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Regional health human resources planning & management : policies, issues and information requirements Kazanjian, Arminée, 1947-; Hebert, Marilynne; Wood, Laura Christine, 1955-; Rahim-Jamal, Sherin, 1963- Jan 31, 1999

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REGIONAL HEALTH HUMAN RESOURCESPLANNING & MANAGEMENT:POLICIES, ISSUES AND INFORMATION REQUIREMENTSHHRU 99:1Health Human Resources Unit Arminée Kazanjian, Dr.Soc.Centre for Health Services and Policy Research Marilynne Hebert, Ph.D.The University of British Columbia Laura Wood, M.H.Sc.Vancouver, British Columbia V6T 1Z3 Sherin Rahim-Jamal, M.Sc.January 1999Canadian Cataloguing in Publication DataMain entry under title:Regional health human resources planning & management (Research report / Health Human Resources Unit : HHRU 99:1) ISBN 1-894966-98-7  1. Medical personnel--British Columbia.  2. Health planning--British Columbia.  3. Medical personnel--Supply and demand--British Columbia.  I. Kazanjian, Arminée, 1947-  II. University ofBritish Columbia. Health Human Resources Unit.  III. Series:Research reports (University of British Columbia. Health HumanResources Unit) ; HHRU 99:1.RA410.9.C2R43 1999 331.12'913621'09711C99-910139-0iHEALTH HUMAN RESOURCES UNITThe Health Human Resources Unit (HHRU) was established as a demonstration project by theBritish Columbia Ministry of Health in 1973.  Since that time, the Unit has continued to be funded onan ongoing basis (subject to annual review) as part of the Centre for Health Services and PolicyResearch.  The Unit undertakes a series of research studies that are relevant to health humanresources management and to public policy decisions.The HHRU’s research agenda is determined through extensive discussions of key current issues andavailable resources with the senior staff of the Ministry of Health.  Various health care providergroups participate indirectly, through on-going formal and informal communications with Ministry ofHealth officials and with HHRU researchers.  Research is undertaken by seven professional staff,including secretarial and analyst support; Arminée Kazanjian is the Associate Director and PrincipalInvestigator for the Unit.Three types of research are included in the Unit’s research agenda.  In conjunction with professionallicensing bodies or associations, the HHRU maintains the Cooperative Health Human ResourcesDatabase.  The Unit uses these data to produce regular status reports that provide a basis for in-depth studies and for health human resources planning.  The Unit undertakes more detailed analysesbearing on particular health human resources policy issues and assesses the impact of specific policymeasures, using secondary analyses of data from the Cooperative Database, data from theadministrative databases maintained under the HIDU, or primary data collected through surveys.The HHRU also conducts specific projects pertaining to the management of health human resourcesat local, regional and provincial levels.Copies of studies and reports produced by the HHRU are available at no charge.Health Human Resources UnitCentre for Health Services and Policy Research#429-2194 Health Sciences MallVancouver, BCV6T 1Z3Ph:  (604) 822-4810Fax:  (604) 822-5690email:  hhru@chspr.ubc.caURL:  www.chspr.ubc.caiiiiiJanuary 12, 1999Dr. Alan ThomsonMedical ConsultantPlanning and EvaluationMinistry of Health and Ministry Responsible for Seniors1515 Blanshard StreetVictoria, B.C. V8W 3C8Dear Dr. Thomson:It is with pleasure that I transmit to you a discussion document developed for theVancouver/Richmond Health Board entitled “Regional Health Human Resources Planning andManagement: Policies, Issues and Information Requirements.”The report was written in response to the Regional Health Board’s Health Providers EducationAdvisory Committee (HPEAC)’s explicit identification of the need for information pertinent to healthhuman resources planning.  It contains recommendations for the Ministry of Health, for RegionalHealth Boards, and other stakeholders.  Issue-specific recommendations are also provided in thereport.We trust you will find this report useful and look forward to your comments and suggestions.Sincerely yours,Arminée Kazanjian, Dr. Soc.Associate DirectorCentre for Health Services and Policy ResearchivvTable of ContentsExecutive Summary ................................................................................................................ 11.  Introduction ....................................................................................................................... 71.1  Health Human Resources and Service Delivery ......................................................... 71.2  Purpose of Health Human Resources Activities ......................................................... 81.3  Information-based Functions of Health Human Resources ....................................... 81.3.1  Monitoring and Evaluation .................................................................................... 81.3.2  Planning ................................................................................................................ 81.3.3  Policy Research ..................................................................................................... 92.  Key Issues in the Management of Health Human Resources ............................................ 92.1  Structural Factors That Have an Impact on Health Human Resources ................. 122.1.1  System Organization and Financing ..................................................................... 122.1.2  Self-Governance and Health Professions Regulation ............................................ 122.1.3  Training and Supply Policy .................................................................................. 132.2  Service Delivery Issues That Have an Impact on Health Human Resources .......... 142.2.1  Organizational Structure ..................................................................................... 142.2.2  Agency-Specific Management Practices .............................................................. 142.2.3  Terms and Conditions of Employment ................................................................. 152.3  Planning Issues That Have an Impact on Supply and Requirements ..................... 152.3.1  Demand Forecasting ........................................................................................... 152.3.2  Supply Forecasting .............................................................................................. 152.3.3  Adjusting Supply to Meet Demand ...................................................................... 162.3.4  Integration of Health Human Resources and Strategic Planning ........................... 163.  Regional Health Human Resources Planning and Management Information ............... 163.1  Determining Information Requirements .................................................................. 163.2  Current Sources of Information ................................................................................ 183.3  Gaps Existing in Current Information ..................................................................... 213.4  Data and Information Issues ..................................................................................... 233.4.1  Determining Data Sources .................................................................................. 233.4.2  Data Ownership .................................................................................................. 233.4.3  Confidentiality .................................................................................................... 243.4.4  Data Reliability and Validity ................................................................................ 243.4.5  Information and Communication Technologies .................................................... 25vi3.5  Learning to Use Information versus Technology: Knowledge and SkillsRequired .................................................................................................................... 264.  Recommendations ............................................................................................................ 264.1  Needs-based Approach to Health Human Resources Planning ............................... 264.2  Information Necessary for Decision-making ............................................................ 264.3  Standardized Data Collection ................................................................................... 264.4  Data Management ..................................................................................................... 264.5  Ministry of Health Responsibilities .......................................................................... 264.6  Representation of Regional Interests ........................................................................ 274.7  Standards for Health Human Resources Databases ................................................ 274.8  Inter-ministry Collaboration .................................................................................... 274.9  Technical Support ..................................................................................................... 274.10  Issue Specific Recommendations ............................................................................ 275.  Description of Selected Models for Organization of Health Human ResourcesPlanning .......................................................................................................................... 295.1  British Columbia Provincial Renal Agency (BCPRA) ............................................. 295.1.1  Steering Committee ............................................................................................ 305.1.2  Operations Committee ........................................................................................ 315.1.3  Advantages and Disadvantages of Adapting the BCPRA Organization toHealth Human Resources Planning ...................................................................... 315.2Provincial Coordinating Committee on Remote and Rural Health Services .......... 325.2.1  Reporting ........................................................................................................... 325.2.2  Duties ................................................................................................................. 325.2.3  Membership ........................................................................................................ 335.2.4  Support .............................................................................................................. 335.2.5  Advantages and Disadvantages of Adapting the PCCRRHS OrganizationalStructure to Health Human Resources Planning .................................................. 335.3  Possible New Structure for Organization of Health Human Resources Planning .. 345.3.1  Advantages and Disadvantages of New Structure ............................................... 356.  Implementation ................................................................................................................ 36Appendices ............................................................................................................................. 37Appendix A - Tables Illustrating Variety of Data Sources ............................................ 38Appendix B - Description of Health Personnel by Educational Preparation andRegulation ................................................................................................ 47viiAppendix C - Identifying and Comparing Categories of Selected Health ServicesWorkers .................................................................................................... 50Appendix D - Summary of Selected Current Health Care Personnel Classificationsand Databases ........................................................................................... 52Appendix E - Health Personnel in B.C. by Data Available for Publication inRollcall ’95 and Place of Graduation ’95 ................................................. 53Bibliography ........................................................................................................................... 54Reports of the Health Human Resources Unit .......................................................................... 55viiiHealth Human Resources UnitRegional Health Human Resources Planning & Management1EXECUTIVE SUMMARY1. IntroductionThe purpose of health human resources management and planning activities is to identify and achievethe optimal number, mix and distribution of personnel, at a cost society is able to afford.  It is notsimply establishing the required number of physicians, nurses, pharmacists, or technologists, etc.; it isestablishing the numbers in each of these and other groups, given the most cost-effective andappropriate mix of required personnel and their equitable geographic distribution based on varyingservice needs.  Therefore, the determination of the depth and breadth of information required tofacilitate such health human resources management and planning activities is complex.Consequently, the information requirements associated with health human resources planning havebeen erroneously identified with the planning itself, in the form of simple counting of supply, or, atbest, the estimation of workforce requirements based on some arbitrary p pulation:personnel ratio.A needs-based approach to health human resources planning draws on techniques that assess theprevalence of diseases and the burden of illness in a target population.  Health deficits can betranslated into health care services or task requirements.  Alternative mixes of inputs (human andnon-human) can be identified, based on evidence of effectiveness and the social context, to meetthese task requirements.  A comparison of human resources requirements against currently availableskills would determine net requirements.  