def�c�ency that l�m�ts the performance of the serv�ce.

Strengths and weaknesses are �dent�f�ed when analys�ng the �nternal bus�ness dr�vers/ �mpacts. Weaknesses h�ghl�ght where organ�sat�onal development may be requ�red. The follow�ng example shows �nternal strengths and weaknesses �n an Intens�ve Care Un�t.

Example 2.1: Internal strengths and weaknesses �n an Intens�ve Care Un�t

Opportunity

An opportun�ty �s a factor external to the serv�ce that presents an area of potent�al for the serv�ce.

Threat

A threat �s an unfavourable factor �n the external env�ronment.

Opportun�t�es and threats are �dent�f�ed when analys�ng the external env�ronment to determ�ne how these may �mpact on the serv�ce when try�ng to ach�eve �ts object�ves. Example 2.2 shows an opportun�ty and a threat to a Commun�ty Health Serv�ce.

Strength

60% of the nurs�ng staff w�ll have a postgraduate qual�f�cat�on �n cr�t�cal care.

Weakness

80% of the mon�tor�ng equ�pment �s s�x years old and breaks down frequently.

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Example 2.2: External opportun�ty and threat to a Commun�ty Health Serv�ce

Note that env�ronmental factors can only be one of the four categor�es of strength, opportun�ty, weakness or threat.

2.9 Agreed service profileFollow�ng d�scuss�on and negot�at�on, an agreed budget for the new f�nanc�al year �s f�nal�sed w�th the management team oversee�ng the area/cost centre.

Once the agreed budget �s f�nal�sed and the level of serv�ce �s agreed, the ‘Proposed serv�ce prof�le’ should be rev�ewed and amended to reflect the budget allocat�on. These amendments are necessary to ensure that the prof�le reflects the ava�lable resources and serv�ce pr�or�t�es.

As the level of activity agreed in the service profile is the driver of nursing workloads, the appropriate allocation of nursing resources (FTE) to the work unit will be required. If agreement is not reached to allocate the required nursing FTE identified, negotiation will then need to focus on the adjustment to the level of activity possible if the resources are not allocated. If the activity levels are not renegotiated, it should be identified that the consequence will be increased nursing workloads and a budget overrun or deficit due to staffing costs associated with contracting external staff to manage the activity or service demand.

The f�nal document �s recogn�sed as the ‘Agreed serv�ce prof�le’ and should be s�gned off by sen�or management and the cost centre manager.

Th�s module has outl�ned the development of a serv�ce prof�le have to �dent�fy the a�ms and object�ves of the serv�ce, and expla�ned the undertak�ng of an env�ronmental analys�s �n l�ne w�th Queensland Health �n�t�at�ves. The next module descr�bes nurs�ng costs, budgets and the types of reports that w�ll be analysed when manag�ng nurs�ng resources.

Opportunity

The Government recently announced a ser�es of grants for �mprov�ng serv�ces to res�dents of caravan parks.

Threat

HACC serv�ces are funded only for g�ven t�meframes, eg. one year, therefore permanent recru�tment to these pos�t�ons cannot occur.

Activity

Categor�se the external and �nternal env�ronmental factors for your serv�ce �nto one of the follow�ng categor�es:

Strength Weakness Opportun�ty Threat


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Module 3: Costs, reports and budgets

3.1 Introduction

3.2 Objectives

3.3 Types of staffing costs

3.4 Patient acuity/activity

3.5 Activity

3.6 Reports

3.7 Budgets





Allocation

Service Demand


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3.1 Introduction In order to develop a budget for nurs�ng serv�ces, �t �s essent�al to understand how a budget �s bu�lt up, the types of costs occurr�ng and the measures of acu�ty and act�v�ty. Var�ous reports need to be rev�ewed and used �n the development of the budget and �n turn, the development of the bus�ness/operat�onal plan. A br�ef descr�pt�on of the d�fferent types of budgets, some examples and the role of nurses �n budget�ng w�ll be descr�bed �n th�s module.


1. Understand the compos�t�on of a budget – types of staff�ng costs and common term�nology.

2. Expla�n acu�ty and l�st key act�v�ty factors for the serv�ce.

3. Ident�fy the data that �nforms the compos�t�on of a budget and the reports that are generated from that data.

4. Descr�be var�ance analys�s and trends together w�th the�r �mportance �n val�dat�ng and manag�ng a budget.


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3.3 Types of staffing costs and common terminology

A number of cost types can be used to descr�be budgets.

Typesofcosts Explanation Examples

Fixed Costs Costs that do not change regardless of other influences

NUM = 1.0 FTE, minimum staffing on night duty (2 per shift), Nurse Educators

Variable Costs Costs that vary with changes in level/type of activity

Cost of agency nurses, increased nursing hours during periods of high demand eg. seasonal

Semi-Variable Costs Costs that are fixed to a certain level of service delivery but will increase if the pre-determined level is exceeded.

If one extra bed is opened in a ward, existing nursing hours may be able to absorb the increased activity. If more than 2 beds are opened, extra nursing hours may be required (depending on acuity)

Total Cost Sum of fixed cost + variable costs + semi-variable cost

Total cost of staffing

Direct Clinical Hours –convertedtocosts

The nursing hours utilised to support direct care to patents converted to costs

The nurse who is involved in planning and assessment of patient care provides direct care

In-direct Clinical Hours–convertedtocosts

The nursing hours utilised to support the delivery of direct care – converted to costs

Staff education, clinical facilitation, quality coordination, staff attending workshops, AIN’s making beds, NUM management time

Total ProductiveHours–convertedtocosts

Sum of Direct and Indirect Clinical Hours – converted to costs

Cost of NUM + CNs + RNs + ENs + AINs + nurse educator + any other nursing roles working on that roster

Non-productive Hours–convertedtocosts

Those hours paid to nurses that are over and above Total Productive Hours. Called ‘on-costs’ for the purpose of costing staff.

Funded sick leave, and annual leave

TOTAL NURSING LABOUR COST = Total Product�ve hours costs + Non-product�ve hour costs

Var�at�ons �n def�n�t�ons for product�ve and non-product�ve nurs�ng hours may occur across organ�sat�ons/fac�l�t�es. When th�s occurs, �t �s cr�t�cal that the organ�sat�on/fac�l�ty and assoc�ated work un�ts have �nternal cons�stency w�th the def�n�t�ons. Add�t�onally, nurs�ng staff requ�re a full understand�ng of what the def�n�t�ons mean, part�cularly for budget preparat�on and report�ng.

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Example 3.1 shows nurs�ng costs for a un�t as extracted from a Queensland Health general ledger (f�nanc�al) report. For another example of a report, see Append�x D.

Example 3.1: Med�cal Ward – Labour – Internal Nurs�ng Costs

3.4 Patient acuity Acu�ty �s a measure of pat�ent complex�ty and can ass�st nurses �n �dent�fy�ng and plann�ng resources requ�red to meet the prov�s�on of care. Acu�ty can be cons�dered as a qual�tat�ve and/or a quant�tat�ve measure.

Qualitative

A reflect�on of acu�ty levels �s �ntegral to dec�s�ons relat�ng to nurs�ng care and the allocat�on of resources requ�red for the prov�s�on of opt�mal pat�ent care. The sk�lled nurse makes these dec�s�ons da�ly by draw�ng on the�r cl�n�cal knowledge, prev�ous exper�ence and an understand�ng of the sk�lls requ�red to meet pat�ents’ needs. Generally as pat�ent acu�ty �ncreases, there should be a rev�ew of the resources needed to care for the pat�ent/cl�ent.

A reflect�on of acu�ty �s embedded �n cl�n�cal paths, care plans and treatment orders. Both qual�tat�ve and quant�tat�ve measures are conta�ned �n the Pat�ent Dependency Systems and demand dr�ven workforce tools used �n some organ�sat�ons. In areas such as mental health, leg�slat�on governs some aspects of pat�ent acu�ty. For example, a pat�ent requ�r�ng su�c�de watch �s on a ‘one nurse to one pat�ent’ rat�o. Another example of the qual�tat�ve aspect of pat�ent acu�ty relates to pat�ents �n the early phase of a card�ac rehab�l�tat�on program, who m�ght �n�t�ally requ�re more �ntens�ve support. It would be expected that th�s support would reduce over the course of the program.

Quantitative

One method used to determ�ne pat�ent acu�ty �s the ut�l�sat�on of the d�agnos�s related group (DRG) class�f�cat�on system. Th�s system class�f�es d�seases/cond�t�ons �nto l�ke groups. Every acute pat�ent adm�tted to a Queensland Health hosp�tal �s ass�gned a DRG upon separat�on (d�scharge, death or transfer).

General Ledger Account Code

Item MonthlyExpenditure$’s TypeofCost

500030 Salaries & Wages 86,005 Productive

501030 Overtime 416 Productive

502030 Penalties 18,069 Non-productive

502130 Shift Allowances 2,517 Non-productive

502930 Other Allowances 229 Non-productive

5035302 Sick Leave 3,589 Non-productive

503630 Maternity Leave 0 Non-productive

503030 Annual Leave nursing 11,121 Non-productive


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Diagnosis related group information

A select�on of the current vers�on of the AR-DRGs (Austral�an Ref�ned D�agnos�s Related Groups) and cost we�ghts are shown here as examples.

Example 3.2

Source: Queensland Health Hosp�tal Benchmark�ng Pr�ces Model 2002/2003, DRG Parameters and Payments: Group A Hospitals, pp. 29-50.

Determination of Cost Weights

Each DRG has an assoc�ated ‘cost we�ght’ wh�ch �nd�cates the use of resources �n car�ng for the pat�ent. Each separat�on �s then mult�pl�ed by �ts ass�gned cost we�ght to g�ve a we�ghted separat�on. Th�s forms part of the data to �nform the nurs�ng hours requ�red �n the un�t.

The current Queensland Health Casem�x Fund�ng Model 2007/08 Techn�cal Supplement (ava�lable on QHEPS), �nforms the determ�nat�on of We�ghted Act�v�ty Un�ts (WAUs) wh�ch are appl�ed to both �npat�ent and outpat�ent act�v�ty. Th�s �n turn w�ll �nform the BPF. D�str�cts are allocated act�v�ty targets, expressed as WAUs, as part of the budget process. The WAU �s a measure of the relat�ve value across all of the var�able components of the Casem�x Fund�ng Model (CFM), and �s used s�m�larly to the prev�ous We�ghted Separat�on. We�ghted Separat�ons were only appl�ed to acute �npat�ents, whereas the WAU appl�es to all CFM pat�ent types �nclud�ng outpat�ents.

AR-DRG Description Public Cost Weight(GroupAHospitals)

Number of Separations

Weighted Separations

60C Acute leukaemia w/o cat/sev CC 0.60 10 6

Q61C Red blood cell disorders w/o cat/sev CC 0.40 10 4

J62A Malignant breast disorder A>69 W CC 3.00 10 30

G65B GI Obstruction w/o CC 0.75 10 7.5

G01B Rectal Resection w/o catastrophic CC 4.45 10 44.5

F20Z Vein Ligation and Stripping 1.00 10 10

Total 10.2 60 102

There are problems �nherent �n the analys�s of th�s data, where serv�ces treat pat�ents �n ‘acute’ and ‘non-acute’ ep�sodes of care, as cost we�ghts per DRG can only be appl�ed to ‘acute’ separat�ons.

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Examples of factors used to calculate quant�tat�ve value of acu�ty �n Queensland Health are as follows:

• average length of stay for the part�cular DRG • number of separat�ons (d�scharges) converted to ‘we�ghted separat�ons’ • �f occup�ed bed days are constant but WAUs for �npat�ent act�v�ty have �ncreased, there

may be a requ�rement to �ncrease NHHPD.

A we�ghted separat�on �s a method of quant�fy�ng pat�ent d�scharges to reflect the cost and complex�ty of the pat�ent’s treated cond�t�on. They are only appl�ed to pat�ents adm�tted �n ‘acute’ ep�sodes of care, and exclude pat�ents changed �nto ‘non-acute’ ep�sodes of care. Examples of non-acute case types �nclude rehab�l�tat�on and pall�at�ve care pat�ents.

3.5 Activity Act�v�ty �s the work performed to produce outputs. In nurs�ng there w�ll be peaks and troughs �n act�v�ty. It �s �mportant to analyse these peaks and troughs �n order to ach�eve a balance between supply and demand.

Key measures of act�v�ty �nclude the follow�ng:

• number of separat�ons (d�scharges, transfers, deaths) • we�ghted separat�ons • total occup�ed beds • average occupancy • occas�ons of serv�ce • emergency department presentat�ons • numbers per tr�age category • number of operat�ons • day surgery cases • outpat�ents occas�ons of serv�ce • number of b�rths • retr�evals • home v�s�ts • cl�ent separat�ons • number of group sess�ons • number of cl�ents attend�ng group sess�ons.

Act�v�ty factors need to be mon�tored and rev�ewed as act�v�ty �s one of the measures of organ�sat�onal performance. Wh�le the l�sted measures are the major ones to be cons�dered on a whole of organ�sat�on bas�s, w�th�n �nd�v�dual serv�ces, there may be other types of act�v�ty that need to be rev�ewed.


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Therefore, each un�t should develop a m�n�mum data set wh�ch �s a l�st�ng of the factors cons�dered to be �mportant �nd�cators of workload for that part�cular serv�ce. For example, the �nformat�on collected �n the operat�ng room w�ll be d�fferent from a surg�cal ward or a commun�ty health serv�ce.

3.6 Reports3.6.1 Types of reports

A range of reports/�nd�cators are relevant to serv�ce del�very and the allocat�on of resources. Cost centre managers should rece�ve monthly reports but the format of these reports may vary between organ�sat�ons and d�str�cts, and are �mportant �n the analys�s of var�ance between serv�ces.

Reports/�nd�cators �nclude, but are not l�m�ted to the follow�ng categor�es.

1. Staffing

Staff�ng reports conta�n employee data and can �nclude:

• approved staff�ng levels • leave replacement costs (annual, s�ck, etc.) • sk�ll m�x/category • full-t�me/part-t�me numbers/rat�os • award ent�tlements • casual staff usage • agency staff usage • overt�me • on call usage • leave ent�tlements (annual, s�ck, profess�onal development, parental, long serv�ce, etc.).

Example 3.3: Staff�ng report – Nurs�ng

Jul Aug Sep Oct Nov Dec Jan-05

Total Nursing Labour Expenditure

$383,874 $630,730 $407,748 $368,292 $319,351 $295,187 $293,800

Approved Nursing FTE

53.95 53.95 53.95 53.95 53.95 53.95 53.95

Total Nursing FTE

84.25 90.6 87.48 81.45 73.58 69.42 68.99

Staff�ng data may be reported by fortn�ght or by month.

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2. Financial - labour

F�nanc�al reports show the actual cost for labour by d�sc�pl�ne and type of cost, for example, ord�nary hours, overt�me, annual leave, s�ck leave. F�nanc�al data can be reported by pay fortn�ght or by month, for example an �npat�ent ward budget plan.

3. Activity

Act�v�ty reports prov�de �nformat�on such as the number of separat�ons, occas�ons of serv�ce, cl�ent v�s�ts and length of stay. Areas of act�v�ty that should be rev�ewed are l�sted prev�ously �n Module 3. Act�v�ty reports usually show act�v�ty on a per month bas�s.

4. Casemix

Casem�x reports show �nformat�on about act�v�ty and costs accord�ng to �nd�v�dual DRGs. Casem�x reports w�ll prov�de �nformat�on on the acu�ty of the pat�ents (refer to sect�on 3.4 on acu�ty).

5. Quality

Qual�ty reports �nd�cate the performance of the serv�ce w�th regard to outcomes of the act�v�t�es of the serv�ce. Th�s �nformat�on must be cons�dered along w�th the f�nanc�al �nformat�on �n evaluat�ng the total performance of an organ�sat�on. Th�s top�c �s exam�ned �n more deta�l �n Module 5 – Evaluat�on.

3.6.2 Rev�ew�ng reports

For all reports �t �s �mportant to:

• determ�ne the�r source • �dent�fy the �tems and know the�r def�n�t�on • determ�ne any relat�onsh�ps that may ex�st between the �tems • determ�ne whether they conta�n enough �nformat�on • assess the rel�ab�l�ty of the data: for example, payroll reports should be checked to ensure

that staff have been accurately charged to the r�ght cost centre • note the t�meframe of the report, wh�ch �s part�cularly �mportant when look�ng at the

relat�onsh�ps between reports. Is the report fortn�ghtly or monthly? Cons�der the �mpact of publ�c hol�days occurr�ng �n the t�meframe of the report.

Activity

1. Obta�n current staff�ng, f�nanc�al, act�v�ty, Casem�x and qual�ty reports for your serv�ce.

2. Ident�fy the key �tems as per above.


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Reports should be presented �n order to fac�l�tate trend�ng for analys�s, w�th deta�ls for: • pred�cted/budgeted result • actual result • the current month • year-to-date average • year-to-date total • same month �n prev�ous year.

The reports should be analysed to determ�ne any changes (var�ances) and patterns �n the changes over t�me (trends).

3.6.3 Var�ance analys�s

Var�ance analys�s �s a process of measur�ng the d�fferences between the expected result and the actual result. The var�ance may be descr�bed accord�ng to volume, pr�ce or quant�ty. Var�ances can be descr�bed as favourable or unfavourable. A favourable var�ance for labour costs would be where expend�ture was less than expected, wh�le a var�ance would be descr�bed as unfavourable when labour costs exceeded the budget. Through analys�s, the cause of the var�ance can be determ�ned.

Typesofvariances

Var�ance analys�s �dent�f�es probable or actual reasons for favourable or unfavourable results, eg. �f an �ncrease �n act�v�ty has resulted �n the use of add�t�onal nurs�ng hours above the agreed funded level. The add�t�onal nurs�ng hours and costs are expla�ned through th�s analys�s. If the act�v�ty �ncrease �s est�mated to rema�n at the h�gher level, �t would be appropr�ate to renegot�ate the funded nurs�ng hours �n l�ne w�th adjustments to the bus�ness plan, tak�ng �nto account the �ncreased act�v�ty. Publ�c hol�days occurr�ng dur�ng the t�me per�od of the report are also a var�ance to cons�der when analys�ng the results.

• A f�xed budget assumes a constant level of act�v�ty. A f�xed budget can have a total var�ance. The total variance of a f�xed budget �s the d�fference between the or�g�nal f�xed budget and the actual expend�ture �ncurred. Once the act�v�t�es have occurred, a total var�ance can be calculated. The total var�ance w�ll �nclude volume, pr�ce and quant�ty d�fferences.

• Quantity variance – A quant�ty var�ance occurs when there �s a d�fference �n the number of nurs�ng hours budgeted to care for a g�ven number of pat�ents and the actual number of hours used. Th�s may occur due to an �nab�l�ty to replace staff on s�ck leave.

• Price variance – An example of a pr�ce var�ance �s where one type of cl�n�cal supply �s subst�tuted for another, thereby cost�ng less (or more).

• Volume variance – An example of volume var�ance �s when the number of adm�ss�ons to the Mental Health un�t �s greater than was pred�cted.

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July August September

Budget Actual Variance Budget Actual Variance Budget Actual Variance

OBD 775 775 0 775 775 0 750 700 (50)

Nrs. Hrs 3,875 3,700 (175) 3,875 3,875 0 3,750 3,750 0

$ $77,500 $74,000 ($3,500) $77,500 $80,000 $2,500 $75,000 $75,000 $0

Example 3.4: Var�ances

F�ve nurs�ng hours per pat�ent day at a cost of $20 per hour has been budgeted for �n th�s un�t. The forecast level of act�v�ty �s 25 occup�ed bed days per day each month.

