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Information needed to support health human resources management Kazanjian, A. Feb 29, 1992

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Centre for Health Servicesand Policy ResearchINFORMATION NEEDED TO SUPPORTHEALTH HUMAN RESOURCES MANAGEMENTHHRU 92:1 FEBRUARY 1992Health Human Resources UnitResearch ReportsTHE UNIVERSITY OF BRITISH COLUMBIAINFORMATION NEEDED TO SUPPORTHEALTH HUMAN RESOURCES MANAGEMENT,Prepared for The National Task Force on Health InformationOctober 22, 1991HHRU 92:1RHealth Human Resources UnitCentre for Health Services and Policy ResearchThe John F. McCreary Health Sciences CentreThe University of British ColumbiaVancouver, British Columbia V6T lZ3A. KazanjianFebruary 1992Table of ContentsPageExecutive Summary 1I. Introduction 51. Health Human Resources and Service Delivery2. Purpose of Health Human Resources Activities3. Health Human Resources ManagementII. Key Issues in Health Human Resources Management57891. Structural Factors That Have Impact Upon Health HumanResources 92. Service Delivery Issues That Have Impact Upon Health HumanResources 123. Health Human Resources Planning Issues That Have ImpactUpon Supply and Requirements 14III. Current Situation 161. Information Currently Available 172. Sources of Information 213. Gaps Existing in Current Information 23IV. Recommendations 261. To Improve Existing Databases 262. To Develop New Databases3. To Coordinate/Link All DatabasesAttachment 1Attachment 22727EXECUTIVE SUMMARY1. INTRODUCTIONThe supply, distribution, quality, deployment, organization and utilization of healthhuman resources are of interest to multiple stake-holders, and interest in policyresearch and planning in this area is particularly strong in all jurisdictions. The purposeof health human resources activity is to identify and achieve the optimal number, mix,and distribution of personnel, at a cost society is able to afford. Due to inter-provincialmigration, policies in one jurisdiction seriously affect the situation in other jurisdictions.Most problem areas require national coordination of proposed solutions.The management of health human resources includes three information-basedfunctions: monitoring and evaluation, planning, and policy research. Understandingsuccessful retention strategies, anticipating change in supply and requirements, andmeasuring workload, turnover, or attrition all require sufficiently developed databases inthese areas of interest. Planning activities include making appropriate use of resources,identifying current and future net requirements and developing new service deliveryoptions. All of these activities presume the availability of accurate and consistentinformation. Efforts in policy development to increase productivity, or improveretention, among other concerns, are seriously hampered by the absence of reliabledatabases.1II. KEY ISSUES IN HEALTH HUMAN RESOURCES MANAGEMENTUnderstanding the key issues in the management of health human resourcesprovides a clearer perspective of its information requirements. Structural factors, suchas system organization and financing, physical resources, professional governance andregulation, and training/supply policy have an impact upon health human resources.Similarly, service delivery issues, such as organizational structure, management style,workplace conditions, also influence the net requirements for health human resources.Planning issues such as ability to adjust supply in order to meet forecast demand willalso influence net requirements, especially in the short-term. Planning undertakenseparately for each profession, rather than starting from future services and moving upthrough skills and competencies required to provide such services, will fail to challengethe somewhat artificial boundaries between the groups, and will not provide the mostappropriate ad cost-effective way of delivering services in a jurisdiction.III. CURRENT SITUATIONSome information is currently available in two forms: printed reports and computer­based files. Included in this is information related to education and training programs,supply, utilization, licensure/certification/registration, and immigration. The proliferationof stake-holders at both the national and provincial levels has contributed to the varietyand diversity of health human resources information and produced an assortment ofdata sources. Licensing bodies, professional associations, provincial pay agencies,2immigration authorities, and special surveys, comprise some of the main sources.Consequently, many gaps exist in the information base that is currently availablebecause it has not been developed specifically for planning and research purposes. Theabsence of a rational, comprehensive human resources planning framework has meantthat information requirements for such activities at the national or provincial level havenot been articulated and defined.IV. RECOMMENDATIONS· That National Health Information Council endorse the Federal/Provincial effort tocontinue the National Physician Database into Phases II and III and promoteaccess to it through the publication of regular reports or through other means.· That the Canadian Nurses Association and Statistics Canada collaboration on thenational registry for RNs examine and document the major limitations of thesedata with the intent to improve the quality of these.· That Health and Welfare Canada, in collaboration with the provinces and thenational professional and/or regulatory bodies, conduct a systematic review of datacurrently published in "Health Personnel in Canada."· That the National Health Information Council support the enhancement of theworkload measurement system.· That federal and provincial governments collaborate with the regulatory bodies fornursing occupations to develop nurse supply and nursing service requirementsmodels based on common definitions of data elements and a common model.· That federal and provincial governments establish regular communication channelswith national and provincial licensing/registering bodies for other health personnel.