Different planning activities can be considered when animbalance is indicated.From a regional planning perspective, a needs-based approach may be more practical and appropriatethan the methods used historically in provincial planning.  Using this approach, local and regionalneeds assessment activities can provide the appropriate input data for health human resourcesplanning.2. Key Issues in the Management of Health Human ResourcesA number of complex issues affect health human resources planning and management:· structural factors,· service delivery issues, and· planning issuesA number of structural factors, some not immediately related to human resources, have majorimplications for the management of health human resources.  These include system organization andfinancing, self-governance and health professions regulation, and training and supply policy.Service delivery issues, which include organizational structure, agency-specific managementpractices, and terms and conditions of employment, also have serious implications for humanresources management.To date, very slow progress has been made towards a systematic planning approach for estimatinghuman resources requirements.  A systematic approach would include forecasting demand andHealth Human Resources UnitRegional Health Human Resources Planning & Management2supply, adjusting the supply accordingly, and integrating health human resources with strategicplanning.  Problems in adjusting supply to meet forecast demand are difficult to address without thejoint development and use of a comprehensive planning database by both the training and healthsectors.  From a regional perspective, the integration of human resources planning with strategicplanning (service and financial planning) is an important consideration.  Undertaking separateplanning for each profession fails to challenge the somewhat artificial boundaries between theprofessions and also does not provide the most appropriate, cost-effective way of delivering servicesin a jurisdiction.  Alternatively, determining the services needed through the development of a healthplan, followed by the identification of the most appropriate and efficient mix of resources forprovision of those services will better enable regions to plan for health human resources in a way thatsupports the region’s specific strategic plan.3.  Regional Health Human Resources Planning & Management InformationThe complexity of issues in the management of health human resources commands complexinformation requirements.  However, certain workforce-related components of such data mayalready exist in one format or another at various jurisdictional levels.As is illustrated by the Proposed Framework for Health Human Resources Planning, depicted in thefigure below, strategic goals of a region are in part derived from population health needs.  Populationhealth needs can play an important role in determining programs and services, which in turndetermine the appropriate mix of resources needed.  While this framework presents a challenge indata collection for a provincial planning effort, it is more manageable on a region by region basis, andstandardization would enable comparison across regions.P r o p o s e d  F r a m e w o r k  f o r  H e a l t h  H u m a n  R e s o u r c e  P l a n n i n g( a d a p t e d  f r o m  P r o c e e d i n g s  o f  t h e  W o r k s h o p  o n  P r i o r i t i e s  i nH e a l t h  H u m a n  R e s o u r c e s  R e s e a r c h  i n  C a n a d a,  H H R U  9 0 :2 )I d e n t i f y / M e e tP o p u l a t i o n  H e a l t hN e e d sD e t e r m in e  M i x  o fH u m a n  a n d  N o n -H u m a n  R e s o u r c e sC u r r e n t  S u p p l y O rgan i za t ionD es ignS c o p e  o f  P r a c t i c e&  T r a in ingI d e n t i f y  P r o g r a m s  a n dS e r v i c e s  N e e d e dD e v e l o p  S t r a t e g i cR e g i o n a l  G o a l sP r o v id e  P r o g r a m sa n d  S e r v i c e sHealth Human Resources UnitRegional Health Human Resources Planning & Management3There are many current sources of information that can be of use in planning for health humanresources at the regional level.  The challenge for regional planning is to determine whatinformation is needed, where it is available, and how to access it and use it.The location of specific information regarding the supply and employment of health servicesworkers in B.C. can be determined by asking questions related to supply and employment (seeFigures 4 and 5 in the report).  The appendices provide a selected listing of primary sources of data(which contain information related to education and training programs, supply, utilization,immigration, and licensure/certification/registration etc.) as well as a list of generic sources whichincludes licensing bodies, professional associations, provincial pay agencies, federal taxation data,employment and immigration data, etc.The variety of provincial information currently available and the multiple sources from which thesedata are drawn present a major drawback to any type of collaborative planning or research effort.  Akey problem, even when all these data are collected at the individual level, is the absence of uniqueidentifiers that could link the data collected by various efforts and hence provide a morecomprehensive information base.  A national system of issuing unique identifiers could providespecific human resources information, including inter-provincial migration of health care providers,as well as population health and service utilization information, at relatively low cost.The gaps in current information exist because health workforce information generally existsprimarily for administrative purposes and not specifically for planning or research purposes.  Theabsence of a rational, comprehensive human resources planning frameworkh s meant thatinformation requirements for such activities at the national, provincial and regional level have neitherbeen articulated nor defined.  To illustrate, while scrambled unique identifiers are used for theNational Physician Database, this is not the case for registered nurses (RN’s), so inter-provincialmigration of RN’s cannot be tracked.  Nor do RN’s have as comprehensive a database as thephysicians. There is a lack of national data for groups other than RN’s and Physicians.  Provincialdatabases may exist, but depending on professional legislation, the databases may not be comparable.Most provincial data on health human resources are limited to head counts.  Details aboutspecialty, employment, labour force activity, etc., if available, are self-reported and subject to seriouslimitations.  Employment data are available only in a few provinces from special surveys and are notamenable to inter-provincial comparisons.  This negative situation would be replicated at theRegional Health Board level if each acted separately from the others in undertaking regionally-basedsurveys.  Since the system has been hospital-based, the existing information is mainly for theinstitutional sector.  Very limited administrative information exists on community-based services.The almost total lack of information on service requirements in the public health sector and,consequently, on its human resources requirements, has created a large knowledge gap in this area.In addition to the gaps existing in current information, data and information management issuesarise in a number of ways.  These are related to det rmining the information needed forplanning, identifying sources of those data and where gaps exist.  Once the data are located,there are a number of additional issues related to the data quality, including validity, reliability andcomparability.Health Human Resources UnitRegional Health Human Resources Planning & Management44.  RecommendationsThe following recommendations for health human resources planning and management are framed soas to take account of the exigencies of planning at a regional level, as well as the existing challengesin the data available for such purposes.  The recommendations are further detailed in the report.Each Health Region should:1. initiate a needs-based approach to health human resources planning that considers the burden ofillness in a population and population health needs as determinants of the necessary resources(versus the traditional approach based on utilization of services, and personnel to populationratios);2. determine what general and specific information is necessary for decision-making, where suchinformation is available and how to gain access to it and use it;3. develop a systematic approach to standardized data collection and/or development for localinformation needs;4. establish efficient systems to manage the data generated in order to make it accessible and usefulfor decision-making.In addition, certain recommendations should be considered to facilitate the implementation of the 23more specific recommendations contained in the report (see Table 1).  The hierarchy of enablingrecommendations is that:5. The Ministry of Health should be responsible for:a) establishing policy expectations in health human resources based on the health goals forthe province;b) setting general guidelines regarding the data required for planning;c) supporting the participation of smaller regions in health human resources planning;d) facilitating linkages with the national level pertaining to issues of national certification;e) appointing an official(s) to facilitate the coordination of health human resources planningby Regional Health Boards and Community Health Service Societies;f) identifying the resources needed to facilitate the above;6.  A provincial organization representing regional interests should coordinate regional developmentof health human resources plans, anda) the Ministry of Health should facilitate inter-regional coordination of health humanresources planning for Community Health Councils in areas without Regional HealthBoards;b) where appropriate, Ministry of Health and Ministry of Advanced Education, Training andTechnology officials should interact with regions via RHB’s and CHSS’s;c) where appropriate, COUTH, HABC and the HEABC should also be involved;7. The Ministry of Health should develop standards for health human resources databases;8.  The Ministry of Health should collaborate with the Ministry of Advanced Education, Trainingand Technology to identify educational information pertinent to health human resources planningand make possible the collection of such data at the regional level;Health Human Resources UnitRegional Health Human Resources Planning & Management59.  The Ministry of Health should provide technical support in the development of unique identifiersand promote their use by Health Regions.5.  Description of Selected Models for Organization of Health Human Resources PlanningIn order to assist the discussion around the best way to organize health human resources planning inthe regions and across the province, three organizational models are described in the report: theBritish Columbia Provincial Renal Agency (BCPRA); the Provincial Coordinating Committee onRemote and Rural Health Services (PCCRRHS); and a possible new structure for organization ofhealth human resources planning.  Each of the two existing models is examined to determine whetherit can be adapted to serve as a provincial framework for health human resources planning; theadvantages and disadvantages of all three models are discussed.6.  ImplementationIn order to facilitate the implementation of any model for organizing health human resourcesplanning in the regions and across the province, generi  implementation steps are outlined in thereport.6Health Human Resources UnitRegional Health Human Resources Planning & Management71. IntroductionThe supply, distribution, quality, deployment, organization and utilization of health human resourcesare of interest to multiple stake-holders: governments, regional authorities, regulatory bodies,professional associations, unions, training institutions and educational authorities, service providers,self-help groups, and the general public.  In short, interest in policy research and planning in healthhuman resources is particularly strong in a wide range of sectors.  It is, therefore, paradoxical thatinformation requirements for health human resources planning and management have beenerroneously associated with the simple counting of supply or, at best, the estimation of requirementsbased on some arbitrary population:personnel ratio.  This paradox is compounded by the severelimitations imposed by the absence of reliable data available for research and planning in healthhuman resources.  The introductory discussion provides an overview of the breadth and depth ofinformation requirements in this field and the resulting complexities.1.1 Health Human Resources and Service DeliveryIn a general climate of economic restraint, cost-effective delivery of, and equitable access to, healthservices has become the primary focus of managers and researchers in the health care industry.  As aservice industry, by far the largest component of health care costs is labour.  While the specificstatistics vary by jurisdiction and/or by year, health human resources expenditures are never below 60percent and may sometimes be as high as 80 percent of total operating costs.  However, researchefforts to understand the relationship between supply and demand, as well as to examine causes ofincreasing costs, have been severely limited by the lack of reliable data for longitudinal analysis.At a national workshop on priorities in health human resources research (HHRU 90:2), participantsemphasized the desirability of establishing human resource requirements based on the health needs ofthe population as opposed to the more usual way of using a utilization-based definition of servicerequirements.  