3.6.4 Trend Analys�s

July: the actual number of nurs�ng hours used was less than budgeted for, and the cost of the nurs�ng hours was less; there was no d�fference �n the level of act�v�ty, therefore a quantity var�ance occurred.

August: the budgeted amount of act�v�ty occurred and the number of nurs�ng hours used was as budgeted; however, actual expend�ture �n dollars was greater than budgeted, therefore a price var�ance has occurred.

September: wh�le the actual number of nurs�ng hours used and the cost of the nurs�ng hours were as budgeted for, the level of act�v�ty was less than expected, therefore a volume var�ance occurred.

Actioning variances

1. Determ�ne the absolute and relat�ve s�ze of the var�ance.

2. Is the var�ance large enough to be of concern? Predeterm�ned levels of var�ance requ�r�ng act�on may be �n place. Management by exception �s a method whereby analys�s of var�ances focuses only on those that are s�gn�f�cant.

3. Determ�ne what �s caus�ng the var�ance, that �s, �s �t due to changes �n pr�ce, quant�ty or volume?

4. Is there a trend or �s �t only appear�ng per�od�cally?

5. Determ�ne whether the var�ance �s caused by someth�ng w�th�n your control, eg. �f a s�gn�f�cant var�ance �n nurs�ng hours used has occurred �n your un�t, then you w�ll need to be able to expla�n why �t �s occurr�ng.


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3.6.4 Trend analys�s

Trend analys�s �s used to understand the relat�onsh�p between �tems and groups of �tems over a g�ven per�od of t�me. Trends need to be �dent�f�ed and mon�tored because they w�ll ass�st �n forecast�ng future act�v�ty and resource requ�rements. Hav�ng the �nformat�on presented �n graph�cal form ass�sts w�th �dent�fy�ng trends.

Example 3.5: S�ck leave trend nurs�ng – the number of s�ck leave hours taken as a % of the hours worked for the per�od. For example, �f dur�ng a month 40 hours of s�ck leave were taken and 1000 hours were worked, the s�ck leave versus worked hours would be 4%.

Trends may be occur on a da�ly, weekly, monthly, annual, seasonal or other regular bas�s.

Factors �n trends to be cons�dered �nclude:

• why they ex�st • how they occurred • the degree of change • the relat�onsh�p among the changes.

Trends can �nd�cate:

• �ncreas�ng or decreas�ng act�v�ty at a steady rate • fluctuat�ons due to seasonal factors • areas that requ�re further �nvest�gat�on and act�on, for example, �ncreas�ng s�ck leave.

Annual Sick Leave Trend181614

121086420

July Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun

Sick Leave

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3.6.5 Forecast�ng

Forecast�ng �s a method of determ�n�ng what may happen �n the future, based on analys�s of trends from the past and cons�dered judgement.

Activityandacuity/complexityforecasting

Accurate forecast�ng of act�v�ty and acu�ty/complex�ty levels w�ll ass�st w�th the allocat�on of resources. There are complex stat�st�cal methodolog�es for forecast�ng demand; however, these are outs�de the scope of th�s document.

Past data (a minimum of 12 months) can be analysed to determ�ne the �mpact of factors that cause var�ab�l�ty of demand (act�v�ty) for serv�ces, such as:

• seasonal, eg. w�nter/summer, s�gn�f�cant events held �n rural commun�t�es, peak tour�st t�mes

• school vacat�ons • sen�or med�cal staff annual leave • annual cl�n�cal meet�ngs • publ�c hol�days.

Annual act�v�ty targets set by Queensland Health (outl�ned �n the serv�ce agreement) need to be factored �nto forecast�ng. Once the data has been analysed, act�v�ty levels can be est�mated for the follow�ng year. It �s �mportant to record assumpt�ons made dur�ng the forecast�ng.

Forecast act�v�ty levels prov�de the bas�s for the allocat�on of nurs�ng resources.

Acu�ty levels may be forecast by analys�ng past data, cons�der�ng the future Casem�x of the serv�ce or changes �n cl�n�cal pract�ce.

Activity

What trends can you �dent�fy �n your serv�ce from the reports you obta�ned for the prev�ous act�v�ty?

1. Staff�ng2. Act�v�ty 3. Expend�ture

When exam�n�ng these reports, you need to cons�der whether the changes are occurr�ng on a da�ly, weekly, monthly, annual or seasonal bas�s.


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3.7 Overview of funding model and budgets3.7.1 Fund�ng Model

Both the Queensland Public Hospitals Commission of Inquiry and Queensland Health Systems Review �dent�f�ed a range of weaknesses �n Queensland Health’s fund�ng and budget�ng systems. In part�cular, a lack of transparency and respons�veness was noted �n the budget�ng system, wh�ch was also character�sed as be�ng centrally controlled and managed.

In response, the Queensland Government del�vered �ts Action Plan – building a better health service for Queensland, wh�ch comm�tted to develop�ng a new fund�ng model based on populat�on health need and Casem�x fund�ng for hosp�tals, and to devolved dec�s�on mak�ng closer to the pat�ent. Pr�or to the development of th�s fund�ng model, Queensland was the only Austral�an jur�sd�ct�on to fund �ts health system on a h�stor�cal bas�s.

Implementat�on of th�s new approach to fund�ng �s expected to del�ver the follow�ng system �mprovements:

• respons�veness to populat�on changes • enhanced accountab�l�ty and transparency • de-central�sed budget control • prov�s�on of a mechan�sm to support �nvestment dec�s�on mak�ng across the health

cont�nuum • format�on of l�nks to pol�cy, plann�ng and performance mon�tor�ng • �mproved equ�ty and eff�c�ency • prov�s�on of greater budget certa�nty.

The New Fund�ng Model (NFM) has been developed to su�t the un�que character�st�cs of Queensland, �n part�cular the h�ghly d�spersed populat�on. It �s based on a Program structure that al�gns w�th the full range of serv�ces that Queensland Health del�vers. These Programs are:

• Promot�on, Prevent�on and Protect�on • Pr�mary Health Care • Ambulatory • Acute Inpat�ent • Rehab�l�tat�on and Extended care • Integrated Mental Health.

The NFM has two levels. The top level, the Resource Allocat�on Model (RAM), w�ll allocate Queensland Health’s budget to the Area Health Serv�ces, based pr�nc�pally on the health needs of the�r populat�ons, w�th adjustment for factors such as remoteness and the Ind�genous populat�on. Th�s �s to ensure Area Health Serv�ces (AHS) rece�ve the�r fa�r share of the fund�ng for the serv�ces they are requ�red to del�ver.

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The lower level of the fund�ng model �s the Casem�x Fund�ng Model (CFM). The CFM w�ll fund hosp�tals based on the serv�ces they prov�de. The focus of the model �s to l�nk fund�ng to the serv�ces prov�ded by the hosp�tal. It w�ll also prov�de fund�ng for cl�n�cal educat�on, research, spec�al grants and h�gh cost pat�ents.

The New Fund�ng Model was �ntroduced �n July 2007. In�t�ally the CFM funded 23 of the state’s largest publ�c hosp�tals, based on the serv�ces they prov�de. These hosp�tals were determ�ned to have the systems necessary to �mplement the new fund�ng model. Appropr�ate act�v�ty based fund�ng arrangements w�ll be developed over t�me for those hosp�tals not mov�ng to the new model �n 2007. The fund�ng model w�ll be rev�ewed regularly to ensure that both aspects of the model rema�n relevant and current.

The ma�n d�fferences seen under the fund�ng model w�ll be:

• report�ng under the new Programs • h�stor�cal budget �tems no longer relevant for report�ng are ‘rolled up’ • new fund�ng w�ll be allocated �n l�ne w�th the NFM • accountab�l�ty for new fund�ng ass�gned to match NFM fund�ng allocat�ons • act�v�ty targets based on Casem�x • �ntroduct�on of �ncent�ves • performance report�ng to �nclude Casem�x.

For more �nformat�on or resources on the Queensland Health’s (NFM), v�s�t the Resource Allocat�on Un�t s�te on QHEPS.

3.7.2 What �s a budget?

A budget �s s�mply a plan for the allocat�on of resources.

3.7.3 Purpose of a budget

Develop�ng a budget ensures that the serv�ce �s able to opt�m�se the ach�evement of �ts object�ves w�th�n the g�ven resources, and enables the performance of the serv�ce to be measured.

3.7.4 How Queensland Health budgets

The Queensland Government operates under a Manag�ng for Outcomes system. A budget for the whole of Queensland Health �s negot�ated w�th Queensland Treasury. The F�nanc�al Un�t budget team of Queensland Health then allocates a budget to each of the Health Serv�ce D�str�cts.

Th�s budget �ncorporates h�stor�cal and spec�al �n�t�at�ve funds and Commonwealth fund�ng for projects and spec�f�c programs, for example, Home and Commun�ty Care (HACC).

Accounting method

Queensland Health ut�l�ses accrual account�ng. Accrual account�ng records revenue and expense transact�ons at the t�me they occur, even though they may not have been pa�d or rece�ved. For example, expenses such as wages are recogn�sed at the t�me the act�v�ty occurs.


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The Queensland Government prev�ously operated under cash account�ng. Cash account�ng records revenue �n the per�od �n wh�ch the cash was rece�ved at the bank, and expenses were recorded as money left the bank.

3.7.5 Nurses’ role �n budget�ng

Queensland Health requ�res all Health Serv�ce D�str�cts to �mplement devolved management systems for resource and act�v�ty management. Nurses �n many areas are appo�nted as cost centre managers and as such need to:

• be act�vely �nvolved �n the development of the budget for the serv�ce they prov�de • have control of �tems charged aga�nst the budget for the�r serv�ce • rece�ve and rev�ew regular t�mely reports of actual expend�ture versus budgeted

expend�ture • be accountable for the f�nanc�al results of those �tems that they control • analyse and expla�n the reason for var�ances

3.7.6 Types of budgets

1. Global budget

A global budget �s an allocat�on of a block sum of money to a department or organ�sat�on. The manager then allocates these funds �n wh�chever way they dec�de �s most appropr�ate.

2. Historical budget

A h�stor�cal budget �s based on the act�v�t�es and expend�tures of a prev�ous year or years.

3. Zero-based budget

A zero-based budget �s developed ‘from the ground’, based on the analys�s and cost�ng of each factor compr�s�ng the budget.

4. Flexible(variable)budget

A flex�ble budget �s a budget adjusted accord�ng to d�fferences �n act�v�ty levels. W�th�n th�s flex�ble budget however, �t �s only the var�able and sem�-var�able (stepped) costs that w�ll d�ffer w�th changes �n act�v�ty levels; f�xed costs rema�n stat�c. A flex�ble budget �s usually prepared at the end of each account�ng per�od once the level of serv�ce prov�ded �s known. It shows the expected costs for the g�ven per�od of t�me. Th�s may then be compared w�th the actual costs that occurred.

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5. Fixed budget

A f�xed budget assumes the level of act�v�ty �s constant. For example, a ward �s assumed to have an occupancy rate of 90% at all t�mes over the budget per�od. Proport�on of an annual f�xed budget ass�sts management as expected costs for a g�ven level of serv�ce �s known. Th�s budget method �s used by most serv�ces w�th�n Queensland Health.

6. Annual operating expenses budget

An annual operat�ng budget �s the allocat�on of resources for a one-year t�meframe. It �s based on the forecast level of serv�ce demand and expenses. Th�s type of budget can be prepared us�ng a h�stor�cal, zero-based, f�xed or flex�ble approach. The operat�ng expense budget cons�sts of labour and non-labour costs. The BPF focuses only on the labour expenses for nurs�ng.

3.7.7 Budget preparat�on pre-requ�s�tes

Prepar�ng a budget �s a formal process. The follow�ng pre-requ�s�tes w�ll ass�st �n ensur�ng an effect�ve budget preparat�on:

• a supply of rel�able data • a l�st of budget assumpt�ons • a t�meframe for prepar�ng budget

Th�s module has exam�ned nurs�ng costs, budgets, and the types of reports that w�ll be analysed when manag�ng nurs�ng resources.

The next module, Module 4, expla�ns how to develop a nurs�ng operat�ng expense budget by calculat�ng nurs�ng hours requ�red and convert�ng these hours �nto dollars. It then demonstrates how to allocate resources accord�ng to act�v�ty levels.


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Module 4: Resource allocation

4.1 Introduction

4.2 Objectives

4.3 Developing the annual operating expense budget for nursing

4.4 Strategies to address an imbalance of supply and demand

4.5 Monitoring the use of resources





Allocation

Service Demand


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4.1 IntroductionResource allocat�on �s the second stage of the Business planning framework: a tool for nursing workload management.

Th�s module outl�nes the process of develop�ng the annual operat�ng expense budget for nurs�ng. It expla�ns �n deta�l how to calculate nurs�ng hours and how these are converted �nto dollars. Methods to allocate nurs�ng resources �n response to demand are expla�ned and strateg�es outl�ned for deal�ng w�th a s�tuat�on where the allocat�on of funds does not balance w�th serv�ce requ�rements.

Remember: Always refer to the serv�ce prof�le when calculat�ng resource allocat�on, tak�ng �nto account negot�at�ons that have occurred at a local level.


1. Develop an annual operat�ng expense budget for the nurs�ng serv�ce.

2. Expla�n the relat�onsh�p between serv�ce demand and resource allocat�on (supply).

3. Descr�be strateg�es to address an �mbalance between resource allocat�on (supply) and serv�ce demand.

4.3 Developing the annual operating expense budget for nursingThe annual operat�ng expense budget �s the f�nanc�al part of the bus�ness plan. The annual operat�ng expense budget for nurs�ng �ncludes all labour expend�ture (�e. salar�es and wages) for nurs�ng staff, �nclud�ng product�ve costs (�nd�rect and d�rect costs) and non-product�ve costs (annual leave, s�ck leave etc.). Develop�ng an annual operat�ng expense budget w�ll prov�de a gu�de/framework for allocat�ng and controll�ng nurs�ng resources.

Determ�n�ng the budget requ�red for each serv�ce can occur once the follow�ng act�v�t�es have been undertaken:

• serv�ce analys�s and prof�le completed • analys�s of nurs�ng hours per un�t of act�v�ty used �n the past • analys�s of trends �n pat�ent acu�ty data • levels of act�v�ty forecast • comparat�ve analys�s w�th s�m�lar serv�ces • consultat�on w�th staff prov�d�ng the serv�ces. The staff who del�ver the serv�ces have

the profess�onal judgment, knowledge and exper�ence to adv�se on the level of resources requ�red to del�ver care.


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Electronic calculation of the total nursing budget

Queensland Health has developed electron�c tools to ass�st w�th the process of develop�ng the total nurs�ng budget. These tools can be accessed on QHEPS at the Off�ce Ch�ef Nurse web s�te. However �t �s �mportant to understand the pr�nc�ples and the methodology beh�nd these calculat�ons. Examples of how to manually perform these calculat�ons are outl�ned �n th�s manual.

4.3.1 Steps requ�red to establ�sh a nurs�ng budget

A total nurs�ng budget �ncorporates both product�ve and non-product�ve components. Module 3 �ntroduced the types of staff�ng costs to be cons�dered when develop�ng the product�ve and non-product�ve components of the annual operat�ng expense budget for nurs�ng. Th�s module outl�nes the steps requ�red to establ�sh the total annual operat�ng expense budget for nurs�ng.

The steps have the follow�ng key components:

• Productive nursing hours Product�ve hours are those that contr�bute to pat�ent care and �nclude both direct clinical

and indirect clinical hours.

Direct clinical hours D�rect cl�n�cal hours relate to the act�v�t�es nurses do that d�rectly relate to care prov�ded

to the pat�ent/cl�ent. Examples �nclude plann�ng and assessment of care, care for the pat�ent/cl�ent, and documentat�on.

Indirect clinical hours Ind�rect cl�n�cal hours relate to the act�v�t�es nurses do for the pat�ent/cl�ent wh�le not

�n d�rect contact w�th them, �nclud�ng Educat�on and tra�n�ng on the cl�n�cal un�t, mandatory competence atta�nment, qual�ty act�v�t�es and un�t or�entat�on t�me.

Total productive hours = Direct clinical hours + Indirect clinical hours

• Non-productive nursing hours Non-product�ve hours are those that are over and above the d�rect and non-d�rect hours

descr�bed above. For example, s�ck leave, annual leave etc. When converted to costs, these are often referred to as ‘on-costs’.

Therefore, �t �s the total of the product�ve and non-product�ve components that are calculated and converted to the requ�red dollars for the nurs�ng budget.

• Converting total hours into FTEs.

• Converting FTEs into dollars (total nursing operating budget).

There are seven steps that take place �n establ�sh�ng the total annual operat�ng expense budget for nurs�ng. As these steps lead to establ�sh�ng the annual operat�ng budget, the nurs�ng hours calculated are cons�dered �n terms of averages for a spec�f�c per�od.

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The seven steps to establ�sh the total nurs�ng operat�ng budget are dep�cted below.

Figure 4.1: Establ�sh�ng a nurs�ng operat�ng expense budget

Step 1

Calculate total product�ve nurs�ng hours

Step 2

Calculate total annual product�ve nurs�ng hours requ�red to del�ver serv�ces

Step 3

Determ�ne sk�ll m�x/category of the nurs�ng hours

Step 4

Convert product�ve nurs�ng hours �nto full-t�me equ�valent (FTE)

Step 5

Calculate non-product�ve nurs�ng hours

Step 6

Convert FTEs �nto dollars

Step 7

Allocat�on of nurs�ng hours to serv�ce requ�rements


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4.3.2 Def�n�ng product�ve and non-product�ve nurs�ng hours

The examples g�ven �n the follow�ng tables w�ll ass�st �n def�n�ng and d�fferent�at�ng a var�ety of nurs�ng act�v�t�es accord�ng to whether they are product�ve (d�rect and �nd�rect) or non-product�ve nurs�ng hours. Us�ng these descr�ptors w�ll help ensure cons�stency when organ�sat�ons want to benchmark nurs�ng hours per pat�ent day (NHPPD), or nurs�ng hours per occas�ons of serv�ce (NHPOS).