· That Health and Welfare Canada and Employment and Immigration Canadacollaborate on the sharing of immigration data.3. That provincial governments require human resource impact statements from allagencies that submit regular or special (operating and capital) funding requests tothe government.. That the use of scrambled unique identifiers be promoted among the federal andprovincial agencies officially responsible for data development and dissemination.4INFORMATION NEEDED TO SUPPORTHEALTH HUMAN RESOURCES MANAGEMENTI. INTRODUCTIONThe supply, distribution, quality, deployment, organization and utilization of healthhuman resources are of interest to multiple stake-holders: governments, regulatorybodies, professional associations, unions, training institutions and educational authorities,service providers, self-help groups, and the public. In short, interest in policy researchand planning in this area is particularly strong in all jurisdictions. It is, therefore,paradoxical that information requirements for health human resources managementhave been erroneously associated with simply counting supply or, at best, estimatingrequirements based on some arbitrary population:personnel ratio. The paradox is that,for more than two decades, research in health human resources has been severelyhampered by the limitations imposed by the absence of reliable data. The ensuingintroductory discussion will provide an overview of the breadth as well as depth ofinformation requirements in this field.1. Health Human Resources and Service DeliveryIn a general climate of economic restraint, cost-effective delivery of and equitableaccess to health services has become the primary focus of health services research. Asa service industry, by far the largest component of health care costs are labour costs.While the specific statistics vary by jurisdiction and/or by year, health human resources5expenditures are never below 60 percent and" may, sometimes, be as high as 80 percentof total operating costs. Research efforts, however, to understand the relationshipbetween supply and demand and to examine causes of accelerated costs have beenseverely limited by the availability of reliable data for longitudinal analysis. Morerecently, a national workshop on priorities in health human resources research(Attachment 1), prepared a consensus statement which identified three broad key areaswhere the research evidence was weakest. Weakness was found first, in the assessmentof population health needs by undertaking demographic analyses, epidemiologicalsurveys, and effectiveness research to assess changing technological and clinicalcapabilities. The second area of priority identified exploratory research in the efficientdeployment of health human resources to meet the health needs of the population,including the investigation of barriers which impede progress towards that goal. Finally,the workshop identified the examination of policy implementation strategies and thestudy of the subsequent political/socioeconomic implications of such strategies to be ofprimary importance. The workshop chose to emphasize the desirability of establishinghuman resource requirements based on the health needs of the population as opposedto the more usual way of using a utilization-based definition of service requirements.The needs-based approach, called the epidemiological approach, draws on suchtechniques to assess the prevalence of diseases and the burden of illness in the targetpopulation. Where it becomes useful to human resources research is in considering theappropriateness of care in managing those conditions. Then, health deficits can be6converted to health care service or task requirements. Alternative mixes of inputs(human and non-human) can be identified to meet these task requirements includingthose in prevention and health promotion. Human resource requirements set againstcurrently available skills would determine net requirements. Such research design ­while conceptually clear and feasible - is, in practice, unlikely to be undertaken due tocurrent data limitations.2. Purpose of Health Human Resources ManagementThe purpose of all health human resources activity is to identify and achieve theoptimal number, mix, and distribution of personnel, at a cost society is able to afford.Briefly stated, it is not simply establishing the required number of physicians, or nurses,or pharmacists, or technologists, etc.; it is establishing the numbers in each of these andother groups, given the most cost-effective and appropriate mix of required personneland their equitable geographic distribution based on varying service needs.Current health human resource management activities are often fragmented - giventhe number of stake-holders - and specific human resource planning initiatives haveoften been hampered by inadequate data and questionable methodologies. It should benoted that the training and employment of health personnel are within provincialjurisdiction and activities undertaken at the national level are in support of policiesdeveloped at the provincial level. However, due to inter-provincial migration, policies7in one jurisdiction seriously affect the situation in other jurisdictions. Most problemareas require careful coordination of national solutions.3. Health Human Resources ManagementThe management of health human resources, in its broadest sense, entails variousactivities that can be assisted and/or enhanced by the availability of relevantinformation. More specifically, the three information-based functions of humanresources management are: monitoring and evaluation, planning, and policy research.Monitoring of relevant information - designed to document particular or generalworkforce trends or to identify specific issues - can serve several purposes. Forexample, systematic monitoring of socio-demographic and employment characteristics ofhuman resources in an institution would develop personnel profiles within the agencywhich would contribute to management's understanding of successful retentionstrategies. Or, to better anticipate regional shifts in supply and/or requirements,monitoring information in each/both of these areas would prove very useful. As well,systematic monitoring of deployment patterns of health personnel would provideaccurate estimates of workload, turnover, attrition, and recruitment.Health human resource planning activities entail the examination of current supplyand requirements to identify imbalances, as well as the examination of future supplyand requirements. In addition, such activities involve making appropriate use ofresources - including the assessment of professional legislation and of training and8skills - to meet service needs. Finally, planning also entails developing new servicedelivery options to meet future service requirements. All of these activities presumethe availability of accurate and consistent information.Research to increase our understanding of factors affecting supply and requirementssuch as productivity, retention, case-mix, etc., to improve forecasting models and toevaluate the impact of clinical, operations, or public policies at various levels, requiresreliable databases; otherwise, efforts of policy development become seriously hampered.In summary, this brief introductory discussion of health human resourcesmanagement vis a vis health care and population health, and the role of information inassisting and enhancing such activities, provides a succinct overview of the breadth anddepth of information required for such purposes.II. KEY ISSUES IN HEALTH HUMAN RESOURCES MANAGEMENTTo gain a better appreciation of the specific information needs of this sector, amore detailed discussion of key issues in the management of health human resourcesprovides a clearer perspective. This discussion is not intended to be an exhaustiveinventory of all issues; it will deal only with the main concerns that are not specific toone profession or another. Concrete examples that may be profession-specific will beused to elaborate the discussion.91. Structural Factors