They identified three key areas where research evidence was the weakest:· assessment of population health needs by undertaking demographic analyses, epidemiologicalsurveys, and effectiveness research to assess changing technological and clinical capabilities;· exploratory research in the efficient deployment of health human resources to meet the healthneeds of the population, including the investigation of barriers which impede progress towardsthat goal;· examination of policy implementation strategies and the study of subsequent political andsocioeconomic implications of such strategies.The needs-based approach draws on techniques that assess the prevalence of diseases and theburden of illness in a target population.  This approach is useful in human resources research whenconsidering the appropriateness of care in managing disease and illness.  Health deficits can betranslated into health care services or task requirements.  Alternative mixes of inputs (human andnon-human) can be identified to meet these task requirements including prevention and healthpromotion.  A comparison of human resources requirements against currently available skills,established through the analysis of existing health workforce training programs, would determine netrequirements.  Different planning activities can be considered when an imbalance is indicated.Health Human Resources UnitRegional Health Human Resources Planning & Management8From a regional planning perspective, a needs-based approach may be more practical and appropriatethan the methods used historically in provincial planning.  Using this approach, local and regionalneeds assessment can provide the appropriate input data for health human resourcesplanning.  A review of the purpose of health human resources activities and related information-based functions sets the stage for discussing these key issues.1.2 Purpose of Health Human Resources ActivitiesThe purpose of all health human resources activities is to identify and achieve the optimal number,mix and distribution of personnel, at a cost society is able to afford.  It is not simply establishing therequired number of physicians, nurses, pharmacists, or technologists, etc.; it is establishing thenumbers in each of these and other groups, given the most cost-effective and appropriate mix ofrequired personnel and their equitable geographic distribution based on varying service needs.Given the number and variety of stakeholders, current health human resources management activitiesare often fragmented.  In addition, specific human resources planning initiatives have often beenhampered by inadequate data and questionable methodologies.  It should be noted that the trainingand employment of health personnel remain within provincial jurisdiction.  However, given inter-provincial migration, educational and employment considerations, policies in one jurisdictionseriously affect the situation in other jurisdictions.  Intra-provincial migration is equally unpredictableand contributes to the complexity of the situation.1.3 Information-based Functions of Health Human ResourcesThe management of health human resources, in its broadest sense, entails various activities that canbe assisted and/or enhanced by the availability of relevant information.  The three information-basedfunctions of human resources management are: monitoring and evaluation; planning; and policyresearch.1.3.1 Monitoring and EvaluationMonitoring relevant information is intended to document particular or general workforce trends or toidentify specific issues and can serve several purposes.  For example, systematic monitoring of socio-demographic and employment characteristics of human resources in an institution develops personnelprofiles within the agency, which contribute to management's understanding of successful retentionstrategies.  As well, systematic monitoring of deployment patterns of health personnel providesaccurate estimates of workload, turnover, attrition, and recruitment.  These activities may beundertaken at the regional level.  To better anticipate local and regional shifts in supply and/orrequirements, routinely monitoring information in each of these areas enables better human resourcesmanagement.1.3.2 PlanningWithin health human resources planning activities, the requirements and available supply areexamined in order to identify imbalances, both currently and in the future.  In addition, theseactivities involve using resources appropriately to meet previously identified service needs.  Thisincludes the assessment of health professions regulation, as well as training and skills for all existingHealth Human Resources UnitRegional Health Human Resources Planning & Management9service providers.  Finally, planning also entails developing new service delivery options to meetfuture service requirements.  All of these activities presume the availability of accurate and consistentinformation.1.3.3 Policy ResearchResearch is necessary to improve the planning process in a number of ways:· to increase our understanding of factors affecting supply and requirements such as demographicand technological changes, and workforce factors such as productivity, retention, case-mix, etc.;· to improve forecasting models; and· to evaluate the impact of clinical, operations, or public policies and programs at various levels.However, without access to reliable databases, policy development efforts become seriouslyhampered.Human resources management, with respect to health care and population health, is a complexprocess.  The breadth and depth of information needed in planning activities is paramount.  Whilehealth and human resources planning has shifted from a provincial to a regional basis, the need forinformation remains critical.  The next section examines key issues in managing health humanresources, followed by more specific regional management issues.2. Key Issues in the Management of Health Human ResourcesThe current framework for managing health human resources provides an avenue for thinking aboutthe information requirements (Figure 1).  Three factors are often thought to be the basis for thisplanning process:  supply; scope of practice and training (assuming training is closely aligned withscope of practice); and organization design.  Consideration of these factors contributes to decisionsrelating to the mix of resources necessary to provide the desired programs and services. While oftennot directly in response to population health needs, the programs are usually developed in responseto existing utilization patterns.A better appreciation of the complex information needs of this sector can be gained through a moredetailed discussion of key issues in the management of health human resources (Figure 2).  Thisdiscussion is not intended to be an exhaustive inventory of all issues; it will deal only with the mainconcerns that are not specific to one profession or another.  Concrete examples that may beprofession-specific are used to elaborate the discussion.Health Human Resources UnitRegional Health Human Resources Planning & Management10Figure 1 - Current Framework for Health Human Resource Planning(adapted from Proceedings of the Workshop on Priorities inHealth Human Resources Research in Canada, HHRU 90:2)Population HealthNeedsMix of Human andNon-Human ResourcesCurrentSupplyOrganizationDesignScope ofPractice &TrainingProvide Programs andServicesUtilization-BasedService RequirementsHealth Human Resources UnitRegional Health Human Resources Planning & Management11Figure 2 - Complex Issues Affecting Health Human Resource PlanningHealth Human Resource PlanningPlanning Issues· demand forecasting· supply forecasting· adjusting supply to meetdemand· integration of health humanresources and strategicplanningService Delivery Issues· organizational structure· agency-specific managementpractices· workplace conditionsStructural Factors· system organization andfinancing· self-governance andhealth professionsregulation· training and supplypolicyHealth Human Resources UnitRegional Health Human Resources Planning & Management122.1 Structural Factors That Have an Impact on Health Human ResourcesA number of structural factors, some not immediately related to human resources, have majorimplications for the management of health human resources. These include:· system organization and financing;· self-governance and health professions regulation; and· training and supply policy.2.1.1 System Organization and FinancingThe most important structural factor is system organization and financing.  A delivery systemtraditionally based on institutional care, public funding of such care and fee-for-service remunerationfor medical services has specific human resources implications that warrant careful examination.Recent emphasis on healthy public policies, health reform initiatives and the consequent shift tocommunity-based care also have major implications for human resources planning.  Reliable andaccurate information on system organization and financing, as well as personnel mix and deployment,is required to evaluate the impact of organization and funding on service and human resourcesrequirements.Rational public policy in these areas should be based on informed judgments with respect to howstructure relates to process, and how they both influence output.  For example, in light of theevidence regarding the efficiency of alternative financing of medical services - HMOs or CHO’sversus fee-for-service - what will be the physician resources requirements in a region partially (ortotally) funded in this way?  Or, when a policy that shifts delivery of hospital care to the communityis implemented, what kind of training will be required for nurses providing community-based acutenursing care?  In addition, physical resources such as health care technology will have an impact onthe requirements for human resources; for example, what is the effect of acquiring diagnosticimaging technology on the demand for technologists and oncologists (among others)?  In sum, whilefederal and provincial legislation determine system structure and financing policies, these haveserious implications for the efficient delivery of services in a region and hence for determining theoptimal number and mix of personnel, and the training of such personnel.2.1.2 Self-Governance and Health Professions RegulationA second important structural factor with human resources implications is professional governanceand regulation.  Such statutory legislation is enacted primarily to protect the public interest; however,it has sometimes been used to promote professional self-interest and protect “turf” through exclusivescope of practice clauses.  Furthermore, where such exclusive scope does not exist, entry-to-practiceand credentialling requirements may often act to further protect professional interests.  Importantquestions on service and the cost implications of professional regulation should be incorporated intoplanning activities at the regional level. These implications can be far-reaching and rather complex toaddress as they are comprised of direct and indirect as well as financial and human costs.  In short,professional regulation has costs and benefits which may not always be balanced; better informationand rational planning would help to yield positive results.  For example, the regulated healthprofessions ensure uniform and high standards of practice, a code of ethics, on-going monitoring ofcompetence, etc.  However, they may, sometimes, impose artificial barriers on interdisciplinarypractice, limiting safe patient choices and protecting the profession’s income level.Health Human Resources UnitRegional Health Human Resources Planning & Management13The Health Professions Act(RSBC 1996) provides a new legislative framework within which issuesof safety, quality, and access to services are addressed.  New and aspiring health professions whichwish to establish a self-regulatory structure can apply for designation to the Health ProfessionsCouncil (HPC).  For example, midwifery services in B.C. are now regulated by the College ofMidwives; an application for designation by the B.C. Dietitians & Nutritionists Association iscurrently under investigation.  More recently, the HPC was mandated to undertake two types ofreviews:  the legislative review comprises an examination of existing health professions Acts relativeto the Health Professions Act(HPA); the other review comprises an examination of the scope ofpractice of all professions which have existing Acts, in order to determine how accurately thoselegislative statements reflect current practice and to facilitate interdisciplinary practice.  Thesereviews are currently underway and, upon completion, will have serious implications regardingoverlapping scopes of practice, risk of harm and patient safety, and reservation of titles to clearlyidentify those with and without regulation.Finally, the supply of health personnel in one jurisdiction is dependent not only on the existence ofhealth professions legislation (with or without exclusive scope of practice) in that province, but alsoon the specific aspects of such legislation in other provinces, as B.C. has historically been a netimporter of health personnel.2.1.3 Training and Supply PolicyA third important structural factor, training and supply policy, has impact on the net human resourcesrequirements in a number of different ways.  Provincial production policies are usually developed bythe training sector in response to its own needs, but also sometimes in conjunction with professionalassociations.  These generally have national implications, given the free movement of workersbetween provinces.  From a narrower local perspective, a better alignment of training and servicesector policies could prove to be useful, especially where recurring personnel imbalances exist.  Forexample, there appears to be some overlap in the scopes of practice of dentists and dental hygienistsin the area of oral health assessment and the scaling of teeth.  With an appropriate division of labour,professionals with higher entry-to-practice requirements could provide only the technically morecomplex services, commensurate with their higher level of preparation.  Yet, dental hygienists couldnot work independently in long-term care facilities where there was a demand for services pertainingto oral assessment and hygiene until they were designated under the HPA in 1993; dentists weregenerally uninterested in providing such care.While there are structures that facilitate the incorporation of employer views on training needs, andsome educational institutions consult with employers, both models of education/employer interfaceoperate largely on a crisis-management basis.  