DRGs (Inpatient) and APCs (Outpatient) are used to define the payment for services. Each payment calculation has a clinical workforce component that is used to define the needs of each patient. Outlier patients and payment adjustments are defined to compensate for extreme cases, but in general all patients’ needs are assumed to be the same. This has worked as a payment strategy but not as a day to day management strategy.
Attempts to regulate safe staffing levels started decades ago when state licensing agencies and the JCAHO called for staffing systems based on the individual needs of the patient. Staffing based on patient acuity became common place, GRASP (PETO) and San Joaquin style assessments were used under a number of proprietary banners, but most had flaws in the mathematics that converted assessments into staffing levels. During the net increase in patient complexity caused by the LOS compression triggered by DRG’s these systems over predicted the staffing increase. This caused a loss in faith in acuity based staffing by fiscal managers and by the end of the managed care experiment in the 90’s most nursing departments had scrapped their acuity systems. Management of acute care inpatient clinical workforces moved to simple single statistical ratios such as hours per visit or hours per patient day, followed by state (California) legislation mandating staffing ratios based on the type of service, critical care, medical, surgical, etc. Rehabilitation and long-term care services adopted patient status assessments (FIM and ??) as a management and payment strategy.
Beginning with the focus on patient safety as 2000 neared nursing departments and associations called for better systems for determining staffing and developed strategies to block looming California type ratio legislation. A new outline for safe staffing emerged calling for systems based on patient intensity (acuity) and patient turnover. Furthermore hospitals were required to use clinical tasks forces made up of at least 50% non management caring professionals. Currently this type of act has made it to the federal level in the form of the RN Safe Staffing Act of 2009. Many state level healthcare associations have been successful in enacting this type of legislation and effectively blocking the expansion of ratio legislation.
Episode Based Workload Calculations
Clinical demand is best calculated using an episode or event based approach. All clinical demand can be characterized by understanding the beginning and end of a clinical episode and the alignment of a level of care during an episode. Recommended standards (levels) of care are readily available from professional organizations. A good example of this are the AWHONN guidelines that pertain to Labor & Delivery, Maternal, and Newborn Care. By combining the level of care with the start and end time of the episode for each patient and adding up the impact of each patient a very accurate, detailed analysis of demand by time of day can be calculated. In labor and delivery this method for calculating the true demand pattern is preferable to the simple hour per delivery ratios commonly used.