That Have Impact Upon Health Human ResourcesA number of structural factors, some not immediately related to human resources,have major implications for the management of health human resources. The mostimportant among these is system organization and financing. A delivery system basedon institutional care, public funding of such care and fee-for-service remuneration formedical services has specific human resource implications that warrant carefulexamination. The recent emphasis on healthy public policies and the consequent shiftto community-based care will also have major implications for human resource planners.Reliable and accurate information on system organization and financing, as well aspersonnel mix and deployment, is required to evaluate the impact of organization andfunding on service and human resource requirements.Rational public policy in these areas should be based on informed judgements onhow structure relates to process and how it influences output. For example, in light ofthe evidence regarding the efficiency of alternative financing of medical services ­HMOs or CHOs versus fee-for-service - what will be the physician resourcerequirements in a jurisdiction partially (or totally) funded in this way? Or, if a policythat shifts delivery of hospital care to the community is implemented, what kind oftraining will be required for nurses providing community-based acute nursing care? Inaddition, physical resources such as health care technology will have impact on therequirements for human resources; for example, the impact of lithotripsy on thedemand for surgeons. In sum, while health human resource requirements do not10determine system structure and financing policies - the latter are often grounded infederal and provincial legislation and are very difficult to revise - these policies haveserious implications for the efficient delivery of services and hence for determining theoptimal number and mix of personnel, and the training of such personnel.Another important structural factor with human resource implications is professionalgovernance and regulation. Such statutory legislation is enacted primarily to protect thepublic interest; however, it is often used to promote professional self-interest andprotect "turf' through exclusive scope of practice clauses. Furthermore, where suchscope does not exist, entry-to-practice and credentialling requirements often act tofurther protect professional interests. Important questions on service and the costimpact of professional legislation can be addressed prior to the enactment of newprovincial legislation, since such statutes are not uniform throughout the country. Forexample, it would be interesting to investigate whether those provinces that haveextended exclusive scope of practice for some health professionals have achieved betterhealth outcomes for their citizens, and therefore are providing better services; costimplications can also be determined from such analyses. The province considering suchlegislation can, therefore, learn from the experiences of other jurisdictions and make aninformed decision. In addition, the supply of health personnel in one jurisdiction isdependent not only on the existence of health professions legislation (with or withoutexclusive scope of practice) in that province but also on the existence of such legislationin the other provinces.11A third important structural factor that has impact in a number of different wayson net human resource requirements is training and supply policy. Domesticproduction policies, usually developed by the training sector and in response to its ownneeds (but sometimes in conjunction with professional associations) generally havenational implications, given the free movement of workers between provinces. From anarrower local perspective, a better alignment of training and service sector policiescould prove to be useful, especially where recurring personnel imbalances exist. Forexample, there appears to be some overlap in the scopes of practice of dentists anddental hygienists in the area of scaling and cleaning teeth. With an appropriate divisionof labour, professionals with higher entry-to-practice requirements could provide onlythe technically more complex services, commensurate with their higher level ofpreparation. Coordination between the sectors would ensure the production of anappropriate number of each type of practitioner, as determined by population healthneeds, and, therefore, would result in the most cost-effective mix of personnel.2. .Service Delivery Issues That Have Impact Upon Health Human ResourcesA number of service delivery issues have serious implications for human resourcesmanagement and, therefore, present another area of information requirements. Inparticular, the institutional sector, where the vast majority of health personnel arecurrently employed, organizational structures vary appreciably: from the traditional with12an administrator at the helm to the corporate or to the matrix organization. Theevolving structures influence the size of the workforce and the quality of care, as well ascosts.Along with organization structure, agency-specific management practices havehuman resource implications. The availability, comprehensiveness, and use of MIS, forexample, in support of the personal style of top-level managers may result in verydifferent workplace conditions and costs. Recruitment, retention, turnover, and attritionare directly affected by management practices, including the monitoring of such trendsfor the purposes of improving human resources planning activities. Such activities alsoentail management decisions regarding the use of substitute, auxiliary, or supportivepersonnel which are always governed by employer policies circumscribed only byrestrictions imposed by professional legislation.Workplace conditions appear to coalesce into variable combinations of the above­mentioned factors, which culminate in the creation of an agency (or hospital) culturethat may be perceived to be supportive or hostile to certain staff. Registered nurses,for example, have perceived the market to be particularly hostile in recent years, andtheir negotiators have demanded improved conditions, along with better wages, as partof the collective bargaining process. Traditional health human resource planning isconcerned with the scope of workforce shortages and factors contributing to thatphenomenon. Until these factors are identified, development of appropriate strategiesis difficult to undertake. A key question for human resource planners, then, is: What13factors are contributing to workforce shortages? Service delivery issues that result inthe inefficient use of human resources can play a major role in explaining shortagesituations. Accurate information collected systematically could provide more definiteanswers to this question.3. Health Human Resource Planning Issues That Have Impact Upon Supply andRequirementsThe literature in this field highlights several problems which are manifested indifferent forms across professional groups and jurisdictions; the