That is, prospective planning and routine consultationis not the norm.  Yet when supply imbalances become persistent, educators express due concerntoward the employment opportunities of their graduates and seek to collaborate with employers.Since both surplus and shortage situations have serious system-wide cost implications, the latter interms of quality of care, the former in fiscal terms (and both have human costs), better coordinationis necessary.Coordination between Ministries of Health and Advanced Education, Training and Technologywould ensure the production of an appropriate number of each type of practitioner, as determined byHealth Human Resources UnitRegional Health Human Resources Planning & Management14population health needs, and, therefore, would result in the most cost-effective mix of personnel.Integration between regional-provincial levels and national levels is also desirable as many nationalprofessional associations have systems of certification which are a mandatory requirement of someemployers (e.g. Canadian Association of Prosthetists and Orthotists, Canadian Society for MedicalLaboratory Science etc.).  On a practical level in a health region, integration of services may alsohave an impact on net requirements and, hence, on the numbers trained and level of training.  Inother words, there are health human resources implications accompanying the model wherein theconsumer travels to only one location for a range of services, provided efficiently by the mostappropriate personnel.  Training and supply policy to support such preferences have to be definedand implemented.2.2 Service Delivery Issues That Have an Impact on Health Human ResourcesA number of service delivery issues have serious implications for human resources management,including organizational structure, agency-specific management practices and terms and conditions ofemployment.  These also present other types of information requirements.2.2.1 Organizational StructureThe institutional sector in particular, where the vast majority of health personnel are currentlyemployed, has organizational structures that vary appreciably: from the traditional with anadministrator at the helm, to the corporate or matrix organization.  As health reform andregionalization efforts mature, the evolving structures will influence the size and mix of theworkforce and the quality of care, as well as costs. Community-based facilities and home care haveworkforce implications which are very different from that of institutional services.  In addition,extensive down-sizing of institutional care has resulted in numerous workforce adjustments withchanges in the deployment of registered nurses and physical therapists (among others).  Costconstraints have led to fewer professional staff and supervisory personnel with more multi-skilledworkers, in contrast to higher acuity patient care.As structures are revised and new ones evolve, new management and care processes are beingestablished which also have human resources implications and, in particular, affect terms andconditions of employment.2.2.2 Agency-Specific Management PracticesAlong with organization structure, agency-specific management practices have important humanresources implications. The availability, comprehensiveness, and use of management informationsystems (MIS), for example, in support of the personal style of top-level managers may result in verydifferent terms and conditions of employment and costs.  Recruitment, retention, turnover, andattrition are directly affected by management practices, including the monitoring of such trends forthe purposes of improving human resources planning activities.  Such activities also entailmanagement decisions regarding the use of substitute, auxiliary, or supportive personnel, which arealways governed by employer policies circumscribed only by restrictions imposed by professionallegislation.  Regional Health Boards may be confronted with a variety of management practiceselicited by contracted agencies of different size and organizational culture.  Routine documentationof such practices creates an information base that is essential for planning.Health Human Resources UnitRegional Health Human Resources Planning & Management152.2.3 Terms and Conditions of EmploymentTerms and conditions of employment appear to coalesce into variable combinations of the above-mentioned factors, which culminate in the creation of an agency (or hospital) culture that may beperceived to be supportive or hostile to certain staff.  Many registered nurses, for example, haveperceived the workplace to be particularly hostile in recent years, and their labour negotiators havedemanded improved conditions, along with better wages, as part of the collective bargaining process.Traditional health human resources planning is concerned with the scope of workforce shortages andfactors contributing to that phenomenon.  Factors contributing to a surplus situation are even lessknown and/or studied, as these are of much less concern to service managers.  Until these factors areidentified, development of appropriate workforce strategies is difficult to undertake.  A key goal forhuman resources planning, then, is to identify what factors contribute to workforce imbalances.Service delivery issues that result in the inefficient use of human resources can play a major role inexplaining shortage situations.  Accurate information collected systematically could provide moredefinite answers to this question, even in times of wide-scale change and re-structuring.  Monitoringchanges and/or patterns provides information for pro-active intervention.  Finally, major recentdevelopments and policies in the area of collective agreements, such as the Labour Accord and theHealth Labour Adjustment Agency, as well as the consolidation of a large number of bargainingunits, and the birth of a revised management organization (the Health Employers’ Association ofB.C.), all have clear health human resources implications for Regional Health Boards.2.3 Planning Issues That Have an Impact on Supply and RequirementsThe literature in this field highlights several problems that are manifested in different forms acrossprofessional groups and jurisdictions.  The absence of reliable information pertaining to humanresources planning contributes to those problems.  To date, very slow progress has been madetowards a more systematic approach for estimating human resources requirements, which includesforecasting demand and supply, adjusting the supply accordingly, and integrating health humanresources with strategic planning.2.3.1 Demand ForecastingDifficulties in demand forecasting arise from many factors; those arising from changes in deliverypatterns (system organization) and service goals (service delivery) were previously discussed.  Inaddition, difficulties arise from the lack of an objective workload-based method of estimatingdemand, which is especially problematic for some professional groups, and contributes to thecomplexity of the task.  Whereas in the past professional judgment was a commonly acceptedmethodology, the external validity of such methodology is extremely limited, and, therefore, itsusefulness is easily discounted.2.3.2 Supply ForecastingDifficulties in supply forecasting arise from the inability to test or verify underlying assumptionsregarding the current workforce, such as career histories, turnover rates, inactivity ratios, part-timeand casual employment, etc.  But even more elementary problems of defining a professional group inorder to count their numbers often present great difficulties for planning.  The information sourcessupporting supply forecasting should be as broad and flexible as possible; for example, the number ofavailable nurses is less than that perceived when the number employed is taken into account; aHealth Human Resources UnitRegional Health Human Resources Planning & Management16further decrease in number is likely when considering numbers employed in permanent positions, andeven further when the number of full-time nurses is taken into consideration.  Measurement problemsin supply arise mainly from multiple sources of data and different dates when information is recorded(from the same source).2.3.3 Adjusting Supply to Meet DemandProblems in adjusting supply to meet forecast demand are difficult to address without the jointdevelopment and use of a comprehensive planning database by both the training and health sectors.Often, there is considerable lag time to make such adjustments and the proactive approach is the onlysolution to that problem.2.3.4 Integration of Health Human Resources and Strategic PlanningFinally, from a regional perspective, the integration of human resources planning with strategicplanning (service and financial planning) is an important consideration.Undertaking separate planning for each profession fails to challenge the somewhat artificialboundaries between the professions and also does not provide the most appropriate (as per scope ofpractice) and cost-effective way of delivering services in a jurisdiction.  Alternatively, determiningthe services needed through the development of a health plan (see, for example, theVancouver/Richmond Health Board’s “Inaugural Health Plan, 1997-98”), followed by theidentification of the most appropriate and efficient mix of resources will better enable regions to planfor health human resources in a way that supports the region’s specific strategic plan.In order to be comprehensive and innovative in planning and policy development, certain informationconditions have to be met in both quantity and quality of data.  A modest investment in thedevelopment of quantitative measures to estimate demand could yield high returns in terms of betterinformation for planning.  In some cases, improved documentation of existing information wouldappreciably enhance supply-side databases.3. Regional Health Human Resources Planning & Management InformationInformation requirements for the human resources sector are complex and ideally should beapproached from a perspective that yields a comprehensive, dynamic database. However certainworkforce-related components of such data may already exist in one format or another at variousjurisdictional levels. The availability, quality and comprehensiveness of data on the health workforceare discussed in some detail.3.1 Determining Information RequirementsAs Figure 1 illustrates, traditional health human resources planning has been based on program andservice requirements. These programs were intended to serve population health needs, but no directlinkages were made between services and health needs.Health Human Resources UnitRegional Health Human Resources Planning & Management17Strategic goals of a region are in part derived from population health needs. As Figure 3 illustrates,this information can play an important role in determining programs and services, which in turndetermines the appropriate mix of resources needed. While this framework presents a challenge indata collection for a provincial planning effort, it is more manageable on a region by region basis, andstandardization would enable comparisons across regions.Figure 3 - Proposed Framework for Health Human Resource Planning(adapted from Proceedings of the Workshop on Priorities inHealth Human Resources Research in Canada, HHRU 90:2)Identify/MeetPopulation HealthNeedsDetermine Mix ofHuman and Non-Human ResourcesCurrentSupplyOrganizationDesignScope ofPractice &TrainingIdentify Programs andServices NeededDevelop StrategicRegional GoalsProvide Programs andServicesHealth Human Resources UnitRegional Health Human Resources Planning & Management18The array of data sources and volume of information available can be overwhelming in the planningprocess.  It is critical to start with strategic plans and from there determine what information isnecessary for decision-making, not what is available or collected by other organizations for their ownpurposes.  Identifying the gaps can also be helpful in influencing the data collection, storage andretrieval process.3.2 Current Sources of InformationWhile health regions are now responsible for health human resources planning, this does not requirethat data need to be collected locally.  There are many current sources of information that can be ofuse.  The challenge for regional planning is to determine what information is needed, where it isavailable, how to access it and use it.Information is currently available in two forms: printed reports and computer-based files.  It isdifficult to claim that any list of reports or files pertaining to health human resources can becomprehensive, given the proliferation of stake-holders at both the national and provincial levels inthis field.  A selected listing of primary sources of data provides a sense of the variety and diversityof such information (Appendix A). These lists contain information related to:· education and training programs;· supply;· utilization;· licensure/certification/registration;· immigration;· additional sources of data.Most of the printed reports come from special projects, while some are generated for administrativepurposes. A few are made available on an on-going basis, at equal time intervals.  