Non-productive nursing hours

Productive nursing hours – examples include but are not limited to:

S�ck leave

Fam�ly leave

Staff development and cont�nu�ng educat�on act�v�t�es

Conference leave

Bereavement leave

Work Cover (�f be�ng pa�d by Work Cover)

Annual leave

Long Serv�ce Leave

Profess�onal Development Leave

Direct – All paid care hours provided for inpatient care, or for direct client care

Med�cat�on adm�n�strat�on

Documentat�on related to pat�ent care

Meal rel�ef

Organ�s�ng pat�ent transfers/procedures/tests

Talk�ng to relat�ves, pat�ents and doctors about pat�ent �ssues

D�scharge plann�ng

Team leader or coord�nator �n charge of the sh�ft

Rev�ew/adjustment of workload allocat�on by the sen�or RN �n charge of the sh�ft

Handover

Nurs�ng hours taken to leave the ward to conduct act�v�t�es �n the operat�ng theatres eg. matern�ty nurses leav�ng the ward to rece�ve a baby at a caesarean sect�on

All nurs�ng hours prov�ded by the ward to attend med�cal emergenc�es �n other wards

Nurs�ng hours used to mon�tor/record observat�ons for pat�ents on remote telemetry

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Cl�n�cal procedures, �nclud�ng recovery

Home v�s�ts

Staff�ng general nursery – does not �nclude bab�es ‘room�ng �n’ 24 hours a day

Nurs�ng care prov�ded to pat�ents who are not �npat�ents - pat�ents may be observed or assessed but not treated or adm�tted

Nurs�ng hours prov�ded to superv�se a pat�ent �n Rad�ology, nuclear med�c�ne centres and CT scans

Escort between wards or to another organ�sat�on

Retr�eval of a pat�ent from another ward or from another organ�sat�on/place

Doctors’ rounds

Organ�s�ng and attend�ng teach�ng ward rounds

Telephone adv�ce to outpat�ents, relat�ves

Pat�ent educat�on

Outpat�ent treatment - eg. wound dress�ngs, removal of sutures, dra�ns, catheters, blood sampl�ng

Antenatal classes or cl�n�cs

Supply�ng med�cat�ons from a pharmacy – small remote hosp�tals

Cl�n�cal sk�lls assessment act�v�t�es

Work Cover (�f be�ng pa�d as part of workforce on a ‘return to work program’)

Indirect – all paid hours for activities contributing to clinical processes but not directly caring for the patient, examples include:

Restock�ng w�th essent�al suppl�es

Or�entat�on

Supernumerary t�me and ongo�ng support and superv�s�on of staff

Educat�on and tra�n�ng on the cl�n�cal un�t

Attendance at ward or fac�l�ty educat�on and tra�n�ng programs

Hours requ�red to support undergraduate programs

Assess�ng cl�n�cal sk�lls (assessor)

Research and pract�ce development act�v�t�es

Nurs�ng hours on spec�al projects

Portfol�o act�v�t�es

Performance appra�sal and development act�v�t�es, manag�ng performance �ssues

Organ�s�ng and attend�ng meet�ngs

Qual�ty �mprovement projects and meet�ngs

Organ�s�ng, rev�ew�ng and updat�ng cl�n�cal pol�c�es and procedures


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Roster�ng act�v�t�es

Develop�ng and mon�tor�ng budgets

Wr�t�ng reports and subm�ss�ons

Recru�tment act�v�t�es

Ward management d�scuss�ons w�th report�ng or rev�ew�ng off�cers

Invest�gat�ng compla�nts

Allocat�ons for supernumerary t�me, ongo�ng support and superv�s�on can vary depend�ng on the model used and the requ�rements of d�fferent groups �nclud�ng new graduates, new starters or nurses part�c�pat�ng �n re-entry/refresher programs. Prepar�ng new staff can have both d�rect and �nd�rect components depend�ng on the model used.

Calculating indirect clinical hours

The number of standard nurs�ng hours used to calculate nurs�ng hours per un�t of act�v�ty �ncludes both d�rect and �nd�rect cl�n�cal hours, as payroll �nformat�on does not d�fferent�ate between these. As �nd�rect requ�rements need careful cons�derat�on, �t �s �mportant that records of th�s t�me are kept. Sources of th�s �nformat�on �nclude Pat�ent-Nurse Dependency systems, Payroll/Human Resources (HR) systems or manual records.

There �s no def�ned formula for determ�n�ng �nd�rect cl�n�cal hours. The Bus�ness Plann�ng Framework �s a gu�de to the management of nurs�ng resources and does not prescr�be what should and should not be �ncluded as �nd�rect cl�n�cal hours. However, statew�de m�n�mum standards have been agreed for mandatory tra�n�ng, profess�onal development and s�ck leave. The allocation of indirect clinical hours for requisite training required by individual clinical units is based on negotiations at a local level. As such there w�ll be d�fferences between serv�ces. The env�ronmental analys�s w�ll h�ghl�ght factors that �mpact on the �nd�rect workload of nurses. Part�cular factors to cons�der �nclude:

• or�entat�on hours for newly recru�ted staff (rev�ew�ng turnover rates w�ll g�ve some bas�s on wh�ch to determ�ne the amount of t�me requ�red)

• mandatory learn�ng requ�rements such as bas�c l�fe support, f�re and safety, �nfect�on control etc.

• �n-serv�ce hours – w�ll they be based on staff learn�ng needs • portfol�o work such as qual�ty �mprovement, workplace health and safety, spec�al projects

etc. • management act�v�t�es �nclud�ng performance appra�sal and development and bus�ness

plann�ng.

G�ven that �nd�rect cl�n�cal hours are negot�ated locally and are s�te spec�f�c, �t �s paramount that the allocat�on of these hours and assoc�ated resources are pr�or�t�sed.

The steps undertaken when establ�sh�ng a nurs�ng operat�ng expense budget are now expla�ned �n deta�l on the follow�ng pages.

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Step 1: Calculate total productive nursing hours

Total productive nursing hours include both direct clinical hours and indirect clinical hours. Total product�ve nurs�ng hours can be presented �n several ways.

1. Calculate d�rect and �nd�rect cl�n�cal hours as average hours per un�t of act�v�ty and present as one number.

2. D�rect and �nd�rect cl�n�cal hours are calculated and presented as separate components/ numbers. The d�rect cl�n�cal hours are calculated as average hours per un�t of act�v�ty and us�ng th�s average, the annual hours/FTEs are determ�ned. The �nd�rect cl�n�cal hours are calculated and presented as annual hours/FTEs.

To effect�vely benchmark and manage the supply/demand aspect of nurs�ng resource management, �t �s essent�al to understand wh�ch of these two methods apply to your bus�ness plan.

If your organ�sat�on has a val�d and rel�able Pat�ent Dependency System (PDS), the d�rect and/or �nd�rect cl�n�cal hours can be taken d�rectly from the PDS. If th�s �s the case, sk�p Step 1 and proceed to Step 2.

Remember that the nurs�ng hours calculated are cons�dered �n terms of averages for a spec�f�c per�od. When cons�der�ng acute �npat�ents, th�s �s usually a 24 hour day and the average recogn�ses that there w�ll be h�gh and low per�ods of demand on a da�ly, weekly and seasonal bas�s. For example, us�ng an annual average of 4.8 product�ve nurs�ng hours per day (NHPPD), a serv�ce w�ll most l�kely have days/hours where demand �s for more than 4.8 NHPPD, and days/hours where demand �s less than 4.8 NHPPD.

Total productive hours

There are several ways to arr�ve at total product�ve hours. Some examples are:

1. Us�ng h�stor�cal payroll or electron�c roster�ng �nformat�on 2. Apply�ng a base staff�ng model 3. Benchmark�ng w�th l�ke serv�ces 4. Us�ng Pat�ent Dependency Systems.

However, pat�ent acu�ty and act�v�ty must be taken into account in all cases.

1. Historical payroll or electronic rostering information

When using historical data derived from payroll or electronic rostering information, it is important to recognise that this information does not differentiate between direct clinical and indirect clinical hours. Additionally, historical nursing hours may not accurately reflect current or future changes in the service. The calculat�on of total product�ve nurs�ng hours (d�rect and �nd�rect cl�n�cal) based on the amount of t�me (converted to hours) used to del�ver serv�ces �n the past only reflects the historical hours supplied. Th�s approach comb�nes d�rect and �nd�rect cl�n�cal hours.


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However, �t �s a start�ng po�nt when there �s l�ttle change �n the serv�ce prof�le from one year to the next and �f a val�d and rel�able electron�c dependency system �s unava�lable.

As an example, h�stor�cal data der�ved from payroll �nformat�on �s used �n th�s step to calculate the average un�ts of act�v�ty. For all calculat�ons �t �s preferable to use at least 12 months retrospect�ve data (see Step 2: Calculate total annual product�ve nurs�ng hours requ�red to del�ver serv�ces).

Un�ts of act�v�ty �nclude:

• pat�ent days/occup�ed bed days – th�s un�t of act�v�ty �s used �n the acute care sett�ng for �npat�ents

• occas�ons of serv�ce • home v�s�ts • procedures.

a. Average nursing hours per unit of activity for hospital inpatients

Nurs�ng Hours per pat�ent day (NHPPD) �s the most commonly used un�t of act�v�ty for hosp�tal �npat�ents. Informat�on systems �nclud�ng Pat�ent Dependency Systems (PDS) can prov�de nurs�ng hours per pat�ent day �nformat�on automat�cally. When ut�l�s�ng a PDS, be aware that not all systems are exclus�vely nurs�ng hours. For example, the res�dent�al class�f�cat�on systems used �n aged care allocate hours per category (see example 4.1.b) �s �nclus�ve of d�vers�onal therapy hours.

Alternat�vely, the follow�ng method can be used.

F�rstly, obta�n the total number of hours worked per day (that �s, per 24 hours). Remember th�s �s product�ve t�me and �ncludes d�rect cl�n�cal and �nd�rect cl�n�cal hours worked by all nurs�ng staff: permanent, temporary, casual and agency nurses.

D�v�de the total number of hours worked for a spec�f�c per�od of t�me by the total number of occup�ed bed days for the correspond�ng per�od of t�me. The formula appears below:

Sources of data for the above calculat�ons �nclude:

Total number of nursing hours worked

The Dec�s�on Support System (DSS) payroll report w�ll prov�de th�s �nformat�on. The total number of nurs�ng hours worked �ncludes the follow�ng paid nursing hours data:

• standard nurs�ng hours • standard casual nurs�ng hours • standard agency nurs�ng hours • overt�me hours.

Total no. of occupied bed days (in the corresponding period)

Total no. of nursing hours worked *(in a specified period) =Average hours

per patient day

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Th�s w�ll g�ve the total number of h�stor�cal nurs�ng hours that were used �n the serv�ce to care for the pat�ents/cl�ents.

Total number of occupied bed days

Th�s �nformat�on �s usually obta�ned from systems such as DSS, HBCIS and the Cl�n�cal Informat�on System (CIS).

b. Average nursing hours per unit of activity for outpatient, ambulatory care and community care (eg. Nursing Hours per Occasions of Service-NHPOS) see Glossary

For outpat�ent, ambulatory, commun�ty and mental health, nurs�ng hours per pat�ent or cl�ent act�v�ty can be calculated as follows:

Total number of nursing hours worked

Data source �s as for prev�ous formula.

Total number of client activities

The total number of cl�ent act�v�t�es can be obta�ned from HBCIS (outpat�ent occas�ons of serv�ce), other �nformat�on systems such as CHIS (Commun�ty Health Informat�on System) or from manually kept records.

It �s noted that work �s underway towards develop�ng val�d and rel�able nurs�ng un�ts of act�v�ty across commun�ty health serv�ces.

Acuity levels

Wh�le the above method of calculat�ng nurs�ng hours �s the bas�s for develop�ng the nurs�ng budget, �t �s h�stor�cal and assumes the level of acu�ty of the pat�ents �n the serv�ce rema�ns constant. However, wh�le the level of act�v�ty �n a un�t may rema�n the same, the acu�ty of pat�ents may change, thereby �mpact�ng on the levels of nurs�ng resources requ�red to care for the g�ven case load of the serv�ce.

More deta�led analys�s of �npat�ent case load may be performed by exam�n�ng nurs�ng hours per pat�ent day by DRG category. If your serv�ce uses a pat�ent/nurse dependency system, nurs�ng hours per pat�ent day by DRG reports may be ava�lable. Th�s data may be comb�ned w�th Casem�x �nformat�on to calculate the Total Nursing Hours requ�red for the g�ven case load of the serv�ce. The follow�ng example demonstrates how th�s data can be used.

Total no. of occas�ons of serv�ce (�n the correspond�ng per�od)

Total no. of nurs�ng hours worked *(�n a spec�f�ed per�od) =

Average hours per pat�ent/cl�ent act�v�ty


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Example 4.1a: Surg�cal un�t

100% of adm�ss�ons are for the follow�ng DRGs (for further �nformat�on on DRG’s see Module 3):

NB: the Av. no. of nurs�ng hours per day have not been extracted from any system and are examples only

(1) (2) (3)Column(1)xColumn(2)

DRG (AR-DRG v4.1) Av. no. of nursing hours per day

No. occupied days Total nursing hours per DRG

D11Z 4.00 3000 12000

D13Z 3.51* 2000 7010

D40Z 5.08 1380 7010

D10Z 3.80 2500 9500

Total 8880 35520* Av. Nurs�ng hours rounded up from 3.505

Total no. of nursing hours worked – 35520 hours = 4.0 Average NHPPDTotal no. of occupied bed days – 8880 days

For th�s un�t the average number of nurs�ng hours per pat�ent day was 4.0 hours.

However, �f the Casem�x of the pat�ents �n th�s un�t changed to:

DRG(AR-DRGv4.1)

Av. no. of nursing hours perday

No.occupieddays Total nursing hours per DRG

D11Z 4.00 3000 12000

D13Z 3.51* 2000 7010

D40Z 5.08 3880 19710

Total 8880 38720* Av. Nurs�ng hours rounded up from 3.505

Total no. of nursing hours worked – 38720 hours = 4.4 Average NHPPDTotal no. of occupied bed days – 8880 days

Average number of nurs�ng hours per pat�ent day would now be 4.4 hours.

Wh�le the total number of occup�ed bed days (act�v�ty) �n th�s un�t rema�ned the same, changes �n the Casem�x (and therefore acu�ty) have �ncreased average nurs�ng hours per pat�ent day.

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Example 4.1b: Res�dent�al aged care fac�l�ty

The Res�dent�al Class�f�cat�on Scale (RCS) �s used as a gu�de to determ�ne the level of dependence and resultant hours requ�red to care for the res�dent. It �s �mportant to note that the hours allocated per category may be �nclus�ve of d�vers�onal therapy and/ or AIN hours. The breakdown of the res�dents’ RCS categor�es and hours per res�dent per day are as follows:

RCS Categories

1 2 3 4 5 6 7 8

Home 1 7 6 6 4 4 2 1 0 30

Home 2 6 11 7 4 3 0 1 0 32

Total no. of residents

13 17 13 8 7 2 2 0 62

Hrs per cat. calc

3.86 3.36 2.79 1.86 1.29 1.28 1.28 1.28

Totalhrs/day 50.18 57.12 36.27 14.88 9.03 2.56 2.56 0 172.54

Indicated nursing hours per day – 172.54 = 2.8 average hours per resident dayNo. of residents – 62

For th�s res�dent�al fac�l�ty, the average number of nurs�ng hours per res�dent day was 2.8 hours.

However, �f the RCS categor�es of the res�dents �n the home changed to:

RCS Categories

1 2 3 4 5 6 7 8

Home 1 10 5 9 4 2 0 0 0 30

Home 2 6 15 3 3 3 1 1 0 32

Total no. of residents

16 20 12 7 5 1 1 0 62

Hrs per cat. calc

3.86 3.36 2.79 1.86 1.29 1.28 1.28 1.28

Totalhrs/day 61.76 67.2 33.48 13.02 6.45 1.28 1.28 0 184.47

Indicated nursing hours per day – 184.47 = 3 average hours per resident dayNo. of residents – 62

Average number of res�dent hours per res�dent day would now be 3 hours.

Wh�le the total number of res�dents �n th�s res�dent�al fac�l�ty rema�ned the same, changes �n the res�dents’ RCS categor�es have �ncreased average hours per res�dent.


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2. Base nursing staff model

Some nurs�ng serv�ces may requ�re a m�n�mum number of nurs�ng staff based on factors other than average hours per un�t of act�v�ty, eg. rural fac�l�t�es, cr�t�cal care un�ts, and operat�ng theatres.

Example 4.2a: Base nurs�ng staff model – rural fac�l�ty

Example 4.2b: Base nurs�ng staff model – operat�ng theatres

3. Benchmarking

Benchmark�ng �s a qual�ty �mprovement methodology that �nvolves compar�son of a range of performance �nd�cators across l�ke serv�ces/fac�l�t�es, or �nternal compar�son of prev�ous w�th current performance. The average number of nurs�ng hours per pat�ent day (NHPPD) for part�cular case groups can be val�dated through the process of benchmark�ng.

When benchmark�ng average NHPPD, the performance �nd�cators used �n the compar�son and type of serv�ce prov�ded need to be s�m�lar. For example, �f the NHPPD for the �npat�ent orthopaed�c serv�ce at one hosp�tal were calculated us�ng d�rect cl�n�cal hours only and the NHPPD for �npat�ent orthopaed�c serv�ces at another hosp�tal were calculated us�ng both d�rect and �nd�rect cl�n�cal hours, th�s compar�son alone, would not be val�d. S�m�lar character�st�cs such as role del�neat�on/Cl�n�cal Serv�ces Capab�l�ty (Framework), Casem�x and act�v�ty should be taken �nto account when benchmark�ng.

To effect�vely strengthen the val�d�ty of benchmark�ng, the serv�ce var�ances �dent�f�ed �n the serv�ce prof�le need to be cons�dered and added/subtracted from benchmarked NHPPD. For example, the NHPPD for Un�t A �s 4.4 hours, but support serv�ces of an adm�n�strat�on off�cer, phlebotom�st and all�ed health staff are ava�lable. If the nurses �n Un�t B are requ�red to take on those add�t�onal dut�es; they w�ll need 4.4 d�rect hours plus extra nurs�ng hours as these dut�es then become nurs�ng dut�es �n order to accommodate the add�t�onal workload.

S�m�larly, any �mpact from external �nfluences on the un�t/fac�l�ty (such as m�n�mum staff�ng levels, �mpact of technology or env�ronmental des�gn), needs to be factored �nto any benchmarked NHPPD. These would have been �dent�f�ed �n the serv�ce prof�le.

To ensure safe staff�ng for opt�mal pat�ent care on n�ght duty, a rural hosp�tal or mult�purpose health serv�ce w�ll requ�re a m�n�mum of two nurses rostered for the n�ght duty sh�ft. Th�s �s desp�te the fact that nurs�ng care hours calculated may �nd�cate less nurs�ng hours are requ�red for the n�ght sh�ft.

The requ�rement for nurs�ng hours �n an operat�ng su�te may be based on the projected number of theatre sess�ons expected to be ava�lable on average per month. In calculat�ng the nurs�ng hours, examples of factors to be cons�dered �nclude sess�on start and f�n�sh t�mes, coverage for emergency cases/theatres, and nurs�ng hours requ�red �n anaesthet�cs and recovery.

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4. Patient Dependency Systems

Pat�ent Dependency Systems (PDS) can prov�de data to �nd�cate the nurs�ng requ�rements (demand) dur�ng d�fferent sh�fts, for example, by day, even�ng or n�ght sh�ft. Th�s �nformat�on can ass�st w�th the allocat�on of nurs�ng resources over the var�ous sh�fts on each day.

When us�ng Pat�ent Dependency Systems, the follow�ng must be cons�dered:

• does the system calculate d�rect and �nd�rect cl�n�cal hours as separate or comb�ned components?

• when compar�ng hours per un�t of act�v�ty, staff need to have a clear understand�ng of the �nclus�ons and exclus�ons �n the make-up of the hours per un�t of act�v�ty

• hours per un�t of act�v�ty generally refer to nurs�ng hours only, but there can be except�ons

• ensure �nter-rater rel�ab�l�ty test�ng �s �n place and the requ�red accuracy levels are ach�eved. Th�s means that the PDS �nformat�on �s val�d and rel�able.

Defining activity in specialty areas

In some spec�alty areas where nurs�ng act�v�ty �s not measured �n NHPPD, add�t�onal cons�derat�on may have to be g�ven to the def�n�t�on or measurement of act�v�ty. The pr�nc�ples of the BPF can be appl�ed �n a cl�n�cal area us�ng an agreed un�t of act�v�ty. Some un�ts of act�v�ty that may apply, other than NHPPD �nclude:

• number of separat�ons (d�scharges, transfers, deaths) • we�ghted separat�ons • total occup�ed beds • average occupancy • occas�ons of serv�ce • emergency department presentat�ons • numbers per tr�age category • number of theatre sess�ons • day surgery cases • outpat�ents occas�ons of serv�ce • number of b�rths • retr�evals • home v�s�ts • cl�ent separat�ons • number of group sess�ons • number of cl�ents attend�ng group sess�ons.