absence of reliableinformation pertaining to human resource planning contributes to those problems. Sofar, very slow progress has been made towards a more systematic approach forestimating human resource requirements. Difficulties in demand forecasting arise frommany factors; those arising from changes in delivery patterns (system organization) andservice goals (service delivery) were previously discussed. In addition, difficulties arisingfrom the lack of objective workload-based method of estimating demand, especiallyproblematic for some professional groups, contributes to the complexity of the task.Whereas in the past professional judgement was a commonly accepted methodology, itis no longer used except by the professions themselves when promoting their own pointof view.Difficulties in supply forecasting arise from the inability to test or verify underlyingassumptions regarding the current workforce, such as career histories, turnover rates,inactivity ratios, part-time and casual employment, etc. But even more elementary14problems of defining a professional group in order to count their numbers often presentgreat difficulties for planners. The information sources supporting supply forecastingshould be as broad and flexible as possible so that assumptions such as "a nurse is anurse is a nurse" - preposterous and unfounded - are not taken as given. For example,the number of available nurses is reduced when the number employed is taken intoaccount; a further decrease in number is likely when considering numbers employed inpermanent positions, and even further when the number of full-time nurses is takeninto consideration. Measurement problems in supply arise mainly from multiple sourcesof data and different dates of record (from the same source).Problems in adjusting supply to meet forecast demand are difficult to addresswithout the creation of a comprehensive planning database jointly developed andavailable to both the education and health sectors. Often, there is considerable lagtime needed to make such adjustments and the proactive approach is the only solutionto that problem. Finally, from a broader perspective, a failure to integrate humanresources planning with strategic planning (service and financial planning) continues tobe a problem. Planning undertaken separately for each profession, rather than startingfrom future services and moving up through skills and competencies required to providesuch services, will fail to challenge the somewhat artificial boundaries between thegroups, and will not provide the most appropriate and cost-effective way of deliveringservices in a jurisdiction. In order to be comprehensive and innovative in planning and15policy development, certain information conditions have to be met - both regardingquantity and quality of data.The National Health Information Council has recently developed a Template forHealth Information which provides a comprehensive conceptual framework for thestudy of factors associated with health and well-being. It also puts in perspective theinter-relationships of human resources to health care and to wellness; the discussion inthe introductory section of this report describes the most important among these andidentifies specific data requirements. It should be noted that these inter-relationshipsare not unidirectional, and that health human resources, in turn, have an impact uponvarious aspects of service delivery, such as quality of care and access.III. CURRENT SITUATIONWhile information requirements for the human resources sector are complex and,ideally, should be approached from a perspective that yields a comprehensive, dynamicdatabase, certain workforce-related components of such data already exist in one oranother format at various jurisdictional levels. The availability, quality andcomprehensiveness of data on population health and health status measures, and onservice organization and capital inputs (including physical resources such as buildingsand technology) have presumably been the subject of other Project Team reports. Thediscussion here is limited to information pertaining to the health workforce.161. Information Currently AvailableInformation is currently available in two forms: printed reports and computer-based files. It is difficult to claim that any list of reports or files pertaining to healthhuman resources can be comprehensive, given the proliferation of stake-holders at boththe national and provincial levels in this field. A preliminary listing of the main oneswill provide a sense of the variety and diversity of such information. Most of theprinted reports come from special projects, while some are generated for administrativepurposes and a few are made available on an on-going basis, at equal time intervals.Computer-based information is, generally, more systematically collected. Included inthis is information related to:Education[fraining Programs· National data (Statistics Canada) on educational enrolment and output byoccupational group.· Provincial reports (from RC., Alberta, Ontario, and Saskatchewan) oneducational enrolment and output for health occupations.· Provincial data (all provinces) on enrolment and output for 30 occupationsreported in "Health Personnel in Canada" (Health and Welfare Canada).· Inter-provincial comparative data on undergraduate medical students(Association of Canadian Medical Colleges).· Inter-provincial comparative data on post-graduate medical students (CanadianPost-M.D. Education Registry).Listing of educational programs, entrance requirements, length of training, andqualifications awarded in the "Annual Directory of the Canadian HospitalAssociation" (Canadian Hospital Association).17Supply· Census data by occupational group.· National Graduates Survey - Census-based data (Employment and ImmigrationCanada), by field of study, by occupation and by age. Special abstracts arepossible.· National data for RNs from provincial licensing bodies (Canadian NursesAssociation and Statistics Canada) provides information on numbers, socio­demographic characteristics and employment.· Data on physicians (Southam Medical Database) containing a listing ofphysicians by location, year and place of graduation, and specialty. Annualstatistical tables are published by Health and Welfare Canada.· The Canadian Medical Association developed its Physician Resources Databasefrom a Masterfile of Canadian physicians and on survey data obtained everyfour years. Data on demographic characteristics are linked to data on practicepatterns.· The 1984 report "Physician Manpower in Canada, 1980-2000" submitted by theFederal/Provincial Advisory Committee on Health Human Resources, containeddata on supply and requirements by major specialty groups.· The first of a three phase project to establish a comprehensive nationaldatabase on physicians is now near completion (National Physician Database).Data on fee-for-service physicians include socio-demographic characteristics ofphysicians and patients and physician activity patterns by specialty. This coversabout 80 percent of physicians in Canada. Phase II will include data on fee­payments by other public agencies (e.g. Workers' Compensation, etc.), as wellas information on non-fee payments (e.g. salaried, sessional fees, contracts,etc.). Phase III will include information on non-clinical activities of physicians(e.g. academic, administrative, etc.).