Computer-basedinformation is generally more systematically collected.The location of specific information regarding the supply and employment of health services workersin B.C. can be determined by asking questions related to supply and employment.a) Supply: Is the person employed?A decision tree is helpful in identifying where information related to employment will be found(Figure 4). If it is mandatory for the person to be registered or certified to be employed, theninformation will be found in the databases of those organizations. If registration or certification is notrequired, then information will be found in payroll/personnel databases (Health Sector CompensationInformation System - HSCIS for public organizations or individual databases if privateorganizations), voluntary professional association registries, through surveys and union records.If the person is not currently employed, but identified as a health services worker (e.g. registerednurse) information may be obtained through the Employment Insurance Commission or professionalassociations.Health Human Resources UnitRegional Health Human Resources Planning & Management19                                                               NO                              YES                                                                NO                             YESFigure 4 - Information About Supply and EmploymentEmployed?Mandatory Registration/Certification?Employment InsuranceCommissionProfessionalAssociationEmployer - Group A(HSCIS)Employer - Group B(payroll/personnel)Union MembershipVoluntary Association(incomplete information)Survey(individuals employed ingiven job categories)Professional Assn. /Certifying Body(some overlap)Health Human Resources UnitRegional Health Human Resources Planning & Management20b) What are the relationships among the various employment databases?Tabulating information in all the available databases will produce an artificially inflated number ofavailable personnel. People may be registered in a variety of ways and therefore their names appearin several databases simultaneously (Figure 5). For example, information regarding a person who isunemployed may be found in records of their professional association, an association they belong tovoluntarily and in the Employment Insurance Commission database.Figure 5 - Relationship of Employment DatabasesEmploymentInsuranceCommissionUnemployedProfessionalAssociation /Certifying BodyEmployed GroupA(HSCIS)Employed GroupB(payroll)Union MembershipVoluntaryAssociationHealth Human Resources UnitRegional Health Human Resources Planning & Management21The variety of provincial information currently available and the multiple sources from which thesedata are drawn present a major drawback to any type of collaborative planning or research effort.Even within the same jurisdiction, information on training and education, if available, may not becompatible with information on supply or labor force behavior.A key problem, even when all these data are collected at the individual level, is the absence of uniqueidentifiers that could link the data collected by various efforts and so provide a more comprehensiveinformation base.  For example, with unique identifiers it is relatively easy to use computertechnology to link information from regulatory bodies to those of special surveys and census surveys.A national system of issuing unique identifiers could provide specific human resources information,including inter-provincial migration, as well as population health and service utilization information,at relatively low cost.Along with specific sources of information noted above, there are other sources that also couldprovide relevant data.  Appendix A (Table 6) provides a list of generic sources, which include:· Licensing Bodies;· Professional Associations and Societies;· Provincial Pay Agencies;· Federal Taxation Data;· Employment and Immigration; and· Surveys and Other Special Purpose Data.Appendix B provides information about specific professions, their educational preparation andregulation.Appendix D provides a summary of current health care personnel classification and databases.Appendix E illustrates the data collected by health personnel in B.C.3.3 Gaps Existing in Current InformationAn exhaustive list of gaps that exist in the information currently available cannot be presentedwithout an exhaustive list of all available information. Nevertheless, it is useful to discuss a fewgeneral problems of existing data.Census data by occupational group provide point-in-time estimates or single snapshots of theoccupation.  The data can be used to establish the socio-demographic profile of an occupationalgroup, but do not lend themselves to longitudinal analyses.  For example, percent change over timemay be calculated from these data, but attrition rates from a profession or average annual rates ofchange cannot be estimated, contributing to limited usefulness of census data.National data on nurses cover only registered nurses; data on total registered nursingassistants/licensed practical nurses, aides, orderlies, etc. in all service settings are unavailable.  Abroader perspective towards planning is required to even begin to address shortage problems.Without information on other nursing categories, it is impossible to examine alternative staffingpossibilities (such as team nursing) and their impact on service delivery.Health Human Resources UnitRegional Health Human Resources Planning & Management22There is a lack of national data for groups other than RN’s and Physicians; while scrambled uniqueidentifiers are used for the National Physician Database, this is not the case for RN’s, so inter-provincial migration of RN’s cannot be tracked.  Nor do RN’s have as comprehensive a database asthe physicians.  Provincial databases may exist but, depending on professional legislation, thedatabases may not be comparable.  Licensure, certification, and registration procedures by definitionyield different qualities and quantities of information.  Where variation exists in the type ofprofessional legislation, data comparability will be greatly reduced, making efforts towards integratedhealth human resources planning very difficult, if not impossible.Most provincial data on health human resources are limited to head counts.  Details about specialty,employment, labor force activity, etc., if available, are self-reported and subject to serious limitations.Without adequate resources to test and verify data quality to prepare these for research purposes,even simple descriptive statistics will have serious limitations.Employment data are available only in a few provinces from special surveys and are not amenable tointer-provincial comparisons. Since there is no coordination or collaboration between provinces inthis area, individual efforts do not yield collective returns.  This negative situation would bereplicated at the Regional Health Board level if each acted separately from the others in undertakingregionally-based surveys.Hospital-based workload data lack specificity for some professions; some data for others arealtogether non-existent. Consistent basic reporting requirements to facilitate determination of case-load management guidelines could provide important information for assessing quality of care. Theinconsistency of provincial reporting requirements at present does not allow the generation of usefulworkload measures.Since the system has been hospital-based, the existing information is mainly for the institutionalsector. Very limited administrative information exists on community-based services, becausehistorically its funding method has not required detailed accountability. The almost total lack ofinformation on service requirements in the public health sector and, consequently, on its humanresources requirements, has created a large knowledge gap in this area.  The initial concern ofRegional Health Boards with and activities in establishing community-based governance structureshas resulted in the persistence of a health human resources information gap.No systematic information exists about health professionals practicing in the private sector(individuals who are being paid through sources other than public funds). The size of this sectorvaries by province and region; therefore, inter-regional comparisons could prove useful from a policyperspective. Special surveys, systematically administered, could yield useful information.In summary, these gaps exist in the current information base because such information generallyexists primarily for administrative purposes, i.e. for licensing one professional or paying another, andnot specifically for planning or research purposes. The absence of a rational, comprehensive humanresources planning framework has meant that information requirements for such activities at thenational, provincial or regional level have neither been articulated nor defined.Health Human Resources UnitRegional Health Human Resources Planning & Management23At the international level, WHO (1971) described in some detail the data requirements for thedevelopment of studies in health human resources (HHRU 92:1 - Attachment 2). Historically,discussions regarding the feasibility of developing a comprehensive nurse planning database in B.C.have not been successful. The Health Human Resources Unit in the Centre for Health Services andPolicy Research at the University of British Columbia developed a preliminary model of such adatabase. The components  of such a database could serve as a starting point for further discussion(see WHO, 1990).3.4 Data and Information IssuesData and information management issues arise in a number of ways. These are related to determininginformation needs for planning, identifying sources of that data and where gaps exist. Once the dataare located, there are a number of additional issues related to the data quality, including validity,reliability and comparability.3.4.1 Determining Data SourcesAs outlined in the previous section, data sources can be determined through a series of questionsrelated to whether the individual is employed or not, belongs to a professional organization, hasmandatory registration or certification requirements for employment. Information on supply andemployment of health services workers is found in a variety of databases.With more health care resources being directed to community services there is an increasing need toquantify the human resources component. As noted above, there is little information on who isemployed in providing non-institutional services. There may be a  role here for Regional HealthBoards through their Human Resources Information Systems.3.4.2 Data OwnershipData that are used for health human resources planning are secondary data. They belong to theorganization that collects them and serve a specific purpose in that organization. Permission to usethe original data for that specific purpose is given by individuals who submit the data. Using theinformation for other purposes requires the permission of the organization and sometimes theindividual member. This is often not a problem if the information is being used for research purposesas is the case for the Health Human Resources Unit in the Centre for Health Services and PolicyResearch (UBC).If necessary, routine information retrieval from these databases may need to be negotiated by thehealth regions. Consideration may be given to accessing aggregated information through publishedreports from the Centre, without having to address ownership questions.The Centre maintains an extensive collection of data on British Columbia health care facilities,providers and utilization. An established procedure for processing requests for access to these datamust be followed. This helps ensure protection of privacy for individuals whose records appear onfiles maintained by the Centre. As well, all requests are handled on a cost-recovery basis.Health Human Resources UnitRegional Health Human Resources Planning & Management243.4.3 ConfidentialityGenerally information that is required for planning is aggregated and does not identify specificindividuals. However, in the specialty categories where there are few individuals, it may become easyto attribute details in the database to individuals. Unless there is a need to plan for specific programsrequiring data that are  narrowly focused, it is advisable to use aggregated information.As Figure 5 illustrates, there are many areas of overlap in the existing databases. In order to drawaccurate conclusions about supply and employment, it is useful to link the information in all thedatabases so data for more than one “Sally Jones” can be correctly aggregated. This can betechnically accomplished through linking the databases using several data points to match the files(e.g. birth date, graduation date, last and first names) or using unique identifiers (e.g. much like thePersonal Health Numbers (PHN’s) used by MSP). These are helpful in reducing duplication in datacollection, but also present concerns with respect to privacy and confidentiality. While “Sally Jones”may have provided information on her application to the professional association, her uniqueidentification number also links this information to her employment records and union membership.This raises some concerns about appropriate use of linked data. Individuals are often not aware ofthe multiple uses of the data they voluntarily provide for specific purposes. The potential for misuseof the data must be addressed in the regional policies, based on considerations of security andconfidentiality for individuals, balanced with the opportunity to improve services and possibly healthcare for the population at large.The Health Information Development Unit (HIDU), in the Centre for Health Services and PolicyResearch at UBC, was established in recognition of the considerable health care-related databaseresponsibilities included in the Centre’s mandate. The Unit is responsible for database developmentand maintenance, data access and security, and database linkage. Their Linked Health Data Project,initiated in 1989, began to explore the planning potential of a data set that would provide the meansto link individuals across data files and over time (HPRU 96:14D). While this project’s focus hasbeen to link files of health care consumers, the success of these efforts may be directly applicable tosimilar data linkages  in the health human resources area.The HIDU has developed a formal set of policies and procedures that outline the Centre’s dataaccess guidelines and articulate internal safeguards intended to protect the confidentiality ofindividual client and provider information. These guidelines provide a solid base from which todevelop appropriate policies pertaining to the use of health human resources linked data.3.4.4 Data Reliability and ValidityA recent review of databases containing information related to health human resources planningrevealed a number of difficulties with respect to the reliability and validity of the data that arecurrently available. Some of these have been noted earlier in this document.Discrepancies in definitions of health care personnel classifications create problems in comparing oraggregating data. Within B.C. alone there is difficulty in synthesizing this information due to thedisparate categories and definitions between the Ministry of Health framework and the Health SectorCompensation Information System. There are some obvious overlaps in categories with similar, butHealth Human Resources UnitRegional Health Human Resources Planning & Management25not exact matches in classes of personnel. For example, Category 12 of the Ministry of HealthFramework is “Diagnostic Medical Sonographers.” This can be mapped to three categories in theHealth Sector Compensation Information System (HSCIS) which are covered by two unionagreements: Ultrasonographer III-IV (HSA); Cardiac Ultrasound III-VI (HSA); Cardiac UltrasoundTechnician (HEU).  (See Appendix C)A second concern with data reliability is the rigor with which the primary data are collected andresulting databases maintained. Organizations collecting the data each have their own methods forrequesting the data, entering them into databases and maintaining them. Quality control on theaccuracy of the data and how frequently they are  updated varies with the organization. There is noway to validate data that are  received secondarily, but  users should ask questions about the data’sorigin and maintenance, including:· who provides the original data? i.e. the individual or as a by-product of some other datacollection system?· are there built-in checks for accuracy? e.g. reasonable data such as Date of Birth at least 18 yearsbefore graduation.· are the data reliable? e.g. does the individual have to include a copy of graduation or otherinformation to confirm they are eligible for membership?· is the database used consistently? e.g. a standard definition of data elements is used by everyonewho enters data and uses the database.· when are the data entered? e.g. is there a specific date when registrations must be in and dataentry occurs one month after that?· how often is information updated? e.g. is information updated only once a year or as it isreceived?3.4.5 Information and Communication TechnologiesThe proliferation of information and communication technologies has created many problems in theexchange of information within organizations and across regional systems. Rather than introduceadditional technology, health regions may now consider other solutions for managing multiple anddisparate data sources.Data warehousing is a valuable strategy used to centrally store primary data for many groups andorganizations. Rather than trying to duplicate the data in other locations, users access theinformation they need and manipulate it locally. This means regional human resources data can behoused centrally, but accessed by the appropriate users from any site in the region. A pilot project inthe Simon Fraser Health Region has successfully demonstrated this approach (Andru, 1997).In addition there are recent advances in the use of advanced programming languages that act asinterpreters. Rather than replacing old (or legacy) systems that are not compatible, new languages(such as JAVA) allow the user to ask for information from a variety of systems. This provides manyalternatives to retrieving information that could not be considered a short time ago.Health Human Resources UnitRegional Health Human Resources Planning & Management263.5 Learning to Use Information versus Technology: Knowledge and Skills RequiredTypically health care organizations are very good at providing training to use new informationtechnologies. However, the answer to finding and using appropriate information is not always foundby implementing new technologies or building new databases. One area that is a common problem isthe user’s lack of ability to use new information, or use current information in creative ways. Acritical factor in human resources planning is identifying the decisions that need to be made and whatinformation is needed. Once these decisions have been made, tools such as ACCESS™ can be usedto manipulate the data in ways that highlight potential strategies and solutions.4. RecommendationsThe recommendations are framed so as to take account of the exigencies of planning at a regionallevel, as well as the existing challenges in the data available for such purposes. From the discussionof issues identified in this report, the following recommendations are made for health humanresources planning and management at the regional and provincial levels (further detailed in Table 1).Each Health Region should:4.1  initiate a needs-based approach to health human resources planning that considers the burden ofillness in a population and population health needs as determinants of the necessary resources(versus the traditional approach based on utilization of services, and personnel to populationratios);4.2  determine what general and specific information is necessary for decision-making, where suchinformation is available and how to gain access to it and use it;4.3  develop a systematic approach to standardized data collection and/or development for localinformation needs;4.4  establish efficient systems to manage the data generated in order to make it accessible and usefulfor decision-making.In addition, certain recommendations should be considered to facilitate the implementation of the 23more specific recommendations outlined in Table 1.  The hierarchy of enabling recommendations isthat:4.5  The Ministry of Health should be responsible for:a) establishing policy expectations in health human resources based on the health goals forthe province;b) setting general guidelines regarding the data required for planning;c) supporting the participation of smaller regions in health human resources planning;d) facilitating linkages with the national level pertaining to issues of national certification;e) appointing an official(s) to facilitate the coordination of health human resources planningby Regional Health Boards and Community Health Service Societies;f) identifying the resources needed to facilitate the above;Health Human Resources UnitRegional Health Human Resources Planning & Management274.6  A provincial organization representing regional interests should coordinate regional developmentof health human resources plans and:a) the Ministry of Health should facilitate inter-regional coordination of health humanresources planning for Community Health Councils in areas without Regional HealthBoards;b) where appropriate, Ministry of Health and Ministry of Advanced Education, Training andTechnology officials should interact with regions via RHB’s and CHSS’s;c) where appropriate, COUTH, HABC and the HEABC should also be involved;4.7  The Ministry of Health should develop standards for health human resources databases;4.8  The Ministry of Health should collaborate with the Ministry of Advanced Education, Trainingand Technology to identify educational information pertinent to health human resources planningand make possible the collection of such data at the regional level;4.9  The Ministry of Health should provide technical support in the development of unique identifiersand promote their use by Health Regions.Finally, the following are detailed recommendations addressing all identified health human resourcesissues.4.10 Issue Specific RecommendationsIssues RecommendationsStructural Factors· System Organization andFinancing· REGION: establish protocol for proposed program andservice delivery changes that examine short term and longterm considerations of human resources needs, includingchanges in training· Self Governance and HealthProfessions Regulation· PROVINCIAL GOVERNMENT: determine standard set ofdata elements that each profession must collect forprofessional designation in B.C.· PROVINCIAL GOVERNMENT: responsible for standards· Training and Supply · REGION + PROV. GOVT.: coordinate between Ministriesof Health and Advanced Education, Training andTechnology, with input from each Regional Health Board toensure production of appropriate number of graduates forchanging service and program deliveryService Delivery Issues· Organizational Structure · REGION: examine potential changes in structure usingsensitivity analysis to determine scenarios with most efficientmix given varying supply factors…  continuedHealth Human Resources UnitRegional Health Human Resources Planning & Management28Issues Recommendations· Agency Specific ManagementPractices· REGION: develop a standard set of variables to bemonitored and reported from each site or program forongoing comparison of recruitment/retention strategies aswell as troubleshooting potential problems· REGION: systematically monitor socio-demographic andemployment characteristics of human resources in eachorganization to develop personnel profiles. These may beexamined for each individual agency or aggregated for theregion to better understand successful retention strategies· REGION: systematic monitoring of deployment patterns ofhealth personnel to provide accurate estimates of workload,turnover, attrition and recruitment. Intended to betteranticipate local and regional shifts in supply andrequirements· Terms and Conditions ofEmployment· REGION: develop and administer systematic workforcesurveys as one method of determining factors contributing toworkforce shortagesPlanning Issues· Demand Forecasting · REGION: adopt industry standard workload measurementtools where available and use consistently across sites (e.g.MIS Guidelines)·  where possible automate data collection as a by-product ofworkload documentation· REGION + PROV. GOVT.: establish provincial standardsfor data collection· Supply Forecasting · REGION: ensure consistency in data recording andreporting across sites· REGION: determine what information is required and inwhat format to influence changes in current and futuredatabase design· REGION + PROV. GOVT.: establish provincial standardsfor data collection· Adjust Supply to Meet Demand· REGION + PROV. GOVT.: develop and usecomprehensive planning databases collected by training andhealth sectors· Integration of Health HumanResources and StrategicPlanning· REGION and PROV. GOVT.: move away from separateplanning for individual professions· REGION and PROV. GOVT.: adopt new planningmethodology that determines services needed frompopulation health needs and then the most efficient mix ofresources required to provide the services…  continuedHealth Human Resources UnitRegional Health Human Resources Planning & Management29Issues RecommendationsRegional Health Human Resources Planning and Management· Information Requirements andSources· REGION: automate data collection where possible· take advantage of data produced as by-products from otherprocesses (e.g. workload stats from documentation of care)· reduce gaps in existing information by collecting humanresources data from all sectors in the Region, not limited toacute care· in concert with the Prov. Govt., establish policies withrespect to security and confidentiality of human resourcesdata· PROV. GOVT.: to provide conduit betweenFederal/Provincial/Territorial initiatives in health humanresources planning and Provincial/Regional initiativesTable 1 - Detailed  Recommendations by Health Human Resources Issue5. Description of Selected Models for Organization of Health HumanResources PlanningIn order to assist the discussion around the best way to organize health human resources planning inthe regions and across the province, three organizational models are described below.  We examinewhether each model can be adapted to serve as a provincial framework for health human resourcesplanning and discuss the advantages and disadvantages of each model.5.1 British Columbia Provincial Renal Agency (BCPRA)The BCPRA is an organization which exists and functions in collaboration with the Ministry ofHealth, the University of British Columbia and the entire Nephrology community.  Its responsibilitiesinclude the following (British Columbia Provincial Renal Agency Preliminary Conceptualization:November 1997):· Developing, monitoring, implementing and evaluating provincial policies and guidelines forchronic renal insufficiency patients, which include predialysis, dialysis, and transplant;· Developing and maintaining an integrated provincial database with the regional networks;· Developing patient classification tools;· Centralizing and/or coordinating purchasing of supplies, services and equipment;· Directing outcome-based research;· Determining funding priorities based on outcomes;· Advocacy role for education and training needs.Health Human Resources UnitRegional Health Human Resources Planning & Management30A Steering Committee and an Operations Committee exist to guide and address issues of importancefaced by BCPRA.  