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The follow�ng case stud�es g�ve an overv�ew of the spec�f�c cons�derat�ons that may be g�ven to un�ts of act�v�ty �n the cl�n�cal areas of emergency and ch�ld commun�ty health. There �s currently work underway �n apply�ng the BPF �n many cl�n�cal spec�alty areas �n Queensland Health. These case stud�es are not �ntended to be prescr�pt�ve, but may g�ve some ass�stance on the appl�cat�on of the tool to the area.

The following are EXAMPLES only and specific details will differ depending on the demographics of the clinical area.

Case Study One – Emergency Departments

S�nce 2003, Queensland Health, the College of Emergency Nurs�ng Australas�a L�m�ted, and the Queensland Nurses Un�on have endeavoured to adapt the BPF model to su�t Emergency Departments �n Queensland. Th�s �s a work �n progress, and cons�derat�ons and dr�vers that �mpact on demand and supply w�th�n Emergency Departments are outl�ned below.

W�th�n any Emergency Department there are four demand dr�vers that need to be cons�dered when calculat�ng the nurs�ng resources requ�red to support pat�ent care and other related act�v�t�es1. They are:

• core bus�ness of the department – Direct care hours • f�xed hours – �ncludes d�rect and �nd�rect • post Emergency Department care dec�s�ons • number of Emergency Department adm�ss�ons.

These four demand dr�vers are �nfluenced by the pat�ent/cl�ents, the staff and the organ�sat�on.

Core Business of the department

Th�s refers to the d�rect nurs�ng hours requ�red for pat�ents from presentat�on to dec�s�on to adm�t/d�scharge/transfer. Calculat�on of nurs�ng hours w�th�n core bus�ness requ�res cons�derat�on of the follow�ng factors:

• acu�ty of pat�ents – th�s �ncludes tr�age category and the complex�ty of the pat�ents wh�ch d�rectly �mpacts on the nurs�ng hours requ�red for that category.

• average length of stay �n Emergency Department • number of pat�ent presentat�ons per tr�age category.

Fixed hours

The f�xed staff�ng hours component �s requ�red regardless of the number of presentat�ons w�th�n the department and �ncludes both d�rect and �nd�rect care. The d�rect component of f�xed hours relates to the requ�rements to staff spec�f�c areas w�th�n the Emergency Department, such as Tr�age or Resusc�tat�on. For example �f the department has greater than 30,000 presentat�ons annually then a Tr�age RN �s requ�red 24 hours a day. Wh�ch pos�t�ons are �ncluded �n f�xed hours �s dependent on the cl�n�cal model and serv�ce prof�le of the department.

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The �nd�rect component refers to the nurs�ng hours requ�red for pos�t�ons that do not prov�de d�rect cl�n�cal care such as the Nurse Un�t Manager, Nurse Educator, Cl�n�cal Fac�l�tator, Floor co-ord�nator, and non-cl�n�cal ass�stant-�n-nurs�ng.

At t�mes there may be a requ�rement to prov�de a serv�ce outs�de the department, namely for transfer or retr�eval, or �n spec�al c�rcumstances such as d�saster. Staff�ng for th�s component would also be �ncluded �n f�xed hours.

Post Emergency Department care decisions

Th�s component refers to the nurs�ng care hours requ�red to care for pat�ents after the dec�s�on for adm�ss�on/d�scharge/transfer has been made but there �s a delay �n enact�ng th�s dec�s�on. Th�s delay should be captured �n the length of stay data used to calculate average nurs�ng care hours requ�red, ut�l�s�ng NHPPD as an agreed amount.

ED/Short Stay admissions

Th�s component refers to the nurs�ng hours requ�red to care for those pat�ents who have been adm�tted under the care of ED phys�c�ans, and are accommodated w�th�n a des�gnated short stay un�t w�th�n the department. There are two methods of calculat�on appropr�ate for th�s group.

The f�rst �s based on a NHPPD wh�ch would be reflect�ve of the s�te spec�f�c Casem�x. The second �s a f�xed staff�ng model, where an agreed amount of nurs�ng resources �s allocated to th�s area, regardless of the occupancy of the un�t.

In pract�ce, g�ven the geograph�cal layout of many departments, the f�xed staff�ng model �s the one ut�l�sed. It �s �mportant to note that these are acute pat�ents and may be resource �ntens�ve.

Example:

TriageCategory Agreed NHPPD/triage category

Number of presentations Total nursing resources required in hours

1

2

3

4

5

Requ�red NHPPD = Presentat�ons per tr�age category X agreed NHPPD


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Us�ng the pr�nc�ples of BPF, other spec�alty areas w�ll be develop�ng models for determ�nat�on of product�ve nurs�ng hours per un�t of act�v�ty. As these are developed, they w�ll be made ava�lable though the Off�ce of the Ch�ef Nurs�ng Off�cer (OCNO) web s�te.

Case Study Two - Community Child Health Service - Primary Care Program

The Bus�ness Plann�ng Framework pr�nc�ples have been used to develop for tr�al a workload management model for the Pr�mary Care Program of the Commun�ty Ch�ld Health Serv�ce. The modell�ng that has been developed to date �s act�v�ty based and reflects the complex�ty of care other than by t�me. Further work �s ongo�ng to develop a workload management system based on the complex�ty of care.

The act�v�ty measure �s based on the b�rth rate for the D�str�ct and the number of act�v�t�es that would be undertaken for th�s group such as home v�s�ts, cl�n�cs, hosp�tal l�a�son serv�ces and school-based programs. A model of serv�ce del�very has been developed and a t�me allocated to the major�ty of health events and act�v�t�es such as home v�s�ts, parent�ng groups and sem�nars, feed�ng support serv�ces and �nfant assessments.

A percentage of the b�rth populat�on �s used to est�mate serv�ce usage. The t�me and percentage are then mult�pl�ed to calculate the d�rect t�me requ�red. For some events, the d�rect t�me requ�red has been based on the t�me the serv�ce �s staffed. The model has been developed est�mat�ng that the serv�ce would see 85% of the b�rth populat�on, w�th a reduc�ng attendance as the ch�ld’s age �ncreases. To ach�eve th�s demand driven serv�ce, the program �dent�f�es the FTE requ�red. The program also �dent�f�es an alternat�ve model wh�ch reflects the funded FTE, or supply driver. Th�s model restr�cts un�versal serv�ces, has ma�nta�ned selected serv�ces and reduced others.

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Step 2: Calculate total annual productive nursing hours required to deliver services

The total number of product�ve nurs�ng hours requ�red to del�ver serv�ces �s based on product�ve hours (d�rect and �nd�rect) only. It is important to note that the productive nursing hours used to deliver services in the past may not be relevant to the future.

Before apply�ng past hours to the total number of nurs�ng hours requ�red to del�ver serv�ces �n the future, �t �s necessary to rev�ew the env�ronmental analys�s �n the serv�ce prof�le sect�on of the bus�ness plan (see Module 2), focus�ng part�cularly on �nternal factor changes such as:

• acu�ty/complex�ty of the act�v�t�es • standards of care • models of care • the role of the nurs�ng staff/sk�ll m�x • est�mated act�v�ty (e.g. occupancy, occas�ons of serv�ce).

S�gn�f�cant changes �n these factors, and/or the results of benchmark�ng w�th other serv�ces, may suggest that the hours used �n the past requ�re adjustment. If adjustments are requ�red to product�ve hours, Step 1 (above) w�ll need to be repeated tak�ng �nto account any more or less nurs�ng hours that may be requ�red dur�ng the l�fe of the bus�ness plan.

A f�xed staff�ng hours component may be requ�red for some serv�ces such as Emergency Departments or cl�n�cs; th�s refers to nurs�ng hours requ�red regardless of the actual act�v�ty w�th�n the work area. These hours may be used for roles such as Floor Co-ord�nator, Tr�age Nurse or Cl�n�c Nurse.

Module 3 refers to trend analys�s and forecast�ng methodolog�es that can ass�st �n determ�n�ng how staff�ng and act�v�ty �n the past can be analysed �n relat�on to the future.

Once the necessary adjustments �n nurs�ng hours from past to future have been made, calculate the total number of product�ve nurs�ng hours requ�red per year. Th�s �s calculated by mult�ply�ng the average hours per un�t of act�v�ty by the total number of act�v�t�es per year. The total number of act�v�t�es per year may be pre-determ�ned or est�mated as per forecast�ng (see ‘Forecast�ng’, Module 3).

Total number of nurs�ng hours requ�red per year:

Example 4.3: Calculat�ng the total number of nurs�ng hours requ�red per day (data taken from Example 4.1a)

35,520 hrs = 4 nurs�ng hours per pat�ent day x 8880 occup�ed bed day

Total annual no. of productive nursing hrs. = Av. hrs. per unit of activity x Total no. of activities per year


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Step3:Determineskillmix/categoryofthenursinghours

Each serv�ce needs to determ�ne an appropr�ate sk�ll m�x/category of nurses. Once the total number of product�ve nurs�ng hours requ�red to del�ver serv�ces has been determ�ned, then cons�der how many total hours of care could be g�ven by each category of nurse, that �s, all levels of Reg�stered Nurses, Enrolled Nurses and Ass�stants �n Nurs�ng. Th�s m�x of sk�lls (and therefore category of nurses requ�red) w�ll be un�que to each serv�ce and should be based on:

• careful analys�s of the needs of the pat�ents/cl�ents be�ng cared for • the scope of pract�ce of each category of nurse • the outcomes requ�red.

The sk�ll m�x/category requ�red for any part�cular serv�ce may d�ffer by t�me of day, day of the week etc.

Example 4.4: Calculat�ng the sk�ll m�x/category for a 30-bed low acu�ty ward

Data

No. of occ. bed days x nurs�ng hrs. per pt. day = Total product�ve nurs�ng hours per year

8880 bed days x 4 NHPPD = 35,520 hours

Nurs�ng hours requ�red per week �s 35,520 hours d�v�ded by 52 weeks = 683 hours

To calculate skill mix/category on a weekly basis

The number of hours for the categor�es of nurs�ng staff has been determ�ned to be as follows:

* Where a component of the NUM/CNC hours �s �ncluded w�th�n the total d�rect nurs�ng hours, th�s needs to be �ncluded �n the above calculat�ons.

• Therefore, the balance of nurs�ng hours requ�red per week �s 403 (683-280 = 403, �nclud�ng NUM/CNC) or 365 hours (683-280-38 = 365, exclud�ng NUM/CNC) and th�s w�ll be compr�sed of Reg�stered Nurses. These hours w�ll then need to be allocated across the var�ous sh�fts/days of the week.

The sk�ll m�x used �n the past may not be relevant to the future. Cons�derat�on should be g�ven to the Queensland Nursing Council’s Scope of Practice Framework for Nurses and Midwives (2005), and changes �n serv�ce demand (refer to your serv�ce prof�le).

Nursing Grades Hours/week

Clinical Nurse – Grade 6 (24 hours per day for 7 days/week) 168

Registered Nurse – Grade 5 (24 hours per day for 7 days/week) 403*

Enrolled Nurse – Grade 3 (16 hours per day for 7 days/week) 112

Total 683

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Step4:Converttotalproductivenursinghoursintofull-timeequivalent(FTE)

Once the total product�ve nurs�ng hours and sk�ll m�x/category requ�red for your serv�ce has been determ�ned, th�s needs to be converted to full-t�me equ�valents for the purpose of:

• workforce plann�ng • recru�tment dec�s�ons • calculat�ng the budget costs.

Weekly full-time equivalents

A full-t�me equ�valent (FTE) nurse works 38 hours per week. To calculate the number of weekly full-t�me equ�valent staff requ�red, d�v�de the number of requ�red hours per week by 38.

Number of productive FTE nurses per week = Total productive nursing hours required per week 38

When a nurse works part-t�me, the full-t�me equ�valency of the�r hours worked �s calculated as follows:

Number of hours worked per week = FTE38

Example 4.5: Convert�ng product�ve hours �nto FTE

A nurse works 3 x 8 hour sh�fts (24 hours) per week.

24 hours d�v�ded by 38 hours = 0.63 FTE

Note: In calculat�ng part-t�me hours, the FTE equ�valent �s based on the standard 38 hour week (see above). Therefore when a part-t�me staff member works �n excess of 7 hours 36 m�nutes per sh�ft (38 hours d�v�ded by 5), the extra t�me needs to be taken �nto account when calculat�ng total FTEs hours.


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Example 4.6: Convert�ng product�ve hours �nto weekly FTEs

A total of 17.97 FTE nurs�ng staff �s requ�red on a weekly bas�s to prov�de serv�ces (product�ve component). Th�s does not take �nto account that each employed FTE nurse has ent�tlements such as annual leave, s�ck leave and profess�onal development leave (�e. non-product�ve component).

(1) (2)

Column(1)÷38

Nursing grade Required hours per week Weekly FTE

7 (CNC/NM) 38 1

6 (CN) 168 4.42

5 (RN) 365 9.6

3 (EN) 112 2.95

Total 683 17.97

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Step 5: Calculate non-productive nursing hours

Non-product�ve hours �nclude all leave. Wh�le not used to calculate nurs�ng hours per un�t of act�v�ty, non-product�ve nurs�ng hours w�ll determ�ne such strateg�es as recru�tment of add�t�onal staff to cover serv�ce requ�rements when staff are on leave.

The number of non-product�ve hours requ�red can be determ�ned by cons�der�ng the follow�ng components.

Annual leave

Depend�ng upon the award ent�tlement, each nurse �s ent�tled to four, f�ve or s�x weeks annual leave (pro rata for part-t�me workers).

Annual full-time equivalents required for leave replacement

For the purpose of workplace plann�ng and recru�tment to cover the serv�ces to be prov�ded (leave replacement), the number of weeks worked per year for each nurse depends on the�r annual leave ent�tlement as per Award, as well as any other leave as determ�ned by the serv�ce, for example, study leave.

Figure 4.2: Annual product�ve hours worked per FTE based on ARL ent�tlements

* These nurses usually have approx�mately 10 publ�c hol�days, �n add�t�on to the�r annual leave ent�tlement. However, publ�c hol�day replacement �s generally not requ�red for th�s category of nurses.

** Where nurses do not work a m�x of all sh�fts, the�r annual leave ent�tlement �s f�ve weeks.

Note: Some fac�l�t�es class�fy FTEs requ�red for leave replacement as product�ve hours.

Sick leave

Each FTE accrues 10 days s�ck leave per year. An analys�s of s�ck leave trends and a process of benchmark�ng �s part of bus�ness plann�ng. The m�n�mum level allocated for s�ck leave �s based on the prev�ous year’s state average.

No. of weeks annual leave Productive hours worked per FTE

4 1824*

5 1786**

6 1748


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Mandatory training requirements

S�nce the �n�t�al publ�cat�on of the BPF, mandatory learn�ng requ�rements have been h�ghl�ghted as an �ssue. Ach�evement of these annual ‘competenc�es’ cannot occur when the �nd�rect hours allocated are �nsuff�c�ent.

Add�t�onally, leg�slat�ve changes (for example, ch�ld safety) have had an �mpact on the number of competenc�es to be addressed each year. Full analys�s of ded�cated nurs�ng t�me requ�red to ach�eve the competenc�es should be documented �n the serv�ce prof�le. The serv�ce prof�le should have documented the strateg�es assoc�ated w�th ach�ev�ng 100% of staff ach�evement. These strateg�es w�ll vary from serv�ce to serv�ce. For example, some serv�ces may have ded�cated down t�me that prov�des them w�th the ab�l�ty to plan for all staff to attend to mandatory learn�ng requ�rements.

There �s an agreed m�n�mum to be allocated annually for mandatory tra�n�ng per head count. For new staff, th�s �s eleven (11) days and for ex�st�ng staff, th�s �s f�ve (5) days.

Wh�le there are core competenc�es to be met for all cl�n�cal staff, add�t�onal learn�ng requ�rements may vary between cl�n�cal spec�alt�es, for example, mental health and cr�t�cal care serv�ces.

Legislated

Child Safety

Patient/Manual Handling

Fire & Emergency Response

QHPolicy/DistrictPolicy

Code of Conduct

Aggressive Behaviour Management

Cultural Awareness

Incident Management/Reporting

Harassment/Bullying

Complaint Handling

Medication Safety

Infection Control

Basic Life Support

Pandemic Planning/FIT testing


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Professional development leave

From 2007, all permanent Reg�stered and Enrolled Nurses, other than those ent�tled to profess�onal development under the Remote Area Nurs�ng Incent�ve Package (RANIP), are ent�tled to three days per annum (pro rata for part-t�me employees) of pa�d Profess�onal Development Leave (PDL) for profess�onal development act�v�t�es relevant to nurs�ng pract�ce. Pa�d PDL �s an ent�tlement over and above all current ent�tlements, ass�stance or obl�gat�ons. It �s �ntended that PDL be used for act�v�t�es over and above any mandatory tra�n�ng, requ�s�te tra�n�ng or sk�ll set tra�n�ng necessary for a nurse to perform the normal dut�es and funct�ons of the�r role or other tra�n�ng that �s requ�red by the�r employer. PDL �s not a subst�tute for ass�stance from the Study and Research Ass�stance Scheme (SARAS) or Industr�al Relat�ons Educat�on leave.

Cond�t�ons assoc�ated w�th PDL are outl�ned �n IRM 2.7-38, �nclud�ng examples of act�v�t�es that would be appropr�ate for th�s ent�tlement.

Conference and training leave

In add�t�on to profess�onal development leave, leave may be granted to attend conferences, sem�nars and tert�ary or other s�m�lar courses. The amount of leave allocated and how the associated funds are managed is negotiated at a local level.

On-costs

On-costs �nclude penalty payments, other allowances and the cost of non-product�ve hours. Once determ�ned, on-costs are generally expressed �n terms of a percentage of the cost of each nurse.

To convert the hours of each on-cost �nto a percentage, the hours of the ent�tlement are d�v�ded by the hours �n one year. If none of the leave ent�tlements were taken �n one year, the work�ng hours would be:

52 weeks × 38 hours/week = 1976

To calculate one day (7.6 hours) as a percentage:

7.6 /1976 = 0.0038Multiply x 100 to express as a percentage = 0.38%


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The follow�ng table �nd�cates hours expressed a percentage us�ng the above formula. Th�s w�ll ass�st �n the calculat�on of on-costs.

These percentages are then added to the product�ve cost to determ�ne the total budget for the nurse. For example:

Where non-product�ve costs = 41.8% and the annual salary cost for a nurse �s $50,000, the total budget for the nurse would be $70,990.

$50,000 + $20,900 = $70,900

A break-down of on-costs �s shown �n the follow�ng example.

Example 4.7: Breakdown of on-costs

Payroll serv�ces can prov�de the average on-costs for each d�ffer�ng level of staff.

Please refer to your Finance/HR Department as the allocations to some items (such as penalty rates) are examples only and can vary.

Days Number of hours Percentage

1 7.6 0.38%

2 15.2 0.77%

3 22.8 1.15%

4 30.4 1.54%

5 38 1.92%

6 45.6 2.31%

7 53.2 2.69%

8 60.8 3.08%

9 68.4 3.46%

10 76 3.85%

Item Amount %

Annual leave 6 weeks 5 weeks (9.6%)4 weeks (7.6%)

11.54

Sick/Family leave Based on previous year QH average 4.00

Professional development

3 days 1.15

Penalties Average of weekends/public holidays etc. 24.00

Total on-costs 40.69

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Step 6: Calculating total nursing FTEs and converting into dollars

Total nurs�ng FTEs are determ�ned by �nclud�ng both product�ve FTEs and non-product�ve FTEs. The latter may be presented as a percentage.