· Data on supply and requirements for Physiotherapists, Occupational Therapistsand Audiologists\Speech-Language Pathologists were published in the"Federal/provincial Report on Rehabilitation Personnel", 1988, submitted to theConference of Deputy Ministers of Health.· Annual publication of "Health Personnel in Canada" provides year-end statisticsby occupation (30 groups) and by province covering a 10-year period.18Utilization· National Physician Database contains information on fee payments; practicepatterns and productivity measures can be obtained from these data.Data on hospital-based personnel from the Annual Return of Health CareFacilities - Hospitals (Statistics Canada). Include (for other than medicine)numbers employed, full-time-equivalents, paid hours, and workload.· Employer surveys of filled and vacant permanent positions in the health sector(Alberta, Saskatchewan, annually) and of difficult-to-fill vacant permanentpositions (B.C., quarterly; periodically in Ontario)."Job Futures 1990" contains labour market information and careeropportunities to 1995 (Employment and Immigration Canada).Licensure/Certification!RegistrationFederal/Provincial Advisory Committee on Health Human Resourcespublication "Statutory Provisions and Entry to Practice Regulations for:Physicians, Registered Nurses, Nursing Assistants, Registered PsychiatricNurses", April 1988; "Statutory Provisions and Entry to Practice Regulationsfor: Pharmacists, Dentists, Dental Hygienists, Denturists/Denturologists, DentalAssistants, Dental Nurses, Dental Therapists", November 1988.Federal/Provincial Advisory Committee on Health Human Resources andHealth and Welfare Canada publication "Catalogue on Health ManpowerLegislation", 1985 edition. Includes legislation by province for Canada,legislative plans/policies by province and comparative provincial legislation byoccupation.A 1985 and 1990 edition of "Directory of National Certification Bodies,National Professional Associations and National Accreditation Agencies forVarious Health Occupations in Canada" (Health and Welfare Canada).Includes information for 59 groups.· "The Practice of Dental Hygiene in Canada" and "Clinical Practice Standardsfor Dental Hygienists in Canada", Part I and II, respectively, of the Report ofthe Working Group on the Practice of Dental Hygiene, 1988.19ImmigrationPeriodic publications on occupational entry requirements, qualificationsrequired for registration/certification/licensure by province or territory(Employment and Immigration Canada).Information provided to the provinces on the annual number of landedimmigrants by immigrant class, intended field of health occupation and byprovince (Employment and Immigration Canada). Data on temporaryemployment authorization can be obtained upon request.. Information provided to the Federal/Provincial Advisory Committee on HealthHuman Resources on "designated occupations" to manage the flow of healthcare workers from abroad (Employment and Immigration Canada).The variety of provincial information currently available and the multiple sourcesfrom which these data are drawn present a major drawback to any type of collaborativeplanning or research effort. Even within the same jurisdiction, information on trainingand education, if available, may not be compatible with information on supply or labourforce behaviour. A key problem, even when all these data are collected at theindividual level, is the absence of unique identifiers that could link the data collected byvarious efforts and so provide a more comprehensive information base. For example,with unique identifiers it is relatively easy (the computer technology is available) to linkinformation from regulatory bodies to those of special surveys and census surveys. Anational system of issuing unique identifiers could provide specific human resourcesinformation, including inter-provincial migration, as well as population health andservice utilization information, at relatively low cost.202. Sources of InformationWhile specific sources of information for the above-mentioned items have beenalready identified, there are other sources which could, potentially, provide relevantdata. Following is a list of generic sources which includes those specifically named.Licensing BodiesFor groups requiring a licence to practice a profession. Such data sources willexclude personnel with relevant training but not licensed.Professional Associations and SocietiesFor groups requiring mandatory registration. These data provide information onthose who choose to be registered at a point in time and thus exclude potentialworkforce not employed in the field and possibly some employed in the field with othertitles who are not registered. For groups without mandatory registration but who haveexclusive use of title, numbers can be ascertained with the relevant professional body,but it cannot be known how many are practising without registration. For groupswithout either mandatory registration or exclusive use of title, membership data are allthat is available. These data will likely exclude some personnel employed in the fieldwith the relevant titles.21Provincial Pay AgenciesFor groups paid directly by provincial pay agencies; beyond physicians, there isconsiderable inter-provincial variability. This source will exclude personnel paid byother means.Federal Taxation DataFor those who are self-employed professionals. It cannot provide any detail onspecialty or area of work, such as pediatric oncologists or obstetric nurses, for example,nor will it include those health professionals who are employed in a related field, e.g.academic physicians or nurse educators.Employment and ImmigrationFor new entrants from abroad, by self-reported profession. Information on socio­demographic characteristics, training and qualifications are available, but have not,traditionally, been made routinely available to health human resource planners(provincial authorities).Surveys and Other Special Purpose DataProvincial sources include special surveys of consumers of services, of sub­populations, of employers, and surveys of personnel. The data are subject to all themethodological limitations of surveys. Special purpose data such as the Southam22Medical Database and the National Physician Database are also subject to limitations;the degree of methodological rigour will determine their "robustness".3. Gaps Existing in Current InformationOnce again, an exhaustive list of gaps that exist in the information currentlyavailable cannot be presented without an exhaustive list of all available information.Nevertheless, it is useful to discuss a few general problems of existing data.Census data by occupational group provide point-in-time estimates (snapshots).The data can be used to establish the socio-demographic