Regional Renal Programs are responsible for the delivery of services to the renalpopulation in the province.5.1.1 Steering CommitteeThe purpose of the Steering Committee is to:· aid the BCPRA in broad strategic direction and development, to ensure systematic and regularevaluation of progress and process;· evaluate that there is consistency of direction and plans of BCPRA with the Guiding Principles ofintegrated care of renal patients, with regional responsibilities for health care delivery;· ensure accountability of BCPRA Director;· assess the appropriateness of the operating budget for the BCPRA (administrative component).The Terms of Reference for the Steering Committee is as follows:“Receives information from Operations Committee and provides direction to the BCPRA to ensureconsistency with the Guiding Principles of the BCPRA; aids in strategy and liaison when necessary;responsible for budget ratification.”The Steering Committee is accountable to the following:· Ministry of Health via the Vancouver/Richmond Health Board· Operations Committee· Patients of BCThe deliverables of the Steering Committee are:· ensure that there is an overt process by which plans and strategies can be evaluated to beconsistent with the Guiding Principles;· ensure, through communication that the processes of decision making/resource allocation areovert and understandable to all constituents;· evolution of concrete objectives/evaluation tools by which to assess BCPRA functioning.The Steering Committee is responsible for:· representing the perspectives of:· Government· Regional Health Boards· Research Community· Transplantation· The Kidney Foundation· Renal Patients· Regional Renal Programs· Health Care Providers· articulating issues identified at the Operations Committee which may require advice/aid frommembers;· representing the whole constituency, not just own program/region.Health Human Resources UnitRegional Health Human Resources Planning & Management315.1.2 Operations CommitteeThe functions of the Operations Committee are as follows:· review macro level issues/functioning;· identify regional/provincial problems and solutions;· review terms of reference including priorities for specific work groups;· review time lines for work groups;· evaluate results of work groups, analyses etc.Note: The expectation is that the discussions of individual region or individual patient issues are tobe reviewed within the regions and only those problems/issues common to all, or not solved at theregional level will be tabled at the Operations Committee.The Terms of Reference for the Operations Committee are to:· Identify successes, problems, and opportunities in the operations of Regional Renal Programs;· Act in collaboration with the BCPRA as the “Grant Committee.”The Operations Committee is accountable to its respective regions and constituents and to thepatients.The Operations Committee is responsible for the following deliverables:· coordinated plans for solution of provincial problems;· advice to the MoH re: needs and resource allocation issues;· ensure the clinical care of patients in the Province is delivered in the context of the guidingprinciples.In summary, the BCPRA functions in collaboration with the Ministry of Health and other relevantagencies.  It works with both an Operations Committee and a Steering Committee.  The SteeringCommittee has representatives from the MoH, RHB’s, the research community, and other relevantgroups on it and basically provides broad strategic direction to the BCPRA. The Steering Committeeis accountable to the MoH, the patients, and the Operations Committee.The Operations Committee of the BCPRA is basically responsible for ensuring the smoothoperational function of the Regional Renal Programs.5.1.3 Advantages and Disadvantages of Adapting the BCPRA Organization to Health HumanResources PlanningAdvantages:· The BCPRA is organized as an agency independent from government which receives fundingfrom the MoH to deliver a provincial service regionally;· Representatives from the MoH and relevant organizations have equal voice in guiding the workof the agency via the Steering Committee by providing broad strategic direction, guidelines, etc.;· The Operations Committee ensures that the regions work within the guidelines set by theSteering Committee, but enables regions to provide services in ways unique to each region;Health Human Resources UnitRegional Health Human Resources Planning & Management32· Provides support to regions in dealing with issues that cannot be solved within regions and whichneed to come to the Operations level;· Coordinates service provision through inter-regional organization.Disadvantages:· Potential exists for individual representatives to represent their own program/region rather thanhaving an overall view;· The BCPRA model is set up around a very narrow focus i.e. a single program/service in contrastto health human resources planning: a multi-level, complex process involving numerous groupswith different mandates;· As a result of regionalization in the province, health human resources is a regional responsibilitynot a provincial responsibility and the BCPRA model may not adequately support this view;· Funding for health human resources is regionally-based and thus the above model is limited inthat it is provincially funded.5.2  Provincial Coordinating Committee on Remote and Rural Health Services (PCCRRHS)The PCCRRHS has been established for a term of three years with a mandate to makerecommendations to the Deputy Minister and to its members on issues which are considered by theCommittee to be relevant to the provision of health services to remote and rural communities.  Thepurpose of the Committee is to provide a forum for communication with stakeholders and tocoordinate activities between the stakeholders in order to enhance the accessibility and effectivenessof health services in the remote and rural areas of the province (BC Ministry of Health CurrentInitiatives/Programs to Address Rural Physician Recruitment, Retention and Relief Issues; ProvincialCoordinating Committee on Remote and Rural Health Services, Terms of Reference).5.2.1 ReportingThe Coordinating Committee reports to the Deputy Minister of Health, who receives minutes of allmeetings, in addition to semi-annual reports.  The Chair of the Committee is appointed by theDeputy Minister from the membership.5.2.2 DutiesThe Committee receives reports from its members on current activities related to:· recruitment and retention of health care providers;· the physician locum program;· the physician outreach program;· providers’ human resources issues;· proposed changes in service delivery systems;· proposed changes in fund allocations;· aboriginal health issues;· provider education issues;· client accessibility issues.The Committee makes recommendations, through its Chair, to the Deputy Minister and to itsHealth Human Resources UnitRegional Health Human Resources Planning & Management33members.  The Committee members, either collectively or separately, facilitate the enhancement ofhealth services in remote and rural areas by the establishment of new programs and evaluation ofexisting programs based on the recommendations of the Committee.5.2.3 MembershipMembers of the Committee are appointed by the Deputy Minister of Health and includerepresentatives from the following:· Health Authorities· Aboriginal interest groups· UBC Faculty of Medicine· College of Physicians and Surgeons of BC· Canadian Society of Rural Physicians· BC Medical Association· Health Employers Association of BC· Union of BC Municipalities· Health Association of BC· Registered Nurses Association of BC· Professional Association of Residents of BC· Ministry of HealthAdditional members may be added from time to time as determined by the Deputy Minister.5.2.4 SupportMembers of the PCCRRHS do not receive remuneration for attendance at the meetings.  Support forthe Committee is provided by the Ministry of Health.5.2.5 Advantages and Disadvantages of Adapting the PCCRRHS Organizational Structure toHealth Human Resources PlanningAdvantages:· Provides a forum for communication with stakeholders;· Enables coordination of activities between stakeholders;· Provides a forum for advising MoH.Disadvantages:· This Committee serves a very specific focus i.e. it is problem-focused versus having a proactiveprovincial mandate;· The Committee is too large a group to be a decision-making body i.e. strictly advisory;· If this model is applied to health human resources planning, would end up with an extremelylarge committee;· The Committee has an advisory not decision-making role;· No funding for the Committee;· The Committee is not managing a program to be implemented but is reporting on existingprograms or lack thereof.Health Human Resources UnitRegional Health Human Resources Planning & Management345.3  Possible New Structure for Organization of Health Human Resources PlanningIn order to effectively and efficiently organize health human resources planning initiatives acrossregions and within the province, it is essential to have an organizational model that is congruent withthe roles and responsibilities of the RHB’s and CHC’s as well as congruent with the provincialaccountability framework.In the updated regionalization document “Better Teamwork, Better Care,” one of the responsibilitiesof the RHB’s is to undertake health human resources planning, including participation in medicalresources planning.  The CHC’s have the responsibility to advise the Ministry of Health of physicianand other health human resources needs.  Furthermore, the ultimate accountability for ensuring highstandards, high quality and consistency of health care throughout the province rests with the Ministerof Health and thus the Ministry of Health has an important role in ensuring that appropriate healthhuman resources planning is undertaken in the province.The model described below places the responsibility for health human resources planning at theregional level, and expects that the regions will be in a position through a provincial organizationrepresenting regional interests, to pull together relevant stakeholders to guide health humanresources planning at a regional and provincial level. In areas of the province where there are noRHB’s, Community Health Service Societies (CHSS’s) should be included in the above process.  Aprovince-wide forum to address health human resources planning is being organized for Spring 1999.It is proposed that this forum would provide the opportunity to all regional interests to participate inthe process of identifying and developing such a provincial structure.In order to be effective, authority for health human resources planning should be vested in a structurewhich can take action and develop new policy.A Steering Committee should be set up with representatives from the following areas to guide thehealth human resources planning process:· Ministry of Health (including representatives from Policy and Planning as well as MSP forphysician workforce planning)· Ministry of Advanced Education, Training and Technology· Ministry for Children and Families· Regions/HABCThe functions of the Steering Committee will be to:· endorse a process for health human resources planning that enables the matching of health humanresources with health service needs in each region;· set objectives and guidelines for health human resources planning;· develop common data collection guidelines for the regions;· monitor data collection at the regional level;· identify and deal with health human resources issues arising at the regional and inter-regionallevel;· provide a forum for discussion of provincial health human resources issues and identification ofsolutions.Health Human Resources UnitRegional Health Human Resources Planning & Management35An Operations Committee should be set up with representatives from the following areas:· HEABC/Employers· Senior managers with responsibility for health human resources at the regional level· Unions· Regulatory bodies/Professional AssociationsFunctions of the Operations Committee:· provide input to the Steering Committee regarding regional and inter-regional health humanresources issues;· provide a forum where regions can bring regional and inter-regional health human resourcesissues and where solutions can be identified;· support medium and long range health human resources planning;· assist regions in meeting the objectives and guidelines set by the Steering Committee.5.3.1  Advantages and Disadvantages of this ModelAdvantages:The model:· has strategic guidance from appropriate levels and groups who have decision-making power;· ensures planning across sectors i.e. planning, management and production sectors;· ensures that health human resources planning is initiated and conducted at the regional level withregional input;· facilitates representatives from relevant areas in having an equal voice in guiding health humanresources planning;· provides support to regions in developing and setting up appropriate data collection systems;· provides support to regions in dealing with issues that cannot be solved within regions and whichmay have consequences at inter-regional and/or provincial levels;· provides a conduit between Federal/Provincial/Territorial initiatives in health human resourcesplanning and provincial/regional initiatives;· provides a forum for communication and coordination of activities with and betweenstakeholders.Disadvantages:· if neither the Steering Committee nor the Operations Committee is mandated by the Ministry ofHealth, implementation will be ineffective despite cooperation and goodwill between the majorstakeholders;· the potential exists for the above committees to become extremely large and thus ineffectual indecision-making and taking action;· funding (new or re-allocated).Since February 1996, the Health Employers Association of BC (HEABC) has had a managementcontract to operate a Central Physician Recruitment Assistance Program.  The purpose of thisProgram is to assist rural and remote communities in recruiting physicians.  HEABC also helps linkHealth Human Resources UnitRegional Health Human Resources Planning & Management36physicians interested in providing locum services with physicians practicing in larger ruralcommunities (BC Ministry of Health Current Initiatives/Programs to Address Rural PhysicianRecruitment, Retention and Relief Issues).  The Central Physician Recruitment Assistance Program isa good example of a program that can be managed by the Operations Committee described above.6. ImplementationIn order to facilitate the implementation of any one of the models described above for organizinghealth human resources planning in the regions and across the province, generic implementation stepsare outlined below.1.  Convene a meeting of the CEO’s of the RHB’s and CHSS’s in the province and establish a modelfor use in organizing health human resources planning and management in the province.2.  Draw together representatives from essential groups to form a Steering Committee for planningpurposes.3.  