To calculate the number of annual FTE staff requ�red, d�v�de the number of requ�red hours per year by the number of product�ve hours worked per year per FTE.

Therefore, the FTE number of staff requ�red to prov�de serv�ces each week of the year �s shown the follow�ng example.

Example 4.8: Total annual FTEs requ�red (data taken from Example 4.6)

Where:

Wh�le 17.97 FTEs are requ�red to prov�de serv�ces, to ensure 100% annual leave rel�ef �s prov�ded, an add�t�onal 2.33 FTEs would be requ�red. Th�s results �n an annual total of 20.23 FTEs. Recru�tment to th�s level could occur �f �ncluded �n the budget calculat�ons.

However, recru�t�ng permanently to th�s number of FTE can reduce flex�b�l�ty when act�v�ty �s less than ant�c�pated. It also assumes 100% of nurs�ng staff requ�re backf�ll�ng for annual leave – th�s amount of backf�ll�ng �s not always necessary as some serv�ces are reduced or closed at t�mes dur�ng the year, for example, Chr�stmas and/or Easter.

F�nance/HR staff w�ll often be �nvolved w�th th�s process. However, �t �s �mportant that nurses have an understand�ng of the methods used. The budget w�ll �nclude the product�ve and the non-product�ve components

Column(1) Column(2) Column(3) Column(4) Column(5)

Nursing grade Required hours per week (from example 4.4)

Weekly FTE Required hours per year

Hours worked per year/1 FTE

Annual FTE

7 (CNC/NUM) 38 1 1976 1786 1.11

6 (CN) 168 4.42 8736 1748 5.00

5 (RN) 365 9.6 18,980 1748 10.86

3 (EN) 112 2.95 5824 1786 3.26

Total 683 17.97 35,516 20.23

Column (1) ÷ 38 hours

= Column (2)

Column (1) x 52 weeks

= Column (3)

Data From Table 4.1

= Column (4)

Column (3)

÷ Column (4)

= Column (5)


72

There are d�fferent methods used to convert FTEs �nto dollars. Two methods are shown on the follow�ng pages based on a 30-bed low acu�ty ward (as used �n prev�ous examples).

Method 1 (nurse-by-nurse)

Th�s method costs �nd�v�dual nurses at the�r level and year of serv�ce. Non-product�ve component �s as follows:

• annual leave �s fully replaced as per award ent�tlements • s�ck/spec�al respons�b�l�ty leave �s based on the Queensland Health average for the

prev�ous year per FTE (currently 4%) • profess�onal development leave �s as per award ent�tlements (3 days per year for a full-

t�me FTE = 1.15%)

Example 4.9a: Calculat�ons (nurse by nurse)

* No penalty rates apply for NUM pos�t�on

** Annual leave: NUM and ENs = 5 weeks, CN and RN = 6 weeks and �nclude leave load�ng

*** Pay rates are current at July 2008 and must be updated accord�ngly

Hourly rate �s rounded up to two dec�mal po�nts. In th�s example, totals rounded up (no dec�mal po�nts)

Mandatory tra�n�ng requ�rements are based on employee Head Count (HC) x average base salary per FTE

Total nursing operating budget = $1,500,452

Productive Non-Productive

Grade Pay pt

FTE Hrly rate

$

Tot/hr

$

Annual Base Salary

$

Penalties @ 24%

$

A/L

$

S/L, Sp Resp @ 4%

$

PDL @ 1.15%

$

Mandatory Training

Total

$

5 New Staff (HC) @ 4.32%

$

20 Existing Staff (HC) @ 1.92%

$

7 (NUM) 3 1 42.25 42.25 83,493 0 8,015 3,340 960 95,808

6 (CN) 2 1 32.84 32.84 64,881 15,571 7,487 2,595 746 91,280

3 1 33.60 33.60 66,387 15,933 7,661 2,655 763 93,399

4 2.42 34.36 83.15 164,320 39,437 18,963 6,573 1,890 231,183

5 (RN) 2 2 25.70 51.4 101,584 24,380 11,723 4,063 1,168 142,918

3 2 26.87 53.74 106,182 25,484 12,253 4,247 1,221 149,387

6 3 30.37 91.11 180,030 43,207 20,775 7,201 2,070 253,283

7 2.6 31.54 82.00 162,019 38,885 18,697 6,481 1,863 227,945

3 (EN) 4 1 22.03 22.03 43,538 10,449 4,180 1,742 501 60,410

5 1.95 22.40 44.80 86,309 20,714 8,286 3,452 993 119,754

Total 17.97 1,058,743 234,060 118,040 42,349 12,175 12,461 22,624 1,500,452

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Method 2 (averaging)

An alternate method of convert�ng nurs�ng FTEs �nto dollars �s to average the cost of each category of nurse (product�ve and non-product�ve) �n the serv�ce and mult�ply th�s by the number of FTE requ�red to prov�de serv�ces.

Example 4.9b: Calculat�ons (averag�ng)

* No penalty rates apply for NUM pos�t�on

** Annual leave: NUM and ENs = 5 weeks, CN and RN = 6 weeks and �nclude leave load�n

*** Pay rates are current at July 2008 and must be updated accord�ngly

Hourly rate �s rounded up to two dec�mal po�nts. In th�s example, totals rounded up (no dec�mal po�nts)

Mandatory tra�n�ng requ�rements are based on employee Head Count (HC) x average base salary per FTE

Total nursing operating budget = $1,500,453.63

Important Note: Both Examples 4.9a and 4.9b prov�de both the or�g�nal 17.97 product�ve FTE (example 4.8, p71) and converts the 2.26 non-product�ve FTE (total FTE 20.23 – 17.97) �nto a dollar amount.

Wh�le Method 1 prov�des a very accurate budget est�mate, costs may change �f nurses leave and the replacements are at d�fferent pay levels. If nurs�ng staff turnover �s low, th�s may be the preferred method; �f turnover �s s�gn�f�cant, then Method 2 may be preferable as �t �s eas�er to calculate.


Grade FTE Annual Base Salary

$

Penalties @ 24%

$

A/L

$

S/L, Sp Resp @ 4%

$

PDL @ 1.15%

$

Mandatory Training Total

$

5 New Staff (HC) @ 4.23%$


$

7 (NUM) 1.00 83,493 0 8,015.33 3,339.72 960.17 95,808.22

6 (CN) 4.42 295,588 70,941.12 34,110.86 11,823.52 3,399.26 415,862.76

5 (RN) 9.60 549,815 131,955.60 63,448.65 21,992.60 6,322.87 773,534.72

3 (EN) 2.95 129,847 31,163.28 12,465.31 5,193.88 1,493.24 180,162.71

Total 17.97 1,058,743 234,060.00 118,040.15 42,349.72 12,175.54 12,461 22,624.22 1,500,453.63

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Cash flowing

Once the annual budget has been calculated, �t �s d�v�ded �nto months of the year to prov�de a bas�s for mon�tor�ng the budget. Cash flow�ng �s the process of allocat�ng dollars across def�ned t�me per�ods.

When a budget �s cash-flowed, �mportant cons�derat�ons are d�fferences �n the allocat�on of dollars accord�ng to such factors as act�v�ty levels eg. w�nter bed demand, compulsory serv�ce closure for Chr�stmas per�od etc.

75

Step7:Allocationofnursinghourstoservicerequirements

Once the rev�ew of the serv�ce and organ�sat�on has been completed, and the total annual nurs�ng hours requ�red to prov�de serv�ces determ�ned, the nurs�ng hours can then be negot�ated accord�ng to the agreed, pred�cted and/or planned act�v�ty/serv�ce levels.

A supply and demand approach to nurs�ng resource management means there �s a need to focus on ach�ev�ng a balance between the supply of nurs�ng resources and serv�ce demands. Var�at�ons �n demand, part�cularly for act�v�ty, can d�ffer accord�ng to:

• t�me of day • day of the week • seasons • med�cal off�cer ava�lab�l�ty • other reasons, for example s�gn�f�cant events �n rural areas such as shear�ng, cane

harvest�ng etc.

Where there �s substant�al var�at�on �n demand, the allocat�on of nurs�ng hours can be matched to th�s demand. Th�s can be ach�eved by develop�ng a staff�ng plan. The staff�ng plan needs to map out the var�at�ons �n the number of nurs�ng hours requ�red to del�ver serv�ces over the year. Examples of allocat�ng nurs�ng hours accord�ng to seasonal and da�ly demand follow:

Example 4.10: Seasonal demand - paed�atr�c ward

The months of Apr�l to September account for 67.5% of the act�v�ty (OBDs); January – March and October – December had 32.5% of the act�v�ty. The data also reveals a h�gher acu�ty for the ‘w�nter’ months. Assum�ng four hours per pat�ent per day (r�s�ng to f�ve NHPPD �n the w�nter months) �s requ�red for th�s un�t, then the total nurs�ng hours requ�red for each week �s as per the bottom l�ne of the table.

So the demand for nurs�ng staff w�ll be greater �n the months of Apr�l through to September than for the other months due to both h�gher act�v�ty and h�gher acu�ty.

Month Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Total

OBD 100 200 200 400 400 500 500 500 400 300 300 200 4000

% 2.5 5 5 10 10 12.5 12.5 12.5 10 7.5 7.5 5 100%

Req. NHPPD 4 4 4 5 5 5 5 5 5 4 4 4

Total hours required/month

400 800 800 2000 2000 2500 2500 2500 2000 1200 1200 800 18700

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Example 4.11: Da�ly demand - surg�cal ward

Data:Us�ng the �nformat�on from Example 4.3 and 4.9:

• occup�ed bed days per year �s 8880 (averag�ng 171 per week) • total nurs�ng hours requ�red per year �s 35,520 hours • the requ�red nurs�ng hours per pat�ent day �s 4.0 hours • the average number of occup�ed bed days per day/pat�ents per day �s as shown below.

Assum�ng act�v�ty levels are constant over the 52 weeks of the year (however da�ly act�v�ty fluctuates), the total nurs�ng hours requ�red for the surg�cal un�t can be allocated accord�ng to da�ly demand as shown

Manual/observation

Close observat�on of workloads at var�ous t�mes of the day may prov�de a rough gu�de.

When there �s var�ab�l�ty �n the demand for nurs�ng resources, match�ng the supply of staff exactly to the demand may be d�ff�cult; therefore, the staff�ng roster needs to represent the average staff�ng needs. Roster�ng fewer hours than requ�red means that �f demand �s unexpectedly below the ant�c�pated level, there �s less chance of us�ng resources that are not requ�red.

Supplying the required nursing hours to variable demand

Workforce plann�ng can be undertaken to plan strateg�es for known demands. Examples of strateg�es for supply�ng the requ�red nurs�ng hours �nclude:

• For seasonal/other longer-term fluctuations:

Recruitment Where there �s extended but temporary �ncreased demand for serv�ces due to seasonal fluctuat�ons, extra staff would be employed to cover th�s per�od of t�me.

Leave arrangements The allocat�on of annual leave can be adjusted �n accordance to demand. For example, when surg�cal serv�ces shut down over the Chr�stmas/New Year per�od, staff other than those requ�red to cover emergency serv�ces could be rostered on annual leave.

Day Mon Tue Wed Thur Fri Sat Sun Total per week

Patient Days

20 30 28 28 25 25 20 171

Hours required perday

80 120 112 80 112 100 80 684

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• For weekly/daily fluctuations:Rostering Roster�ng �s the method by wh�ch the nurs�ng hours requ�red to del�ver serv�ces �s allocated on a da�ly bas�s. Demand dur�ng the 24 hours of a day d�ffers, and therefore the number of nurs�ng hours allocated across the day w�ll need to be ta�lored. Da�ly demand can be met by allocat�ng d�fferent numbers of nurses to each sh�ft, as well as vary�ng the sh�ft commencement and f�n�sh t�mes, and us�ng d�fferent lengths of sh�fts.

Queensland Health’s Best Practice Framework for Rostering Nursing Personnel (2003) should be used to ass�st �n creat�ng a roster that �s respons�ve to the peaks and troughs �n act�v�ty expected �n the work area.

Non-productive hours:

All leave may be added to the non-product�ve hours for the purpose of determ�n�ng backf�ll�ng and recru�tment strateg�es. Non-product�ve hours can be staffed (where requ�red) by the follow�ng methods:

– permanently recru�t�ng staff; the s�ze of the serv�ce �n terms of the total nurs�ng FTE requ�red to cover serv�ces w�ll determ�ne whether th�s w�ll be ach�eved w�th cost- effect�veness. If the total annual leave rel�ef component �s less than one FTE, then th�s would not usually be an effect�ve strategy

– use of extra hours by part-t�me staff – casual, agency staff – temporary contracts of employment – overt�me/t�me off �n l�eu (TOIL).

In manag�ng the replacement of non-product�ve hours, the dec�s�on maker needs to understand the cost �mpl�cat�ons of each of the opt�ons. For example, agency staff cost more, however, th�s may be the only alternat�ve ava�lable.

78


Analyse:• Reports– total occupied bed days– number of separations– ED presentations and – number per triage category– day surgery cases– outpatients occasions of

service• Identify trends

• Compare with benchmarks

Activity

What to consider when establishing levels and trends in service demand.

Serv�ce Demand

– number of births

– number of home visits

– number of group sessions

– number attending

Calculate productive nursing hours (Average hours per unit of activity)

Calculate total hours required to deliver services

Determine skill mix of the nursing hours

Calculate non-productive nursing hours

Convert nursing hours into FTE

Convert nursing hours into dollars $

Allocate nursing hours

Analysis of Service Demand and Resource Allocation

(Supply) relationship

Degree of match between these outcomes

Consider:• Indicators• Corporate direction• Targets determined by

District Service Agreements• Teaching/learning• Performance management• Support staff• Technology• Factors identified in the

environmental analysis

Other Factors

Acuity/ Complexity

Analyse:• Reports– Casemix data eg. weighted

separations– Patient dependency data• Identify trends• Compare with benchmarks

Steps in establishing a nursing operating budget

Resource Allocat�on (Supply)

Does not balance – (Consider alternative strategies)

Balance – deliver the service

Figure 4.2: The relationship of service demand to the allocation of resources (supply)

The relationship of service demand to the allocation of resources (supply)

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Over-Supply* of nurseUnder-Supply* of Nurses

Service Demand

Considerations when service demand exceeds supply:• change Casemix• improve support services• improve bed utilisation• explore alternate funding

sources• prioritise service activity• explore alternative models

of service deliveryThe Environmental Analysis identifies factors that influence Demand. Refer to Module 2 in the Resource Manual.

Patient/Client • infection rates• complaints & compliments• satisfaction• incidents (falls, medication)

Staff• absenteeism• turnover• re-deployment

Organisation• policy compliance• budget integrity• compliance with nursing

practice standards

* Supply of nursing staff to meet demand – examples of terminology used are ‘hours per unit of activity’, ‘hours per patient per day’.

Demand(Supply) Demand

(Supply)

Resource Allocaton (Supply) exceeds

Demand

Service Demand exceeds Resource

Allocation (Supply)

Considerations when supply of nursing staff exceeds service demand:• reduce nursing hours• no action as acuity is high• review flexibility of nursing

hours (too many full-time staff to be able to reduce hours when required)

• review nursing practices

Considerations when there is an under-supply of nursing staff in relation to service demand:• increase nursing hours• review skill mix (no action

may be required if patient acuity is low)

• availability of agency/casual staff

• review nursing practices• check indicators, for

example:

Figure 4.3: Achieving a balance between allocated resources (supply) and service demand

Achieving a balance between resource allocation (supply) and service demand

80


4.4 Strategies to address an imbalance of supply and demandUse of the systemat�c approach of bus�ness plann�ng to develop the nurs�ng operat�ng expense budget allows the nurse to understand the many �ssues �mpact�ng on resourc�ng. The a�m of the BPF process �s to ach�eve a balance between supply and demand. However d�fferences occurr�ng between serv�ce demand and supply are:

• serv�ce demand �s greater than the supply of resources • supply of resources �s greater than serv�ce demand.

When d�fferences occur, a balance can be ach�eved by adjust�ng e�ther supply or demand. F�gure 4.3 dep�cts an �mbalance between serv�ce demand and supply of resources. Strateg�es are as follows.

Where service demand is greater than the supply of resources

The env�ronmental analys�s �dent�f�es factors �mpact�ng on serv�ce demand. Wh�lst changes to any of these may reduce demand, the follow�ng strateg�es are suggested.

Cons�der:

• nurs�ng team to clearly �dent�fy capab�l�t�es w�th the ava�lable staff • chang�ng pat�ent m�x • explor�ng �mproved support serv�ces • �mprov�ng bed ut�l�sat�on/bed reduct�ons • explor�ng alternate fund�ng sources • pr�or�t�s�ng cl�n�cal/work un�t act�v�ty • explor�ng opportun�t�es for eff�c�enc�es • chang�ng the nurs�ng sk�ll m�x • mod�fy�ng the role and funct�on of the nurs�ng staff • rev�ew�ng �nd�cators – pat�ent/cl�ent, staff, qual�ty.

Where supply of resources is greater than service demand

When an over-supply of resources has been �dent�f�ed, the follow�ng strateg�es could be cons�dered:

• reduce nurs�ng hours • approve leave • rev�ew flex�b�l�ty of core roster • rev�ew nurs�ng pract�ces • re-d�rect allocated nurs�ng hours • �ncrease serv�ces

There needs to be procedures/agreements in place for managing variances in expenditure and/or activity as they emerge.

81

4.4.1 Strateg�es for manag�ng temporary vacanc�es

Trad�t�onally, casual staff and agency staff have been employed on temporary contracts to backf�ll temporary vacanc�es created by Award leave ent�tlements such as long serv�ce leave, matern�ty and parental leave, parental work agreements, approved leave w�thout pay; long-term s�ck leave and staff secondments. The vacanc�es created by these forms of leave and secondments can be s�gn�f�cant �n a work un�t. Th�s may result �n:

• �nstab�l�ty of staff�ng �n work un�ts • var�able sk�ll m�x • �ncreased workloads • �ncreased need for preceptor�ng and tra�n�ng of temporary staff • decreased staff morale • �ncreased s�ck leave • �ncreased costs.

Ult�mately th�s w�ll �mpact on the ab�l�ty of the work un�t or fac�l�ty to effect�vely manage nurs�ng workloads. Ex�st�ng pract�ces of backf�ll�ng by temporary contracts of external/casual staff, or manag�ng the unf�lled sh�fts on a da�ly bas�s w�th agency staff, add�t�onal part-t�me sh�fts or overt�me, can be �neff�c�ent when look�ng at the �mpact on the work un�t.

One strategy wh�ch may �ncrease eff�c�ency �s the establ�shment of a Nurs�ng Support Un�t/Bank/Pool (NSU). The purpose of such a un�t �s to prov�de appropr�ately sk�lled, permanent staff to backf�ll temporary vacanc�es. In turn th�s prov�des permanent employment to add�t�onal nurses who then prov�de backf�ll for the requ�rements descr�bed. Th�s strategy �s not �ntended to prov�de backf�ll for annual leave wh�ch �s bu�lt �nto the work un�t establ�shment.

Staff recru�ted to such a un�t would be able to backf�ll a pos�t�on �n a work un�t for a temporary per�od (poss�bly up to two years), allow�ng them the benef�ts of be�ng members of the ward staff w�th pre-rostered sh�fts, and part�c�pat�ng �n act�v�t�es managed at work un�t level such as performance appra�sal and development.

• If a pos�t�on then becomes ava�lable �n the allocated work un�t, a NSU staff member may take that pos�t�on and the NSU pos�t�on can be recru�ted aga�n. The NSU then becomes a ‘feeder’ for ward permanent staff.