profile of anoccupational group but do not lend themselves to longitudinal analyses. Forexample, percent change over time may be calculated from these data, butattrition rates from a profession cannot be estimated nor can average annualrates of change, making the usefulness of census data very limited.National data on nurses covers only registered nurses; data on total registerednursing assistants/licensed practical nurses, aides, orderlies, etc. in all servicesettings are unavailable. A broader perspective towards planning is required toeven begin to address shortage problems. Without information on othernursing categories, it is impossible to examine alternative staffing possibilities(such as team nursing) and their impact on service delivery.. Absence of national data for groups other than RNs and Physicians; provincialdatabases may exist but, depending on professional legislation, may not becomparable. Licensure, certification, and registration procedures by definitionyield different qualities and quantities of information. Where inter-provincialvariation exists in the legislation, data comparability will be greatly reduced.Most provincial data on health human resources are limited to head counts.Details about specialty, employment, labour force activity, etc., if available, areself-reported and subject to serious limitations. Without adequate resources totest and verify data quality to prepare these for research purposes, even simpledescriptive statistics will be impossible to obtain.23· Employment data are available only < in a few provinces from special surveysand are not amenable to inter-provincial comparisons. Since there is nocoordination or collaboration between provinces in this area, individual effortsdo not yield collective returns.Hospital-based workload data lack specificity in some professions; some datafor others are altogether non-existent. Consistent basic reporting requirementsto facilitate determination of case load management guidelines could provideimportant information for assessing quality of care. The inconsistency ofprovincial reporting requirements at present does not allow the generation ofuseful workload measures.· Since the system is hospital-based, the existing information is mainly for theinstitutional sector. Very limited administrative information exists oncommunity-based services, mainly because of its funding, one method that doesnot require detailed accountability. The almost total lack of information onservice requirements in the public health sector and, consequently, on itshuman resources requirements, has created a large knowledge gap in this area.· No systematic information exists about health professionals practising in theprivate sector (who are being paid by other than public funds). The size ofthis sector varies by province; therefore, inter-provincial comparisons couldprove useful from a policy perspective. Special surveys, systematicallyadministered, could yield useful information.In summary, these gaps exist in the current information base because suchinformation generally exists primarily for administrative purposes, i.e. for licensing oneprofessional or paying another, and not specifically for planning or research purposes.The absence of a rational, comprehensive human resources planning framework hasmeant that information requirements for such activities at the national or provinciallevel have not been articulated and defined. At the international level, WHO haddescribed in 1971, and in some detail, data requirements for the development of studiesin health human resources (Attachment 2). Preliminary discussions regarding the24feasibility of developing a comprehensive nurse planning database in B.c. are underway.The Health Human Resources Unit has developed a preliminary model of such adatabase. The following list describes the components of such a database, and couldserve as an example for a prototype.Information Components for a Model for Nurse Planning Database- unique identifier- Social Insurance Numbernamehome street address- work street address- city of homecity of work- postal code of home- postal code of workregistration numberunit of work (ward number)structure of work (patient care system)- position- education - when, where, how much- gender- age- marital status- children- registration statusregistration history- employment statusregular (full, part); casual (full, on-call)union affiliation- work schedulehours worked- wages per individuallength of employment- seniorityjob description- statutory provisionslicensing standards - foreign;provincial; national- contractual provisions- benefits - pensions- personnel records (start date, end date, transfers)- exit interviews- employer policies re: leave (education, personal)child care, orientation, hiring preferences,nurse:patient ratios- employing facility - structure, number of beds,hospital role, status, dtf vacancies- UIC statistics - provincial, nationalcollege and university training programs- enrolments, attrition, enrolment demographics,curricula, training costs - to student; toeducator- wage rates for other selected professions- enrolments for other selected professional trainingprogramsattrition from other selected professional trainingprogramscosts of other selected trainingprovincial population demographicsinter-provincial migrationutilization datapatient acuity measuresdisability data from Worker's Comp and UIChospital and educational accreditation standardseconomic indicators - provincial- prime rate- inflation rate- GDP- unemployment rate- productivity indicators- taxation data (aggregate)- . physician supply25IV. RECOMMENDATIONSIn general, data currently used for health human resources planning and researchactivities are secondary data, compiled and developed from administrative information.Very rarely may primary data be available through surveys of special sub-populations(e.g. specific occupational groups or, employers of such groups). Thus,recommendations regarding human resource information requirements are based onpossible action to improve and build on what already exists.1. To Improve Existing Databases· That National Health Information Council endorse the Federal/Provincial effortto continue the National Physician Database into Phases II and III and tocomplete the information package on physicians (specific data comparabilityrecommendations are contained in the report of the Project Team on theComparability of Health Services Information) and promote access to it for thevarious stake-holder groups through the publication of regular reports orthrough other means.· That the Canadian Nurses Association and Statistics Canada collaboration onthe national registry for RNs examine and document the major limitations ofthese data with the intent to improve the quality of these by: a) changing thedate of record to provide a more complete picture of the year, b) investingmore resources to the data verification and clean-up aspects of such datadevelopment, and c) making this information available to a broader user-groupand through machine-readable media.· That Health and Welfare Canada, in collaboration with the provinces and thenational professional and/or regulatory bodies, conduct a systematic review ofdata currently published in "Health Personnel in Canada" to enhance itsaccuracy and completeness and to reconcile it with data from provincialsources.26· That the National Health Information Council support the enhancement of theworkload measurement system through the implementation of the ManagementInformation Systems guidelines.2. To Develop New Databases· That federal and provincial governments collaborate with the regulatory bodiesfor nursing occupations to develop nurse supply and nursing servicerequirements models based on common definitions of data elements and acommon modeL The RN supply model developed by Re. could serve as aprototype.· That federal and provincial governments establish regular communicationchannels with national and provincial licensing/registering bodies for otherhealth personnel in order to promote the systematic development ofcooperative health human resource databases that fully describe supply.· That Health and Welfare Canada and Employment and Immigration Canadacollaborate on the sharing of immigration data (sufficiently disaggregated to beuseful to health planners), including socio-demographic characteristics ofmigrant populations.· That provincial governments require human resource impact statements fromall agencies that submit regular or special (operating and capital) fundingrequests to the government. The role of the federal government would be oneof national coordination of the criteria to be included in such statements andof national dissemination of the research evidence.3. To CoordinatelLink All DatabasesWhile the issue of inter-provincial coordination has been addressed in anotherreport (Project Team on Data Comparability), the concern here is the long-term goal oflinking databases to make the most efficient use of the resources invested increating/developing multiple data sets by different stake-holders.27· That the use of scrambled unique identifiers be promoted among the federaland provincial agencies officially responsible for data development anddissemination, in order to obtain a comprehensive administrative databasecomprised of individual components that are complementary to one anotherand could be supplemented by periodic and regular survey data such as Censussurveys or health status surveys of sub-populations.28ATTACHMENT 1EXECUTIVE SUMMARY FROM THEWORKSHOP ON PRIORITIES ON HEALTH HUMAN RESOURCES RESEARCHWORKSHOP ON PRIORITIES IN HEALTH HUMAN RESOURCES RESEARCHEXECUTIVE SUMMARYThis workshop, funded by the National Health Research Development Program(NHRDP), was held on September 27 and 28, 1989 at the University of BritishColumbia in Vancouver. It was attended by 27 academic and governmentrepresentatives from the federal, provincial/territorial levels. A discussionpaper on the issues and activities in health human resources, prepared byLourdes Flor of Health and Welfare Canada, served as background material forworkshop participants. Two papers were presented: 1) Overview of problemareas by David Pascoe (Manitoba), and 2) Current status of health humanresources research by Marc-Andre Fournier (University of Montreal) prior totwo workshops.Workshop 1, entitled Priorization of Problems, included the following topicsfor group discussion:ShortagesThis group found that the issue was not one of shortages or surpluses but oneof appropriate mix of manpower and barriers to changing the current mix.While shortage situations can be 'real' or simply a redistribution problem,the issue to consider is what combination of skills/personnel and deliverymodels will provide for the needs of the population.SurplusesThis group developed a conceptual framework for health human resourcesplanning. They concluded that population health needs should define the mix ofmanpower rather than professional assertion of need. In essence, to switchthe onus of proof of need to the providers.Retention and DeploymentThis group concluded that the definition of need was complex; problemscentering on recruitment and retention were related but the latter was moreacute. Also, distribution and management strategy/politics could be addressedthrough a better mix and more efficient utilization of personnel.Workshop 2, entitled Identification of Research Gaps, included the followingtopics for group discussion:Program EvaluationThis group identified that there are research opportunities in distribution/redistribution incentive programs with a focus on process evaluation, andalternative designs to the randomized control trial (RGT); examination ofservice needs (definition of skills and training required); focus onevaluations that are not program-specific but taken in the context of societalvalues (the village square vs the chi square).Planning/forecastingThis group focused on different models that embodied regional, short-term andlong-term planning. Use of current models was accepted if changes intechnology, personnel mix, and service delivery mechanisms were incorporatedas key variables. Simulation modeling was identified as a potentially usefultool.Organizational DesignThis group discussed the roles of government, educational institutions,professional associations and regulatory bodies, and the influence of publicperception, employers and unions, in fostering or impeding health structuralreorganization. They proposed that research should be aimed at documentingperformance relative to legislated scope of practice, public accountability,and how effectively statutory acts represent the public interest. As well,alternate production possibilities should be a key consideration of futureresearch.Workshop 3,the Identification of Priority Research Areas, was preceded bybrief comments on the purpose of health human resources planning by Dr.Arminee Kazanjian. The group in its entirety participated in the consensusdevelopment workshop, with Dr. Stephen Gray acting as facilitator. Theydefined the following priorities in health human resources research:1. Assessment of population health needs by examination of demographicanalyses, epidemiological surveys and effectiveness research (changingtechnological and clinical capabilities).Addressing population health needs from an efficiency perspective byresearch into alternate production and service delivery possibilities(both in an ideal situation and taking account of current scope ofpractice limitations), as well as an examination of the direct andindirect implications of surpluses/shortages.2. Exploration of the optimal number and mix of providers to meet the healthneeds of the population.Research related to development of policies to achieve efficient mixes byexamining resource allocation decisions between competing servicerequirements; and by investigating political, legal, economic and socialbarriers which impede progress toward a more efficient deployment ofhuman resources.3. Examination of policy implementation strategies and the study ofsubsequent political/socioeconomic implications