• New graduate nurses can also be placed �n the NSU and allocated to work un�ts requ�r�ng rel�ef, wh�ch �n turn �ncreases the fac�l�t�es’ capac�ty to employ an �ncreased number of graduate nurses.

• No budget �s requ�red for the NSU apart from the costs of sett�ng up and ma�nta�n�ng the processes, as the work un�t pays for the staff member.

Of course w�th the current shortage of nurses worldw�de, there rema�ns a r�sk that the numbers of nurses requ�red to backf�ll all pos�t�ons may not be adequate. Therefore, there w�ll st�ll be a need to f�ll some vacant sh�fts w�th casual/external staff as requ�red. Cr�t�cal to the success of a Nurs�ng Support Un�t (NSU) w�ll be appropr�ate market�ng of the role and �ntent�on of the un�t, and the ab�l�ty to recru�t appropr�ate nurs�ng staff.

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Benefits to an organisation from an NSU

• Ava�lab�l�ty of permanent employment for nurs�ng staff • Reduced dependence on casual staff and reduct�on �n agency usage • Staff stab�l�ty • Forward plann�ng of workforce management strateg�es • Ant�c�pated cost eff�c�enc�es through decreased overt�me and use of external staff eg.

agency • Rap�d f�ll�ng of temporary vacanc�es

Add�t�onal costs would be �nvolved w�th sett�ng up and ma�nta�n�ng the process.

Steps for establishing a Nursing Support Unit

1. Ga�n execut�ve support at D�str�ct level.

2. By �dent�fy�ng the number of FTEs requ�red for backf�ll�ng of leave, rev�ew�ng approved pos�t�ons across the fac�l�ty and determ�n�ng the number of temporary staff/contracts currently �n place, the average-FTE on above types of leave can be �dent�f�ed.

3. Determ�ne the d�str�but�on of Reg�stered Nurses and Enrolled Nurses requ�red.

4. Determ�ne the proport�on of the NSU’s FTEs that w�ll be des�gnated to backf�ll�ng planned leave and the component des�gnated to f�ll�ng emergent leave, eg. 40 FTE for planned leave and 8 FTE for emergent leave.

5. Create the relevant number of permanent pos�t�ons.

6. Allocate a ded�cated coord�nator w�th adequate resources.

7. Establ�sh pol�c�es and protocols perta�n�ng to:

• appo�ntment and allocat�on processes • or�entat�on • expected core competenc�es • performance management • prov�s�on of educat�on and profess�onal development support • �dent�f�ed key performance �nd�cators for assessment of the serv�ce.

8. Mon�tor monthly leave replacement requ�rements.

9. Regularly reassess requ�rements of NSU.

83

4.4.2 Management of emergent s�tuat�ons

Emergent s�tuat�ons w�ll ar�se such as unexpected s�ck leave of staff members who are unable to be replaced, or an unplanned number of �npat�ents. Us�ng the follow�ng flow sheet, nurses �n cl�n�cal work un�ts can cons�der strateg�es for �mplementat�on to manage the workload �n the short-term. It �s essent�al �n these s�tuat�ons that safety for pat�ents and staff �s the pr�or�ty.

Figure 4.4: Emergent management of nurs�ng workloads

Causes:• shortfall in roster for

the clinical activity• patient numbers are

higher than number of funded beds

• patient acuity or staff skill mix does not allow for the appropriate level of supervision or support

Determine a ‘high workload’

Confer with NUM or AHNM

Staff available No staff available

Coordinate and confer with nursing team

Re-evaluate throughout the shift.Will the shortfall resolve with the next shift or is it ongoing?Can beds be reopened?

Extra nursing hours from • casual staff• part-time extra

shifts• agency staff• current or next shift

hours

Document workload issue as per local process and forward to NUM, Nursing Director, NCF

Feedback to work unit

Consider alternative strategies• Prioritise activities

required based on clinical need and ability of available staff

• Adapt pattern of work eg. team nursing or task allocation

• Skill mix alternatives eg. roles for ENs or AINs to support prioritised activities

• Activity reduction eg. close beds as patients are discharged, no new admissions – implementation of escalation strategy/policy

84


4.5 Monitoring the use of resources Mon�tor�ng nurs�ng hours, as well as expend�ture, �s essent�al as �t �s the product�ve hours per un�t of act�v�ty that the nurse can manage. The number of nurs�ng hours used can be recorded on a da�ly bas�s:

• manually • electron�cally • us�ng a PDS • us�ng a computer�sed roster system.

4.5.1 Mon�tor�ng

By mon�tor�ng the use of nurs�ng resources enables assessment of the effect�veness of the allocat�on of resources can be assessed. It �s �mportant to mon�tor the use of nurs�ng resources both �n nurs�ng hours and by expend�ture, �n order to expla�n var�ances. For example, an �ncrease �n the cost of nurs�ng serv�ces may be due to an �ncrease �n the number of nurs�ng hours used (quant�ty var�ance), or an �ncrease �n the cost of the nurs�ng hours (pr�ce var�ance) – see the sect�on on ‘Var�ance Analys�s’ (Module 3).

Rev�ew�ng the �nformat�on allows the early �dent�f�cat�on of var�ances. Some �ssues to be �nvest�gated when the nurs�ng budget and actual expend�ture do not match �nclude:

• whether pay po�nt d�fferences for nurs�ng staff are d�fferent to those budgeted • leave taken �s d�fferent to that budgeted • d�fferent levels of staff have been subst�tuted • use of agency/casual nurses (h�gher hourly rate).

All the above elements w�ll cause var�ances �n costs when the actual number of nurs�ng hours used �s the same as was budgeted.

4.5.2 Deal�ng w�th var�ances

Unfavourable variances

Reasons for unfavourable var�ances may �nclude �ncreased act�v�ty and/or costs. It �s �mportant to determ�ne whether the budget allocat�on �s suff�c�ent to meet the demand (for example, �f demand was underest�mated). Unfavourable var�ances may be act�oned by any of the strateg�es l�sted �n the prev�ous sect�on, ‘Strategies to address an imbalance of supply and demand’.

Favourable variances

It �s �mportant to also �nvest�gate why favourable var�ances are occurr�ng. Obv�ous reasons may be act�v�ty �s less than pred�cted or eff�c�enc�es have been made. However, sav�ngs may also have been made by under-staff�ng, wh�ch may lead to a decrease �n the qual�ty of serv�ce.

Th�s module has exam�ned the process of develop�ng the annual operat�ng expense budget for nurs�ng. The f�nal module, Module 5, br�efly descr�bes evaluat�ng the performance of the serv�ce and d�scusses mon�tor�ng �n further deta�l.

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Module 5: Evaluate Performance

5.1 Introduction

5.2 Objectives

5.3 Measuring performance

5.4 Balanced scorecard

5.5 Frequency of measurement

5.6 Comparative analysis

5.7 Benchmarking

5.8 Conclusion




Allocation

Service Demand



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5.1 IntroductionPerformance measurement occurs at var�ous levels across Queensland Health, from mon�tor�ng performance �n contr�but�ng to the Queensland Government’s pr�or�t�es and outcomes to measurement at HSD or fac�l�ty level.

The Queensland Health Integrated Performance Report Pol�cy has been developed to prov�de greater r�gour and transparency to performance report�ng w�th�n the department. Key performance �nd�cators have been �dent�f�ed for a number of �ssues such as safety and qual�ty, eff�c�ency, act�v�ty, budget performance and staff�ng.

The �nd�cators �n the performance reports are to �nform the Queensland Health Execut�ve Management Team, Resources Comm�ttee, Pat�ent Safety and Qual�ty Board and the Health Commun�ty Counc�ls.

Evaluat�ng performance �s the th�rd stage of the Business planning framework: a tool for nursing workload management. Evaluat�ng the performance of the serv�ce and al�gn�ng w�th key performance �nd�cators w�ll:

• determ�ne the extent to wh�ch stated object�ves are be�ng ach�eved • determ�ne the effect�veness and eff�c�ency of the allocat�on of resources • h�ghl�ght changes to the bus�ness plan that may be requ�red • �dent�fy whether a balance between allocated resources (supply) and serv�ce demand has

been ach�eved.

Th�s module prov�des a br�ef overv�ew of measur�ng performance, benchmark�ng and comparat�ve analys�s.


1. Descr�be the �mportance of evaluat�ng serv�ce performance.

2. Al�gn serv�ce spec�f�c performance �nd�cators w�th the strateg�c d�rect�on of Queensland Health.

5.3 Measuring performanceMeasur�ng performance �s the means of evaluat�ng the overall effect�veness, eff�c�ency and outcomes of the allocat�on of resources. It �nvolves the evaluat�on of both f�nanc�al and non-f�nanc�al results.

In evaluat�ng performance, actual results are compared w�th:

• planned �nd�cators, measures and targets • prev�ous results • the performance of other serv�ces, e�ther �nternal or external to the organ�sat�on.

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Queensland Health Integrated Performance Reporting

Introduced �n 2006, the Queensland Health Integrated Performance Report�ng Pol�cy a�ms to �mprove performance and performance report�ng. Th�s ensures that Queensland Health �s accountable to government across the range of d�mens�ons of expected performance and publ�c �nterest.

Th�s �s ach�eved by Areas, D�str�cts and other health serv�ce prov�ders rev�ew�ng and report�ng aga�nst the key d�mens�ons of:

• safety and qual�ty • access to serv�ces • eff�c�ency, act�v�ty, budget performance and staff�ng • workplace culture partnersh�ps and corporate culture • prevent�on and health outcomes.

D�str�cts develop key performance �nd�cators �n each of the d�mens�ons, �nclud�ng the �nd�cators used for report�ng to the Queensland Health Resources Comm�ttee and all the safety and qual�ty �nd�cators used by the Pat�ent Safety and Qual�ty Board.

Th�s �s supported by the Data, Report�ng and Analys�s Centre wh�ch prov�des a performance mon�tor�ng framework and report�ng system. W�th�n the centre, the Qual�ty Measurement and Strategy Un�t prov�des a core set of performance �nd�cators that measure organ�sat�onal performance �n add�t�on to support�ng the statew�de qual�ty and strategy reforms of Queensland Health.

Another source of data used for report�ng �s the Queensland Health Dec�s�on Support System (DSS). DSS �s a management tool used by l�ne managers to �mprove dec�s�on mak�ng �n appropr�ate resource management.

Some other report�ng systems are Commun�ty Health Informat�on System (CHIS) and Commun�ty Health Informat�on Management Enterpr�se (CHIME). (Append�x C: Sources of Data).

When performance �s compared to targets or performance �nd�cators, trends can be �dent�f�ed, and appropr�ate act�on can be taken as requ�red.

5.4 Scorecard reportingA ‘scorecard’ �s compr�sed of a range of �nd�cators used to measure organ�sat�onal performance, both f�nanc�al and non-f�nanc�al.

Develop�ng a scorecard performance measure �nvolves the follow�ng steps.

1. Ident�fy serv�ce object�ves.

2. Cons�der measures for the object�ves.

3. Cons�der whether the set of measures w�ll ensure a suff�c�ent assessment of progress towards the ach�evement of these object�ves (key performance �nd�cators).

4. Develop report�ng formats.

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By develop�ng key performance �nd�cators:

• adverse trends can be �dent�f�ed • compar�sons can be made w�th�n or w�th other organ�sat�ons.

The use of a scorecard and assoc�ated �nd�cators w�ll ass�st the bus�ness plann�ng process by allow�ng the �dent�f�cat�on and collect�on of �nd�cators relevant to the serv�ce.

Analys�s of the performance of a serv�ce needs to focus on three perspect�ves that are al�gned to the pr�nc�ples underp�nn�ng the BPF. These are:

1. Pat�ent/cl�ent

2. Staff

3. Organ�sat�on – f�nanc�al and process.

Performance indicators

Relevant �nd�cators are developed to measure and analyse the performance of a serv�ce. These performance �nd�cators are al�gned w�th Queensland Health’s strateg�c d�rect�on. Examples of key �nd�cators that could be mon�tored for each of the perspect�ves are:

The patient/client

The staff

The organisation

Financial Process

• Compla�nts • Sat�sfact�on • Inc�dents (�ncludes falls, med�cat�on errors)

• Infect�on rates• Wa�t�ng t�mes • Access

• Absentee�sm (�nclud�ng s�ck leave, workers’ compensat�on)

• Inc�dents• Total hours worked (where staff are salar�ed)

• Re-deployment• Turnover• Educat�on hours• Sat�sfact�on

• Budget �ntegr�ty• Leave• Workforce data• Overt�me• Workers’ compensat�on ($’s)• Cost per un�t of act�v�ty

• Act�v�ty• The extent to wh�ch serv�ce object�ves have

been ach�eved• Hours per un�t of act�v�ty• The extent to wh�ch planned sk�ll m�x

levels and recru�tment strateg�es have been reached

• Levels of non-cl�n�cal support• Types of aud�t processes that are �n place• The levels of ach�evement of performance

management

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Data set

Each serv�ce needs to �dent�fy relevant performance �nd�cators and al�gn these w�th the Queensland Health strateg�c d�rect�on. The performance �nd�cators should �nclude serv�ce spec�f�c �nd�cators, measures and targets. The measures developed need to be rel�able and val�d.

5.5 Frequency of measurementThe frequency of measurement and evaluat�on of the �nd�cators developed w�ll vary by �nd�cator and by serv�ce. For example, trends �n da�ly staff�ng need to be rev�ewed. It �s suggested th�s be done at least every three months, or whenever s�gn�f�cant changes occur �mpact�ng on the serv�ce del�very area.

Most �nd�cators could be reported on a monthly bas�s, w�th the data aggregated �nto three, s�x or twelve monthly reports. Queensland Health �s requ�red to report monthly on f�nanc�al performance and quarterly on non-f�nanc�al performance; however th�s �s aggregated data from the Health Serv�ce D�str�cts and �s not nurs�ng spec�f�c.

Hours per un�t of act�v�ty can be reconc�led w�th fortn�ghtly payroll reports and act�v�ty reports.

5.6 Comparative analysisCompar�sons of the current performance of your serv�ce may be made aga�nst prev�ous performance or other serv�ces.

Internal comparison

Evaluat�on of the serv�ce may �nclude compar�ng the performance of the spec�f�c serv�ce �n the current month or year w�th the same serv�ce’s performance �n prev�ous months or years. Th�s may �nd�cate whether performance �s �mprov�ng or deter�orat�ng. Th�s �s referred to as an �ntra-ent�ty compar�son.

Examples

• Commun�ty health serv�ces may compare wa�t t�mes and response t�mes for cl�ents awa�t�ng serv�ce commencement, cost per un�t of act�v�ty, wound �nfect�on rates for a trans�t�onal care serv�ce or occas�ons of commun�ty engagement for a per�od of t�me compared w�th another s�m�lar per�od of t�me.

• A hosp�tal ward may compare length of stay for spec�f�c DRGs, NHPPD for a spec�f�c per�od or cost per OBD for a per�od of t�me compared w�th s�m�lar per�od of t�me.

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External comparison

An external compar�son �nvolves compar�son of the performance of a serv�ce w�th other s�m�lar serv�ces. In compar�ng your serv�ce w�th other serv�ces, part�cular attent�on should be pa�d to the �nternal and external env�ronmental factors that �mpact on them. D�fferences �n these env�ronmental factors, such as the s�ze of the serv�ce, need to be cons�dered as they may affect resource requ�rements (for example, a smaller organ�sat�on such as a rural hosp�tal may have h�gher f�xed costs than a prov�nc�al hosp�tal).

Examples

• S�m�lar commun�ty health serv�ces may compare cost per un�t of act�v�ty, wa�t t�mes and response t�mes for serv�ces or occas�ons of commun�ty engagement.

• S�m�lar hosp�tal wards may compare NHPPD, OBDs for a spec�f�c DRG, length of stay for spec�f�c DRG or cost per OBD.

5.7 Benchmarking Benchmark�ng �s a part�cular area of performance evaluat�on. The process of benchmark�ng exam�nes the operat�on, processes and methods used to ach�eve best pract�ce. It can be done �nternally w�th�n the organ�sat�on or externally w�th other organ�sat�ons. When benchmark�ng, select other un�ts/organ�sat�ons w�th s�m�lar character�st�cs of:

• role del�neat�on/Cl�n�cal Serv�ces Capab�l�ty (Framework) • Casem�x • act�v�ty.

In analys�ng the use of nurs�ng resources, �t �s �mportant that where there are d�fferences �n the benchmark results, the analys�s of the d�fferences be carefully cons�dered.

The analys�s should part�cularly focus on:

• sk�ll m�x/category of nurses • support serv�ces • team structure/numbers (other than nurs�ng).

5.8 ConclusionModule 5, Evaluat�ng Performance, �s the f�nal stage of the BPF. Hav�ng completed the f�ve modules, �t �s expected that the reader/workshop part�c�pant could develop a bus�ness plan that balances nurs�ng human resource requ�rements (supply) w�th the demand placed on the local health serv�ce, and evaluate the performance of the nurs�ng serv�ce.

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Glossary of termsADO: Accrued day off

Casemix: The m�x of d�fferent types of pat�ents treated �n a spec�f�c health serv�ce

Cost centre: A un�t or department �n an organ�sat�on w�th a manager who has respons�b�l�ty for costs

Diagnosis-related groups (DRGs): A system that categor�ses pat�ents �nto spec�f�c groups based on the�r d�agnos�s and other character�st�cs

Favourable variance (expenses): A var�ance �n wh�ch less was spent than ant�c�pated

Fixed costs: Costs wh�ch do not change as volume changes

Forecast: A pred�ct�on of some future value, e.g. act�v�ty levels, acu�ty levels

Full-time equivalent (FTE): The equ�valent of one full-t�me employee work�ng for one year

Health Service District (HSD)

Nursing hours per patient day (NHPPD): The average nurs�ng hours per un�t of act�v�ty for hosp�tal �npat�ents

Nursing Hours Per Occasions of Service (NHPOS): The average nurs�ng hours per un�t of act�v�ty for ambulatory pat�ents (eg. ED, outpat�ents)

NIBB: Nurses Interest Based Barga�n�ng

NIBBIG: Nurses Interest Based Barga�n�ng Interest Group

Non-productive hours: Pa�d, non-worked hours such as annual leave, s�ck leave etc.

Objective: An object�ve descr�bes the expected outcome of an act�v�ty. It �s usually stated �n terms that enable the extent of ach�evement to be measured

Occupied Bed Day (OBD): pat�ent day = 1 pat�ent occupy�ng 1 bed for 1 day

Office of the Chief Nursing Officer (OCNO)

Operating expenses: The costs assoc�ated w�th the operat�ons of the serv�ce

Patient Dependency System (PDS): A system that class�f�es pat�ents accord�ng to the �ntens�ty of nurs�ng care needs and therefore �nd�cates the amount of nurs�ng hours requ�red. Systems currently used �n Queensland �nclude Trendcare and Excelcare.