of such strategies.Research into the fiscal and organizational modalities which promote amore efficient mix of health personnel through the analysis of the costs(both economic and political) of implementing specific public policies,as well as the cost of no policy intervention. Figure 2(a) illustratesthe current health human resources situation while 2(b) indicates whatthe process should be.Concluding RemarksAcademic researchers and policy analysts have indicated that national healthinsurance has been a missed opportunity to implement organizational change andto consider a more efficient use of health human resources. The Canada HealthAct is a newer opportunity to apply lessons learned from these analyses. Astated commitment by the government to health promotion and a healthy publicpolicy provides another opportunity to implement changes in the organizationand financing of health care. So far, the focus of manpower policy has beencost control; given the current rate of diffusion of health care technology,quality of care and accessibility have become major areas of public concern,providing an additional avenue for policy formulation and the implementationof structural change.In summary, three policy areas that impact health human resources planningare: professional governance and regulation, manpower supply policy, anddelivery organization and financing. The crucial interrelationships betweenthese three areas have not, heretofore, been fully investigated and warrantmuch closer attention. The participants to the Workshop concurred thatresearch in these areas is not only important in understanding and explainingthe current situation, but also central to the development of public policylevers with which governments can take responsible action. In fact, thedeliberations of Workshop participants resonate very well with the particularhealth human resource areas of concern expressed by the NHRDP's Committee ofProvincial and Territorial Representatives. The workshop setting facilitatedthe exchange of perspectives and provided the necessary detail for identifyingspecific gaps in research which can be bridged given the current state of theart.Figure 2(a)Current Health Human ResourcesSituationContextofPo Ii tical,Social,EconomicBarriers/OpportunitiesPopulationHealthNeedsPrograms/ServicesMix of Human& Non-HumanResourcesCurrentSupplyScope ofPractice &TrainingOrganizationDesignWorkshop on Priorities in Health Human Resources ResearchSeptember 27 & 28, 1989Vancouver, B.C.Figure 2(b)Framework For EstablishingResearch PrioritiesPopulationHealthNeedsPrograms/ServicesScope ofPractice &TrainingCurrentSupplyContext ofPolitical, Social,Economic Barriers/OpportunitiesOrganizationDesignWorkshop on Priorities in Health Human Resources ResearchSeptember 27 & 28, 1989Vancouver, B.C.ATTACHMENT 2DATA REQUIREMENTS - WHO SCIENTIFIC GROUP ONTHE DEVELOPMENT OF STUDIES IN HEALTH MANPOWER, 1971DATA REQUIREMENTSA WHO Scientific Group on the Development of Studies in HealthManpower recommended the development for manpower planners of adetailed list of the information required, perhaps supplementedby model questionnaires that had been satisfactorily field testedunder varying conditions. As an initial effort in this regard,the Scientific Group included in its report' a list of the majorinformation categories it considered potentially relevant tomanpower planning, discussing the special significance of, andthe problems associated with, each category. These categorieswere more a checklist of items for possible inclusion in the datacollection design than a mandatory list of minimum requirements,and indeed, depending on the planning approach and the specificproblems to be studied, some are of little or no relevance. Thereport of the Scientific Group includes supplementary comments onthe potential uses and limitations of these informationcategories, which are listed below.(1) Demographic dataPresent and projected population by age and sex,population density and distributionMigrationLife expectancyPresent and projected birth and death rates(2) Economic informationPatterns and tendencies regarding national, health sector,and personal income and expendituresCost of providing health services and of maintaining thedifferent manpower categoriesCost-effect estimates for selected health programmesEmployment rates and distribution according to majoroccupational groupingsHealth insurance benefits(3) Health status and needsMortality and morbidity data according to major causes, age,sex, and geographical distributionThe extent to which the leading causes of death and illnessresult in a demand for health care and in disabilityEnvironmental, nutritional, cultural, and other factorsaffecting health status'WHO Technical Report Series, No. 481, 1971 (The developmentof studies in health manpower: report of a WHO ScientificGroup. )(4) Use of health care services by the populationHealth services used (or "met" demand) according to number,types, quality, and effectsCharacteristics of users, including their attitudes andknowledge regarding health services use and the healthsystem that provides themApproximate volume of services desired (and/or needed) thatare not obtained, according to type of serviceCharacteristics of those who desire (and/or need) servicesReasons for not obtaining desired (and/or needed)services(5) Health manpower supplyData, by manpower category, on the number, activity status,sex, age and/or year of graduation, work, geographical location,and speciality qualifications of personnel(6) The health system and health manpower utilizationData on the number, size, characteristics, and distributionof health facilities, on their staffing patterns including jobvacancies, and on their functional interrelationshipsData on the diverse aspects of health manpower productivity,functions in different settings, and institutional,organizational, and legal contexts within which health personnelare active.(7) Health manpower trainingQuantity and quality of applicants for training'Enrolments by year of study'Institutional objectives and orientationDuration of studyNumber and qualifications of teaching personnelActual and potential capacity of training institutionsStudent attrition and repetition and their major causesData on past graduates and the revalidation of foreign­earned degreesTrainging costsContent and organization of curricula'In some cases it may be necessary to obtain adisaggregation of applicant and enrolment data according to suchadditional variables as sex, ethnic origin, linguistic group, andresidence.(8) Health manpower planning in the national contextInformation about (a) planning bodies, professionalorganizations, educational and service institutions, and consumerand political groups interested in health manpower and healthservices; (b) non-health sector requirements for trainedmanpower; (c) the present government's policies, priorities, andtime remaining in office; (d) long-range development plans andprospects; and (e) administrative capacities and constraints.


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