Productive hours: Hours worked and pa�d for

Service: May be a un�t, number of un�ts or organ�sat�on

Staffing plan: A document wh�ch �dent�f�es the numbers and categor�es of staff members requ�red for pat�ent/cl�ent care

Trend: A general tendency �n any g�ven d�rect�on, for example an upward trend


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Variable costs: Costs wh�ch change w�th the level of act�v�ty

Variance: The d�fference between the expected and actual result

Variance Analysis: A compar�son of actual results w�th expected results, and �nvest�gat�on �nto the reasons for the d�fferences

Year-to-date: The sum of the values for all months from the beg�nn�ng of the year to the current t�me

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Bibliography and further readingAwards and agreements

Human Resource Pol�cy – HR Policy B5 Nursing Workload Management 2008http://www.health.qld.gov.au/hrpol�c�es/resourc�ng/b_5.pdf

Nurses (Queensland Health) Certified Agreement (EB6) 2006http://www.health.qld.gov.au/eb/agreements/nurses.pdf

Nurses (Queensland Health – Section 170MX Award 2003http://www.health.qld.gov.au/eb/agreements/qhnurse_170mx.pdf

Documents

Queensland Health 2005, Action Plan – Building a better service for Queensland http://www.health.qld.gov.au/publ�cat�ons/corporate/Act�onPlan.pdf

Queensland Health 2003, Best Practice Framework for Rostering Nursing Personnelhttp://qheps.health.qld.gov.au/ocno/docs/roster�ng_bp.pdf

Queensland Health 2007, Casemix Funding Model Overview Paperhttp://casem�x.health.qld.gov.au/CFM/WhatIsCMX.html

Queensland Health 2007, Casemix Roadshow Presentationhttp://casem�x.health.qld.gov.au/CFM/CFM-f�les/cfm_rshow_updated_07.pdf

Queensland Health 2007, Clinical Governance Policyhttp://www.health.qld.gov.au/qual�ty/docs/cl�ngovpol.pdf

Queensland Health 2005, Clinical Services Capability Framework, Vers�on 2.0http://www.health.qld.gov.au/Leg�slat�on/rev�ews/cl�n�cal_framework/28712_CSCF_full.pdf

Queensland Health 2006, Integrated Performance Reporting Policyhttp://www.health.qld.gov.au/performance/docs/30828.pdf

Queensland Health 2007, Queensland State-wide Health Services Planhttp://www.health.qld.gov.au/publ�cat�ons/corporate/stateplan2007/QHSHS_plan.pdf

Queensland Health 2007, Queensland Health Strategic Plan 2007 – 12http://www.health.qld.gov.au/publ�cat�ons/corporate/QHstratplan2007_2012/QHStratPlan07_12.pdf

Queensland Nurs�ng Counc�l 2005, Scope of Practice Framework for Nurses and Midwiveshttp://www.qnc.qld.gov.au/content/Nurs�ng_&_M�dw�fery_Pract�ce/documents/ScopeofPract�ceFramework2005.pdf


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Articles

A�ken, L, Clarke, S, Sloane, D, Sochalsk�, J & S�lber, J 2002, ‘Hosp�tal nurse staff�ng and pat�ent mortal�ty, nurse burnout and job d�ssat�sfact�on’, Journal of the American Medical Association, vol.288, no.16, pp. 1987-1993.

Berkow, S, Jagg�, T, Fogelson, R, Katz, S & H�rschoff, A 2007, ‘Fourteen un�t attr�butes to gu�de staff�ng’, Journal of Nursing Administration, vol.37, no.3, pp. 150-155.

Duff�eld, C, Forbes, J, Fallon, A & Roche, M 2005, ‘Nurs�ng sk�ll m�x and Nurs�ng t�me: the roles of Reg�stered Nurses and Cl�n�cal Nurse Spec�al�st’, Australian Journal of Advanced Nursing, vol.23, no.2, pp.14-21

Duff�eld, C, Roche, M & Merr�ck, E 2006, ‘Methods of measur�ng nurs�ng workload �n Austral�a’, Collegian, vol.13, no.1, pp. 16-22.

Dunn, S, & Schm�tz, K, 2005, ‘Nurses’ percept�ons of pat�ents requ�rements for nurs�ng resources’, Australian Journal of Advanced Nursing, vol.22, no.3, pp.33-40.

Gaud�ne, A, 2000, ‘What do nurses mean by workload and work overload’, Nursing Leadership, vol.13, no.2.

Gerdtz, M, 2007, ‘5-20: A model of m�n�mum nurse-to-pat�ent rat�os �n V�ctor�a, Austral�a’, Journal of Nursing Management, vol.15, pp.64-71.

Harr�son, J, 2004, ‘Address�ng pat�ent acu�ty and nurs�ng workload’, Nursing Management, vol.11, no.4, pp.20-26.

Hurst, K, 2004, ‘Relat�onsh�ps between Pat�ent dependency, nurs�ng workload and qual�ty’, International Journal of Nursing Studies, vol.42, pp. 75-84.

Internat�onal Counc�l of Nurses 2007, Pos�t�ve pract�ce env�ronments: Qual�ty workplaces = qual�ty pat�ent care – Informat�on and act�on tool k�t, International Council of Nurses, Geneva, Sw�tzerland.

Lacey, S, Cox, K, Lorf�ng, K, Teasley, S, Carroll, C & Sexton, K 2007,’Nurs�ng support, workload and �ntent to stay �n Magnet, Magnet-Asp�r�ng and Non-Magnet hosp�tals’, Journal of Nursing Administration, vol.37, no. 4, pp.199-205.

L�n, L, & L�ang, B, 2007, ‘Address�ng the nurs�ng work env�ronment to promote pat�ent safety’, Nursing Forum, vol.42, no.1, pp.20-30.

Moore, M, & Hast�ngs, C 2006, ‘The evolut�on of an ambulatory nurs�ng �ntens�ty system: measur�ng nurs�ng workload �n a day hosp�tal sett�ng’, Journal of Nursing Administration, vol.36, no.5, pp.241-248.

Needleman, J, Buerhaus, P, Mattke, S, Stewart, M & Zelev�nsky, K 2002, Nurse-staff�ng levels and the qual�ty of care �n hosp�tals, The New England Journal of Medicine, vol.346, no. 22, pp.1715-1722.

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Potter, P, Barr, N, McSweeney, M, & Sledge, J, 2003, ‘Ident�fy�ng nurse staff�ng and pat�ent outcome relat�onsh�ps: a gu�de for change �n care del�very’, Nursing Economics, vol.21, no.4, pp.158-166.

Rauhala, A, K�v�mak�, M, Fagerstrom, L, Elova�n�o, M, V�rtanen, M, Vahtera, J, Ra�n�o, A, Ojan�em�, K & K�nnunen, J, 2007, ‘What degree of work overload �s l�kely to cause �ncreased s�ckness absentee�sm among nurses? Ev�dence from the RAFAELA pat�ent class�f�cat�on system’, Journal of Advanced Nursing, vol.57, no.3, pp.286-295.

Spence, Ilsch�nger, H, & Le�ter, M, 2006, ‘The �mpact of nurs�ng work env�ronments on pat�ent safety outcomes: the med�at�ng role of burnout engagement’, Journal of Nursing Administration, vol.36, no.5, pp.259-267.

Upen�eks, V, Akhavan, J, Kotlerman, J, Esser, J, & Ngo, M, 2007, ‘Value-added care: a new way of assess�ng nurs�ng staff rat�os and workload var�ab�l�ty’, Journal of Nursing Administration, vol.37, no.5, pp.243-252.

Welton, J, Unruh, L, & Halloran, E,2006, ‘Nurse staff�ng, nurs�ng �ntens�ty, staff m�x and d�rect nurs�ng care costs across Massachusetts hosp�tals’, Journal of Nursing Administration, vol.36, no.9, pp.416-425.

Wr�ght, P, Bretthauer, K, & Cote, M, 2006, ‘Re-exam�n�ng the nurse schedul�ng problem: staff�ng rat�os and nurs�ng shortages’, Decision Sciences, vol.37, no.1, pp.39-70.

Books

Berger, S 2002, Fundamentals of Health Care Financial Management, 2nd ed, Jossey-Bass Publ�shers, San Franc�sco.

Carroll, P 2006, Nursing Leadership and Management: A Pract�cal Gu�de, Thomson Delmar Learn�ng, New York.

Cl�nton, M (ed.) 2004, Management in the Australian Health Care Industry, 3rd ed, Pearson Educat�on Austral�a, New South Wales.

Cl�nton. M & Sche�we, D (eds) 1998, Management in the Australian Health Care Industry, 2nd ed, Longman, Melbourne.

Coulthard, M, Howell, A & Clarke, G 1996, Business Planning – The Key to Success, Macm�llan Educat�on, Melbourne.

Courtney, M (ed) 1997, Financial Management in Health Services, MacLennon & Petty, Sydney.

Courtney, M & Br�ggs, D (eds.) 2004, Health Care Financial Management, Elsev�er Austral�a, New South Wales.


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Dunham-Taylor, J & P�nczuk, J 2006, Health Care Financial Management for Nurse Managers: Merging the Heart with the Dollar, Jones & Bartlett Publ�shers, Massachusetts.

Dunham-Taylor, J & P�nczuk, J 2006, Health Care Financial Management for Nurse Managers: Applications in Hospitals, Long-term Care, Home Care and Ambulatory Care, Jones & Bartlett Publ�shers, Massachusetts.

F�nkler, S, Kovner, C & Jones, C 2007, Financial Management for Nurse Managers and Executives, 3rd ed, Saunders Elsev�er, M�ssour�.

F�nkler, S & Ward, D 2006, Accounting Fundamentals for Health Care Management. Jones & Bartlett Publ�shers, Massachusetts.

Gruen R & Howarth, A 2005, Financial Management in Health Services, Open Un�vers�ty Press, England.

McLean, R 2003, Financial Management in Health Care Organisations, 2nd ed, Thomson Delmar Learn�ng, New York.

Sperry, L 2003, Becoming an Effective Health Care Manager: The Essential Skills of Leadership, Health Profess�ons Press, Maryland.

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Appendix A: Example – Proposed Business Plan

Proposed unit profile

Medical ward

Matilda Hospital 2007/2008


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ServiceProfile

Aim

To prov�de value-dr�ven, eff�c�ent and safe, pat�ent focused care to renal, resp�ratory, alcohol, tobacco and other drugs of dependence (ATODS) pat�ents/cl�ents and general med�cal pat�ents who access the serv�ce.

Objectives

• To prov�de a h�gh standard of pat�ent focused care through assessment, plann�ng, early �ntervent�on and evaluat�on of acute med�cal problems to support people �n ach�ev�ng opt�mal health outcomes.

• To ensure a coord�nated, mult�-d�sc�pl�nary approach �n the management of the pat�ent w�th complex med�cal needs.

• To work �n partnersh�p w�th the Renal Un�t, Resp�ratory Un�t, Endoscopy Un�t, Rehab�l�tat�on and ATODS to ma�nta�n a coord�nated approach to management of med�cal pat�ents across the cont�nuum.

• To work �n partnersh�p w�th H�gh R�sk Elders and Commun�ty Agenc�es to manage the care of h�gh r�sk, confused and dement�a pat�ents �n the acute care sett�ng.

• To ensure cont�nu�ty of support, educat�on and rehab�l�tat�ve measures to encourage pat�ent �ndependence and trans�t�on back to the commun�ty.

• To encourage pat�ent and fam�ly part�c�pat�on �n health care dec�s�ons and d�scharge plann�ng.

• To foster partnersh�ps w�th commun�ty agenc�es to support appropr�ate follow-up and health ma�ntenance across the cont�nuum.

• To foster a culture that encourages research �n the del�very of ev�dence based care. • To promote leadersh�p �n nurs�ng, the partnersh�p model of care and the Bus�ness

Plann�ng Framework �n the management of nurs�ng resources.

Priority areas for service development

• Rev�ew of the h�gh r�sk elderly pat�ents’ un�t (Safe Haven) and resources. • Subm�t proposal to �ncrease CN: RN sk�ll m�x rat�o on Med�cal Ward to account for 28

acute med�cal beds �nclud�ng Safe Haven. • Educat�on and �mplementat�on of the Buprenorph�ne Op�ate Detox�f�cat�on cl�n�cal

management pathway. • Commence �n-depth analys�s of renal pat�ent adm�ss�ons and length of stay. • Cont�nue recru�tment and retent�on of sk�lled nurs�ng staff. • To support the role and development of the nurse �n Med�cal Ward.

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EnvironmentalAnalysis

Internal environmentMed�cal Ward �s a 28 bed med�cal ward wh�ch has 24 acute med�cal beds, �nclud�ng four beds allocated as the ‘Safe Haven’ for h�gh r�sk elderly pat�ents. The ward has two ante-�solat�on negat�ve pressure rooms.

Four of the beds �n Med�cal Ward are acute alcohol and drug detox�f�cat�on beds allocated through the bed management process.

Cost centre structureCost Centre number �s 123498 and the Nurse Un�t Manager �s accountable for manag�ng the cost centre.

Nursing structureMed�cal Ward has:

The staff�ng allocat�on �s based on 92% average bed occupancy.

Model of careThe nurs�ng staff �n Med�cal Ward prov�de total pat�ent care w�th�n a profess�onal partnersh�p model of care as per the D�str�ct nurs�ng standards and pol�cy statement.

Med�cal Ward operates a four bed ‘Safe Haven’ w�th�n the 28 beds for the management of ‘h�gh r�sk’ elderly pat�ents. (Th�s model �s currently under rev�ew).

Nursing hours per patient day (NHPPD)

NHPPD �ncludes d�rect and �nd�rect cl�n�cal hours (total product�ve hours).

FTE

Nurse Unit Manager 1.0

CNC/Educator 0.5

Clinical Nurses 5.08

Registered Nurses 11.18

Enrolled Nurses 8.86

Total 26.62

Type Number of beds NHPPD

Safe Haven beds 4 6.5

Acute medical/detox 24 6.0


100

Categories/scope of practice/staff skills

• The Nurse Un�t Manager (1.0 FTE) prov�des nurs�ng management and leadersh�p support f�ve days per week.

• The CNC/Educator Med�cal (0.5 FTE) prov�des cl�n�cal expert�se and leadersh�p w�th�n the un�t f�ve days per week.

• The CNC/Ed Renal, Resp�ratory, D�abetes, Endoscopy support the un�t as needed. • Nurs�ng sk�ll m�x target: Cl�n�cal Nurses – 25% Reg�stered Nurses – 55%: Enrolled Nurses - 20% for 25 acute med�cal beds Enrolled Nurses – 100% for 4 bed Safe Haven.

RosteringD�str�but�on of nurs�ng hours for 28 beds: • morn�ng sh�ft – 63 hours • afternoon sh�ft – 53 hours • n�ght sh�ft – 28 hours.

The Queensland Health Best Practice Rostering Framework was �mplemented �n the ward dur�ng 2004-2005. The follow�ng roster�ng pr�nc�ples are used �n the ward: • A m�n�mum of one Cl�n�cal Nurse rostered e�ght hours per day, as able • Des�gnated Sh�ft Coord�nator each sh�ft • Reg�stered Nurses w�th Renal and ATODS competenc�es rostered each sh�ft, as able • Enrolled Nurses rostered each sh�ft • Enrolled Nurse cover from Med�cal Two for 4 hours across the n�ght sh�ft for Safe Haven • Cl�n�cal Nurses ma�nta�n Renal and ATODS competenc�es • Cl�n�cal Nurse Resource for Cyst�c F�bros�s and Resp�ratory pat�ents • Enrolled Nurse – Safe Haven.

Information technology • Desktop computers w�th access to NOVELL, HBCIS, AUSLAB, PACS, QHEPS ava�lable �n

off�ce and wr�te-up bays. • One central pr�nter �n nurse wr�te-up bay. • Nurse call pag�ng system - not currently ut�l�sed. • One fax mach�ne at recept�on area. • Wanderer Alarm Software and sens�ng hardware �nstalled �n Safe Haven Bay for more

effect�ve mon�tor�ng of ‘at r�sk’ pat�ent wander�ng act�v�ty outs�de bay.

Information management • NUM has access to Trans�t�on II, FAMMIS, HR Roster�ng Systems, Staff Development

Databases, QHEPS, QHERS, NOVELL and GroupW�se for rap�d d�ssem�nat�on of �nformat�on and pat�ent care del�very:

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– Records from the Staff Educat�on Database can be accessed and pr�nted out for staff

– QHERS – prov�des �nformat�on on cl�n�cal act�v�ty prof�le – Balanced Scorecard report�ng. • Two Dect phones �n use by Nurse Un�t Manager and des�gnated sh�ft coord�nator. • Nurses – access to databases HBCIS, AUSLAB, QHEPS, NOVELL and GroupW�se for

commun�cat�on and pat�ent care act�v�t�es. • Currently awa�t�ng user/manager/superv�sor tra�n�ng for Queensland Health Electron�c

report�ng of pat�ent �nc�dents; awa�t�ng roll-out of S�ngle S�gn On System �n Med�cal Ward.

• Awa�t�ng Inst�tute support for supply and �nstallat�on of nurse call enunc�ator panel at front desk.

Service PerformancePerformance indicators

• NHPPD, Occupancy, Casem�x Index, LOS • S�ck leave • Falls • Pressure ulcers • Infect�on rates • >28 days LOS

Historical OBD, Occupancy and Casemix Data (Per�od start date – Per�od end date)

(Source: HBCIS Stat�st�cal Summary Report, DSS Casem�x Act�v�ty Module)

Jan06

Feb06

Mar06

Apr06

May06

Jun06

Jul06

Aug06

Sep06

Oct06

Nov06

Dec06

Total /Avg

Total OBD 850 806 858 822 852 834 866 865 822 869 834 857 844

One Day Stay (ODS)

1 2 1 1

Actual Total 850 806 858 822 853 836 866 866 822 870 834 857 845

Available Bed Days

868 812 868 840 868 840 868 868 840 868 840 868 854

Occupancy%OBD+ODS

97.9 102.8 98.8 97.9 98.2 99.6 99.8 99.8 97.9 100.2 99.3 98.7 99.2

Weighted Seps 126 148 151 154 133 211 135 93 187 108 107 203 146

Total Seps 60 57 72 69 73 73 60 59 87 59 65 75 67

Casemix Index 2.1 2.59 2.09 2.23 1.82 2.9 2.25 1.57 2.1 1.83 1.64 2.71 2.15

ALOS 8.22 12.07 8.36 8.71 8.64 10.99 12.88 8.32 8.71 8.14 7.57 10.97 9.46


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Proposed Staffing and Activity for (Period start date – period end date)

*:- �nd�cates un�t of act�v�ty eg. Theatre sess�on

#:- NHPPD �s Nurs�ng hours per pat�ent day, NHPOS �s Hours per Occas�on of Serv�ce, HPUA �s Hours per Un�t of Act�v�ty

MonthlyAverage Top10DRG’s

NHPPD/NHPOS/HPUA# Average 5.2(6.5 – 4 bed Safe haven, 5.0 for 24 beds)

E62C Respiratory Infections/Inflamm.

OBD/OOS/UA# 845 E65B Chronic Obstructive Airways Disease

Occupancy 99.2 L67C Other Kidney and Urinary Tract

Separations 67 F74Z Chest Pain

E65A Chronic Obstructive Airways Disease

Casemix Index 2.15 E62B Respiratory Infections/Inflam.

ALOS 9.4 G67B Oesophagitis, Gastroent &

% or Number of Enrolled Nurses

20% 24-beds +60% 4-bed Safe Haven

F62B Heart Failure and Shock W/O

% or Number of Registered Nurses

55% 24 beds +40% 4-bed Safe Haven

F72B Unstable Angina W/O Catastrophic

% or Number of Clinical Nurses 25% (24 beds + Safe Haven)

F75C Other Circulatory System Diag.

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Appendix B: Example – Agreed Business Plan

Matilda Health Service

1. Service profile

Aim:To prov�de a pat�ent/cl�ent focused health serv�ce that meets the needs of the commun�ty w�th�n the g�ven resources.

Objectives: • max�m�se opportun�t�es to prov�de care on a cont�nuum • prov�de an �ntegrated serv�ce • �mprove staff development opportun�t�es

Description of present service:

Location: Prov�nc�al c�ty located on the central coast of Queensland.

Boundaries: The Health Serv�ce extends approx�mately 150 kms north of the c�ty, 60 kms south of the c�ty and 100 kms west of the c�ty. It prov�des health serv�ces to the populat�on of the c�ty as well as to res�dents �n the surround�ng rural area.

Type of service: The serv�ce cons�sts of: • 100 �npat�ent beds compr�s�ng: – 30 bed ward for med�cal – 30 bed ward for surg�cal – 20 beds matern�ty and paed�atr�cs – 20 bed mental health and med�cal/surg�cal overflow. • Outpat�ents Department • Commun�ty Health Serv�ces.

Functions of the service: The serv�ce prov�des med�cal, surg�cal, matern�ty, paed�atr�c, mental health �npat�ent and commun�ty care.

Role delineation: Level 3/4 as per Cl�n�cal Serv�ces Capab�l�ty (Framework) 2005

Significant achievements in the last 12 months:

• the hosp�tal and commun�ty serv�ces were �ntegrated �nto an organ�sat�onal structure w�th a resultant comb�n�ng of management pos�t�ons across both areas of serv�ce del�very

• a number of spec�f�c cl�n�cal serv�ce adv�sory comm�ttee w�th membersh�p from all health serv�ces �n the area were formed (�e. �ncluded GPs and dom�c�l�ary nurs�ng serv�ces)

• devolvement of budget respons�b�l�ty to m�ddle managers commenced.

Non-achievements in the last 12 months: • devolvement of budget respons�b�l�ty to m�ddle management not completed as planned • �mplementat�on of new parent�ng program d�d not occur due to delays �n rece�v�ng funds.


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Priority areas for service development:

• new parent�ng program • expand cl�n�cal home care serv�ces • �mplement strateg�es to reduce the number of paed�atr�c adm�ss�ons for m�nor a�lments • develop �ntegrated care gu�del�nes for asthmat�cs w�th the a�m of reduc�ng hosp�tal

adm�ss�ons.

The serv�ce w�ll be seek�ng accred�tat�on �n June.

Environmental analysis:

Internal

Structural• Physical environment Location Size Design

• Organisational/unit structural design

• Cost centre structure

• Service structure

• Nursing structure Roles/functions

• Model of care/service options Current model of care Alternatives

Newly built hospital and community health centre on one campus

Located on the western outskirts of the city, (well-serviced by public transport

100 inpatient beds, community health centre will allow for future expansion of service

Integrated health service with one executive for entire service

Hospital building is two stories with 2 wards on each floor. These wards have the ability to ‘swing beds’. Operating theatres (2) are located on the top floor

Each ward is a designated cost centre

Nursing structure:DON, 1 ADON

NUM’s manage each of the 4 wards, Operating Suite/CSSD, Outpatients Department and Emergency Department. The NUM’s function approximately 70% clinical and 30% administration. This will change as cost centre accountability is devolved to them

Care is patient focused. Wards area use a team nursing approach to care

Human Resource Management• Leadership & management organisational culture

• Core staff working in the service-categories, scope of practice, skills

• Support staff, levels and roles/responsibilities

Training and development needs

Senior leaders of the service have broad experience. They have been with the organisation between 2 and 6 years

The organisation embraces change

Nurses in the service comprise Grades 7, 6 and 5 and Enrolled Nurses. The nurses have advanced clinical practice role, eg. Venipuncture, cannulation, minor suturing, midwives clinic

Priority needs are: Cost centre management, training to support movement between community practice and hospital

InformationTechnology/Management• Information technology• Information management

There is good access to computers in all clinical areas. A number of systems support patient census, HRM, payroll and rostering. There is no Patient Dependency System in use

Staff require further education in information management.

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SWOT analysisStrengths: Strong culture of qual�ty �mprovement Low turnover rates amongst nurs�ng staffWeakness: Low number of staff w�th postgraduate qual�f�cat�onsOpportunity: Enthus�asm from staff for opportun�t�es to work across both hosp�tal and commun�ty sett�ngsThreat: Reluctance by local un�vers�ty campus to ass�st w�th the prov�s�on of courses �n the area of ch�ld health/paed�atr�c nurs�ng

Internal

Service Performance• Patient/client complexity/acuity• Patient/client activity• Financial outcomes• Service standards/quality

Thisiscoveredinthefollowingsectionon‘Reports’

External

Policy/legal• Commonwealth policies/funding• State Government policies/funding• Qld. Health policies/funding• Legislation• Licensing requirements• Professional groups• Industrial groups/issues• Education imperatives

Currently have HACC funding until end of current financial year. This supports 2 FTE nursing positions and 0.5 Social Worker in community services

Received extra funding for expanded parent program (1 FTE nurse, 0.5 FTE Social Worker)

Currently implementing changes in practice for ENs to give medications

There is strong membership of nurses in professional special interest group/colleges, eg. ACMI

Will be implementing most recent EB imperatives

Currently provide clinical placements for undergraduate student nurses and post-graduate critical care course

Economic• International/national economy• Public/private interface• Private health care providers• Capital Works

There is one small private hospital of 30 beds

There is one domiciliary nursing service. This service has increased the number of nurses employed and has increased service provision

The local GPs are supported by a Division of General Practice

Capital works are complete

Social• Community expectations• Workforce issues

Demographics

Local community has strong support for health service. A recent survey indicated that the greater community believed that the health service met their health care needs at a high level

Stable population size overall. Birth rates have decreased over the last 5 years, however the rate of decrease is low (approx. 6% over 5 years)

Stable nursing workforce. Occasional delays in recruiting to positions requiring specialist skills, eg. mental health, operating theatre

Technological• Technology • Research

Use of technology is similar to large city hospitals

A generous community assists with updating of equipment.


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Reports

To assess past performance of the service, staffing, activity, financial, Casemix and quality reports were obtained and analysed.

Key �tems noted �ncluded:

Staffing • m�n�mal turnover of nurs�ng staff • s�ck leave rate 3% • workers’ compensat�on below that budgeted.Activity • hosp�tal act�v�ty decreased, however average acu�ty of Casem�x sl�ghtly h�gher than

last year. Notable seasonal trends of decreased surgery over December/January due to VMO leave and �ncreased med�cal and paed�atr�c act�v�ty for May, June, July, August, September. A notable �ncrease �n the number of adm�ss�ons for asthma �n ch�ldren and adults

• commun�ty act�v�ty �ncreased.

Finance • the health serv�ce ach�eved budget overall. Commun�ty health serv�ces were overspent by

15%, hosp�tal serv�ces underspent by 15%.

Quality • Med�cat�on errors low and decl�n�ng • Staff �nc�dents low and decl�n�ng • Pat�ent �nc�dents low, sl�ght �ncrease noted over w�nter months.

2. Resource allocation

The follow�ng resource calculat�ons have been done for the 30–bed med�cal ward.

• Productive hours

Formula for �npat�ent serv�ces:

Total no. of occupied bed days (in the corresponding period)

Total no. of nursing hours worked (in a specified period) =Average nursing hours

per patient day

107

Last year:

Total no. of nurs�ng hours worked 44,070 hours = 4.43 NHPPD Total no. of occup�ed bed days 9945 OBDS

Acuity of CasemixThe acu�ty of the Casem�x �s not expected to change s�gn�f�cantly.

Indirect hours (non-clinical)The follow�ng factors w�ll �ncrease the non-cl�n�cal workload of the nurs�ng staff: • preparat�on towards accred�tat�on �n June • complete �mplementat�on of devolved management to grade 7 (NUM) nurs�ng staff.

It �s est�mated that an add�t�onal 4 hours per week for the grade 7 NUM w�ll be requ�red.

Therefore, 208 hours (52 weeks x 4 hours) w�ll be added to the above total number of nurs�ng hours worked �n order to determ�ne the requ�red NHPPD for th�s current year:

44,278 hours = 4.45 NHPPD. 9945 OBDS

• Total productive nursing hours required to deliver services

Act�v�ty �s est�mated to decrease. The forecast number of occup�ed bed days �s 9,300, therefore:

Total number of nurs�ng hours requ�red per year:

Total no. of productive nursing hrs. = Av. hrs. per unit of activity x Total no. of activities per year

4.45 NHPPD x 9300 OBDs = 41,385 hours


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• Skill mix/category

Total nurs�ng hours per week: 41,385 hours/52 weeks = 796 hours/week

·

• Non-productive time

The follow�ng non-product�ve t�me has been allocated:

Breakdown of on-costs:

Nurse grade Details Hours/week

7 (NUM) (7.6 hours per day Monday to Friday) 38

6 (CN) (24 hours per day for 7 days per week) 168

5 (RN) (24 hours per day for 7 days per week) 478

3 (EN) (16 hours per day for 7 days per week, no night duty) 112

Total 796

Item Amount %

Annual leave 6 weeks (5 weeks = 9.6%) 11.54

Sick/SR leave State average for last financial year 4.00

Conference / Training Leave#

2 days 0.77

Professioanl Development

3 days per FTE 1.15

Penalties Average of weekends/public holidays etc.Set by QH Resource Committee

24.00

Other Includes A/L loading, meal allowances 0.70

Total 42.16

Item Amount %

Mandatory training requirements*

11 days per new employee ( head-count ) 4.23

5 days for existing employees ( head-count ) 1.92

# Conference/Tra�n�ng leave �s a local dec�s�on (refer P.69)

* Mandatory tra�n�ng requ�rements are based on employee Head Count (HC) x average base salary per FTE

109

• Converting hours into FTE

Annual FTEs

Where:

Item Amount $

In charge shift allowance

Set at the amount expended in the previous financial year adjusted for any award increases

Qualifications allowance

Set at the amount expended in the previous financial year adjusted for any award increases

Superannuation, Long Service Leave etc

Set as per Corporate agreed rates

(1) (2)Column(1)/38

Nurse grade Required hours per week WeeklyFTE

7 (NUM) 38 1.00

6 (CN) 168 4.42

5 (RN) 478 12.60

3 (EN) 112 2.95

Total 796 21.00

Column(1) Column(2) Column(3) Column(4) Column(5)

Nurse grade Required hours per week

WeeklyFTE Required hours peryear

Productive hours per year/1FTEofthiscategory

Annual FTE

7 (NUM) 38 1.00 1,976 1,786 1.11

6 (CN) 168 4.42 8,736 1,748 5.00

5 (RN) 478 12.60 24,856 1,748 14.21

3 (EN) 112 2.95 5,824 1,786 3.26

Total 796 21.00 41,392 23.58

(1)From previous exercise

(2)Column(1)/38hours

(3)Column(1)x52weeks

(5)Column(3)/Column(4)

Annual FTE Required hours per year

Productive hours per year per FTE=


110

• Conversion into dollars


Year FTE Hrlyrate

Tot / hr

Annual Penalties @ 24%

A/L @ 11.54%

S/L,SRL @ 4%

Professional Development @ 1.15%

MandatoryTraining requirements

TOTAL

5 New Staff (HC) @ 4.23%


NUM 3 1 31.7 31.7 62639 0 7,229 2,506 720 7,3094

CN 2 1 27 27 53352 12,804 6,157 2,134 614 7,5061

3 1 27.7 27.7 54735 13,136 6,316 2,189 629 7,7006

4 2.42 28.3 68.5 135356 32,485 15,620 5,414 1,557 190,432

RN 2 2 20 40 79040 18,970 9,121 3,162 909 111,202

3 3 21 63 124488 29,877 14,366 4,980 1,432 175,142

6 5 24 120 237120 56,909 27,364 9,485 2,727 333,605

8 2.6 26 67.60 133577 32,058 15,415 5,343 1,536 187,929

EN 4 1 18 18 35568 8,536 4,105 1,423 409 50,041

5 2 18.4 36.8 72717 17,452 8,392 2,909 836 102,306

Total 21 242.1 500.3 988,592 222,229 114,085 39,544 11,369 9,957 18,077 1,403,850

Month Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Total

OBDs 720 739 776 767 823 785 841 846 795 823 740 645 9300

Req. NHPPD

4.45 4.45 4.45 4.45 4.45 4.45 4.45 4.45 4.45 4.45 4.45 4.45

Total hours required/month

3204 3289 3453 3413 3663 3493 3742 3765 3538 3662 3293 2870 41385

Day Mon Tues Wed Thurs Fri Sat Sun Total per week

OBDs 28 29 29 27 25 25 27 190

Hours required per day

125 129 129 120 111 111 120 845

• Allocating resources according to demandAnnual demand

Daily Demand (for the month of July)

111

Care roster using 8 hour shiftsNumber of sh�fts

A total of 792 hours have been scheduled on the core roster. Th�s leaves 53 hours to be used as requ�red.

3. Evaluation

Scorecard �nd�cators for med�cal ward:

Day 6 7 7 6 6 5 5

Evening 5 6 6 6 5 5 5

Night 3 3 3 3 2 2 3

Total hours 112 128 128 120 104 96 104

The Client• Complaints• Satisfaction• Incidents (includes falls, medication errors)• Re-admission rates

The Staff• Absenteeism (including sick leave, workers’

compensation)• Incidents• Re-deployment• Turnover• Education hours• Satisfaction

TheOrganisationFinancial • Budget integrity• Annual leave• Workforce data• Overtime ($’s)• Workers’ Compensation ($’s)• Cost per NHPPD

TheOrganisationProcess• Activity• The extent to which service objectives have

been achieved• Hours per unit of activity• The extent to which planned skill mix levels

have been reached• Level of non-clinical support• Types of audit processes that are in place• The levels of achievement of performance

planning and review


112

Appendix C: Sources of Data

Sources What is availableDSS (Dec�s�on Support System)

• historical financial data – actual, budgets, forecasts

• ledger transactions

• expenditure by account and cost centre

• payroll analysis – financial and non-financial, fortnightly data, hours analysis

• graphs

• variances

• cost trends, peaks, troughs

• some accrual reporting capacity

FAMMIS (SAP) • historical financial data – (cash and accrual), actual, budgets, forecasts

• ledger transactions

• expenditure by account and cost centre

• equipment and other assets management – location and cost centre, value, age, replacement

Roster�ng • a number of spreadsheets have been developed in-house that allow analyses of

- standard roster costs - costs of rosters var�at�ons - roster matched to bus�ness (pat�ent) needs - care hours per occup�ed bed days

HBCIS • patient activity – occupied bed days, separations, public, private, acute, nursing home type and other, occasions of service

• % day of surgery admission, % day surgery

COMBO • cost modelling, DRG data, inpatient fraction, average length of stay, case weights, cost per case weighted separations

EDIS • used to manage and report on activities in all large public hospitals across Queensland.

• EDIS system monitors progress and provide alerts and record treatment details from the time of arrival of patient and as they progress through the ED.

ORMIS • A system to improve operational service delivery and enhance emergency management in operating theatre environment.

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Trans�t�on II • cl�n�cal cost�ng, act�v�ty cost�ngBEIMS • asset management – maintenance, preventative maintenance,

asset replacement

WIMS • employee injury data, workers’ compensation premium

Pat�ent Dependency • rosters, patient acuity, seasonal trends

Other sourcesCap�tal Works Plans • infrastructure, equipment, information technology

D�str�ct Serv�ce Agreements • scope of services, quality, quantity, new services, enhancements to existing services

Un�t Bus�ness Plans • services – scope, location, quality, quantity

• resourcing – staffing, locations, equipment, communications

• cost/benefit analyses of initiatives – cost savings, outcomes improvement

• links to QHealth and District plans

Hosp�tal Redevelopment – 10 year Bus�ness Plans

• activity:

- �npat�ent separat�ons - same day separat�ons - proport�on of same day separat�ons - average length of stay – non same day - occup�ed bed days - ava�lable beds - average DRG cost we�ght—�npat�ents - case we�ghted separat�ons - non �npat�ent occas�ons of serv�ce - cost

Hosp�tal Fund�ng Model • the model, guidelines for development of budgets, elective surgery funds

Equ�P • accreditation checklist, PI thresholds

Monthly Hosp�tal Management Stat�st�cs

• statistics compiled each month and distributed to all Divisions and Departments


114

Appendix D: Queensland Health General LedgerExtract from Queensland Health General Ledger

115

Appendix E: Definitions of Full-Time EquivalentsWhat is a Full-Time Equivalent (FTE)?

Calculat�on of an FTE �s based on the relevant Award/Enterpr�se Barga�n�ng (EB) Agreement and currently a full-t�me nurs�ng employee �n the publ�c sector works a 38 hour week. Therefore, when nurs�ng hours care converted to FTEs they are d�v�ded by 38. There are a range of def�n�t�ons related to the term ‘FTE’ used throughout Queensland Health for analys�ng and report�ng purposes, wh�ch can become very confus�ng.

The FTE references used throughout Queensland Health �nclude ‘affordable FTEs’, ‘budgeted FTEs’, ‘Product�ve FTEs’, ‘Non-Product�ve FTE’, ‘rostered FTEs’, etc. These FTE def�n�t�ons are used (and reported) by a range of areas �nclud�ng nurs�ng, f�nance, HRM, d�str�ct execut�ve and corporate staff.

For example, the HRM department, when report�ng on the number of FTEs �n a cost centre, may �nclude those staff that have a substant�ve pos�t�on �n the cost centre but are on secondment to another area, on matern�ty leave, long serv�ce leave, undertak�ng a project, on leave w�thout pay etc. The latter group of staff most l�kely w�ll be backf�lled, w�th the staff undertak�ng the backf�ll �ncluded �n the cost centre. The FTE report for the part�cular cost centre w�ll be h�gher than the budgeted FTE as both groups of staff are �ncluded �n the calculat�on but the cost may be w�th�n budget.

The follow�ng are the some commonly used def�n�t�ons relat�ng to FTE type, as reported by the Queensland Health F�nanc�al Based Dec�s�on Support System (DSS). DSS �s a management tool used by l�ne managers to �mprove dec�s�on mak�ng �n appropr�ate resource management. The DSS Human Resource module rece�ves data from LATTICE and PAYman on deta�led employee �nformat�on (annual leave, overt�me etc.) for each fortn�ght as the pay �s processed. V�ew�ng reports on the d�fferent categor�es of FTE allow the user to evaluate the�r area of respons�b�l�ty �n terms of payments made and the �mpact on budgets.

• Total FTE – th�s shows the total FTE for nurs�ng staff calculated as full-t�me equ�valents (FTE), and �ncludes all pa�d and unpa�d FTEs for the per�od. It �ncludes �nternal, casual, full-t�me and part-t�me staff, as well as external or agency staff.

• Approved Full-T�me (AFT) – th�s �s calculated as the Base Standard funded hours + Permanent funded leave replacement (hours that are funded for permanent appo�ntment to replace leave) d�v�ded by Award Full-T�me Standard Hours

• Pa�d FTE – th�s shows the total salary pa�d for nurs�ng staff calculated as FTE. Th�s �ncludes all temporary, full-t�me, part-t�me, casual and agency staff employed d�rectly by a d�v�s�on.

• Standard FTE – Th�s �s the total salary pa�d for nurs�ng staff calculated as FTE, exclud�ng pa�d long serv�ce leave and recreat�on leave. Th�s �ncludes all pa�d s�ck leave, spec�al leave (eg. matern�ty, bereavement), product�ve salar�es, overt�me, penalty allowances, base non-worked and base term�nated.


116

• Product�ve FTE – standard + overt�me • Non-product�ve FTE – all leave type categor�es • Occup�ed FTE – th�s �s calculated by totall�ng the FTE Hours of each occupant where

‘Not Current Pos�t�on’ and ‘Cross D�str�ct Employee’ do not appear aga�nst the employee d�v�ded by Award Full-T�me Standard Hours.

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118

119


120

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Date post:	11-Sep-2021
Category:	Documents
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