The Steering Committee should be empowered to act on the implementation scheme implied bythe model chosen (includes allocation of necessary resources by governments andRHB’s/CHC’s/CHSS’s).4.  The Steering Committee should begin to look at the development of a health human resourcesplanning process, with advice from researchers and planners.5.  The Steering Committee should begin to address the data collection and management issuesraised in the report.  One way in which this  process could begin is by utilizing one or moreadministrative/regulatory databases and assessing the completeness, reliability, accessibility,appropriateness, and accuracy of the data.6.  The planning stage of this activity could be contracted out, with the undertaking itself being theresponsibility of the data owners, guided by a sub-committee of the Steering Committee and/or inconjunction with a contracting agency.Health Human Resources UnitRegional Health Human Resources Planning & Management37AppendicesHealth Human Resources UnitRegional Health Human Resources Planning & Management38Appendix A - Tables Illustrating Variety of Data SourcesTable 1 - Education/Training ProgramsSource of Data and Collection Type of Data Occupational GroupNational data (Statistics Canada)educational enrollment and outputoccupational groupProvincial reports (from B.C.,Alberta, Ontario, andSaskatchewan)educational enrollment and outputhealth occupationsProvincial data (all provinces)enrollment and output 30 occupations reported in "HealthPersonnel in Canada" (Health andWelfare Canada)Association of Canadian MedicalCollegesinter-provincial comparative dataundergraduate medical studentsCanadian Post-M.D. EducationRegistryinter-provincial comparative datapost-graduate medical studentsHealth Human Resources UnitRegional Health Human Resources Planning & Management39Table 2 - Sources of Supply DataSource of Data and Collection Type of Data Occupational GroupNational Graduates SurveyEmployment and ImmigrationCanadaSpecial abstracts are possibleCensus-based data by field ofstudy, by occupation and by ageNational dataprovincial licensing bodies(Canadian Nurses Association andStatistics Canada)information on numbers, socio-demographic characteristics. andemploymentRN’sCanadian Institute of HealthInformation (CIHI):Southam Medical DatabaseNational Physician Database -three phase project to establishcomprehensive national databaseon physiciansRN DatabaseHealth Personnel Databaselisting of physicians by location,year and place of graduation, andspecialtyPhase I: data on fee-for-servicephysicians includes socio-demographic characteristics ofphysicians and patients andphysician activity patterns byspecialtyPhase II: will include data on fee-payments by other public agencies(e.g. Workers' Compensation,etc.), as well asinformation on non-fee payments(e.g. salaried, sessional fees,contracts, etc.).Phase III: will include informationon non-clinical activities ofphysicians (e.g. academic,administrative, etc.).Demographic data includingage/sex, year and province ofgraduation, education, employmentstatus, hours worked, location ofemployment, location of residenceand type of employerData available from 1980Number of people active,employed and licensed in varioushealth fields, as well as number ofnew graduatesPhysiciansCovers about 80 percent ofphysicians in CanadaRegistered Nurses30 occupational groups covered… continuedHealth Human Resources UnitRegional Health Human Resources Planning & Management40Table 2 - Sources of Supply Data (continued)Source of Data and Collection Type of Data Occupational GroupCanadian Medical AssociationPhysician Resources Database(from a master file of Canadianphysicians; survey data collectedevery four years)data on demographiccharacteristics are linked to dataon practice patternsPhysicians"Physician Manpower in Canada,1980-2000”-submitted by theFederal/Provincial AdvisoryCommittee on Health HumanResources in 1984ta on supply and requirementsby major specialty groupscontained in the reportPhysicians"Federal/Provincial Report onRehabilitation Personnel", 1988,submitted to the Conference ofDeputy Ministers of Health.Data on supply and requirementsPhysiotherapistsOccupational TherapistsAudiologists/Speech-LanguagePathologistsAnnual publication of "HealthPersonnel in Canada"year-end statistics by occupationand by province covering a 10-year period.30 occupational groupsHealth Human Resources UnitRegional Health Human Resources Planning & Management41Table 3 - Sources of Utilization DataSource of Data and Collection Type of Data Occupational GroupNational Physician Database(CIHI)-information on fee payments,practice patterns and productivitymeasuresAnnual Return of Health CareFacilities - Hospitals(Statistics Canada)- numbers employed, full-time-equivalents, paid hours, andworkloadData on hospital-based personnel(other than medicine)Employer surveys(Employment and ImmigrationCanada)-filled and vacant permanentpositions in the health sector(annually in Alberta,Saskatchewan)-difficult-to-fill vacant permanentpositions (to 1995 in B.C.,occasionally in Ontario)"Job Futures 1990”(Employment and ImmigrationCanada)-labour market information andcareer opportunities to 1995Health Human Resources UnitRegional Health Human Resources Planning & Management42Table 4 - Licensure/Certification/Registration Sources of DataSource of Data and Collection Type of Data Occupational GroupFederal/Provincial AdvisoryCommittee on Health HumanResourcesStatutory Provisions and Entry toPractice RegulationsDocument 1 (April 1988)Document 2 (November 1988)Document 1: Physicians,Registered Nurses, NursingAssistants, Registered PsychiatricNursesDocument 2: Pharmacists,Dentists, Dental Hygienists,Denturists/ Denturologists, DentalAssistants, Dental Nurses, DentalTherapistsFederal/Provincial AdvisoryCommittee on Health HumanResources and Health and WelfareCanada publication Catalogue onHealth Manpower Legislation(1985 edition)legislation by province for Canada,legislative plans/policies byprovince and comparativeprovincial legislation byoccupationDirectory of NationalCertification Bodies, NationalProfessional Associations andNational Accreditation Agenciesfor Various Health Occupationsin Canada(1985 and 1990 editions)(Health and Welfare Canada)information for 59 groups… continuedHealth Human Resources UnitRegional Health Human Resources Planning & Management43Table 4 - Licensure/Certification/Registration Sources of Data (continued)Source of Data and Collection Type of Data Occupational GroupReport of the Working Group onthe Practice of Dental Hygiene(1988)Part 1: The Practice of DentalHygiene in CanadaPart 2: Clinical PracticeStandards for Dental Hygienistsin CanadaHealth & Welfare Canada:Health Personnel in Canada, 1987Canada Health ManpowerInventory, 1980, 1976, 1970Canadian Dental Association:1982a Board of Governors’Report1982b Manpower SupplyForecast, 1981-2001 - TechnicalReport1982c Manpower Supply Study,Scenarios for the Future: DentalManpower to 2001Employment and ImmigrationCanada - National Job Bank dataStatistics Canada:Health Manpower, No. 83-230,1976 & 1977Health Manpower, non-cataloguedreports, 1978, 1979, 1981, 1983House, R.K. Canadian DentalAssociation Manpower StudySupply, 1982Lewis et al, Demographic &Employment Profile of DentalHygienists in Canada, 1979, 1981Lewis, DW - Canadian DentalManpower - Supply, Distribution,Requirements, 1977Dental HygienistsHealth Human Resources UnitRegional Health Human Resources Planning & Management44Table 5 - Sources of Immigration DataSource of Data and Collection Type of Data Occupational GroupPeriodic publications(Employment and ImmigrationCanada)-occupational entry requirements,qualifications required forregistration/ certification/licensureby province or territoryInformation provided to theprovinces(Employment and ImmigrationCanada)-annual number of landedimmigrants by immigrant class,intended field. of health.occupation and by province-data on temporary employmentauthorization can be obtained uponrequestInformation provided to theFederal/Provincial AdvisoryCommittee on Health HumanResources on “designatedoccupations” to manage the flowof health care workers fromabroad(Employment and immigrationCanada)Health Human Resources UnitRegional Health Human Resources Planning & Management45Table 6 - Additional Sources of DataData Source Data Included OccupationLicensing Bodies -groups requiring a license topractice a profession-excludes personnel with relevanttraining who are not licensedProfessional Associations andSocieties-groups requiring mandatoryregistration-data provides information onthose who choose to be registeredat a point in time - excludespotential workforce not employedin the field and possibly someemployed in the field with othertitles who are not registered-groups without mandatoryregistration, but who haveexclusive use of title, numbers canbe determined with the relevantprofessional body, but it cannot beknown how many are practicingwithout registration-groups without either mandatoryregistration or exclusive use oftitle, only membership dataavailable --these data likelyexclude some personnel employedin the field with the relevant titlesProvincial Pay Agencies - for groups paid directly byprovincial pay agencies; beyondphysicians, there is considerableinter-provincial variability. Thissource will exclude personnel paidby other meansFederal Taxation Data -cannot provide any detail onspecialty or area of work, e.g.pediatric oncologists or obstetricnurses-does not include healthprofessionals who are employed ina related field, e.g. academicphysicians or nurse educators.-self-employed professionals… continuedHealth Human Resources UnitRegional Health Human Resources Planning & Management46Table 6 - Additional Sources of Data (continued)Data Source Data Included OccupationEmployment and Immigration Information on socio-demographiccharacteristics, training andqualifications available-this information has not beenmade available routinely to healthhuman resources planners(provincial authorities).For new entrants from abroad, byself-reported profession.Surveys and Other SpecialPurpose DataProvincial sources include specialsurveys of consumers of services,of sub-populations, of employers,and surveys of personnel. The dataare subject to all themethodological limitations ofsurveys. Special purpose data suchas the Southam Medical Databaseand the National PhysicianDatabase are also subject tolimitations; the degree ofmethodological rigor willdetermine their “robustness”.Health Human Resources UnitRegional Health Human Resources Planning & Management47Appendix B - Description of Health Personnel by Educational Preparation and RegulationField Certificate Diploma Baccalaureate Post-graduatePublic Protection:OccupationalRegulationPublic Protection:Administration ofRegulationAdministrative Services -- Basic 5 5Dental Receptionist  104 h - 5 m 5 5Medical/Dental Receptionist  480 h 5 5Medical Office Assistant  191 h - 10 m 5 5Medical Receptionist  n/a 5 5Medical Secretary  720 h - 9 m 5 5Medical Transcriptionist  720 h - 9 m 5 5Nursing Unit Clerk  350 h - 30 w 5 4Health Administration -- Master's Bachelor's 24 m 5 3Health Care & Epidemiology -- Master's Bachelor's 1 - 6 y 5 5Dental Services -- BasicDental Assisting  10 m 1 1Dental Hygiene -- Diploma  1 y univ. + 20 m 2 1Dental Technician  36 m 2 1Dentistry  3 y univ.  126 w 1 1Denturist  24 m 2 1Health Standards -- BasicEnvironmental Health: Public Health Inspection  70 w 3 3Occupational Health & Safety  70 w 5 5Human Services -- BasicCommunity Support Worker  786 h - 45 w 5 5Counselling Skills  n/a 5 5Developmental Disabilities  2 - 5 y 5 5ECE -- Integrated Diploma  16 m 2 2Home Support Attendant  15 - 41 w 5 4,5Home Support/Resident Care Attendant  660 h - 29 w 5 4,5Human Service Worker  1110 h - 10 m 5 4,5Institutional Aide  14 w 5 4,5Pers. Care Atten. Working for People withDisabilities 8 m 5 4,5Resident Care Attendant  600 h - 24 w 5 4,5Sign Language Intrepreter  13 m  2 y 3 3Social Service Worker 9 m - 80 w 5 4Social Work -- Baccalaureate  1 - 2 y univ.. + 2 - 3 y 3 3Special Needs  378 - 1096 h 5 5Substance Abuse Counsellor  16 - 20 m 5 5Human Services -- Post-basicCaring for Persons with Dementia  120 h 5 4,5Children with Special Needs -- ECE Level II 320 h - 3 y 2 2Geriatric Activity Coordinator  276 - 490 h 5 4,5Social Work -- Master's  Bachelor's  26 w - 2 y 3 3Laboratory Services -- BasicBiomedical Engineering  70 w 3 3Cardiology Technologist 35 w 3 3Cytotechnologist  1 y + 23 m 3 3,4Electroneurophysiology Technologist  18 m 3 3,4Medical Clinical Assistant  26 w 5 3,4… continuedHealth Human Resources UnitRegional Health Human Resources Planning & Management48Appendix B - continuedField Certificate Diploma Baccalaureate Post-graduatePublic Protection:OccupationalRegulationPublic Protection:Administration ofRegulationMedical Laboratory Assistant  18 - 26 w 5 4Medical Laboratory Technologist  20 m - 120 w 3 3,4Medical Radiography Technologist  25 m 3 3,4Nuclear Medicine Technologist  24 m 3 3,4Radiation Therapy Technologist  1 y + 27 m 3 3,4Respiratory Therapist  27 m 3 3,4Cardiovascular Perfusion Technology  Dipl. + 2 y 3 3,4Cardiovascular Technology  Dipl. + n/a 3 3,4Laboratory Services -- Post-basicCytogenetics Laboratory Technologist  Bach. + 13 m 3 3,4Diagnostic Medical Sonographer  Dipl. + 12 m 3 3,4Echocardiography  Dipl. + Dipl. + 4 m 3 3,4Medical & Treatment Services -- BasicMedicine  3  y  153 w 1 1Dispensing Optician -- Certificate  38 w 2 1Dispensing Optician -- Diploma  76 w 2 1Occupational First Aid -- WCB Level III  70 - 105 h 4 5Medical & Treatment Services -- Post-basicEmergency Medical Assistant I  80  h 2 2Emergency Medical Assistant II  5 m 2 2Emergency Medical Assistant III -- A.L.S.  12 m 2 2Emergency Medical Assistant III -- I.T.T.  18 m 2 2Genetic Counselling -- Master's  Bachelor's  2 y 5 5Mental Health Services -- Post-basicClinical Psychology -- Master's  Bachelor's  2 - 4 y 5 3Clinical Psychology -- Doctorate  Bachelor's/Master's  5 - 8 y 2 1Counselling Psychology -- Master's  Bachelor's  1 - 3 y 5 3Counselling Psychology -- Doctorate  Bachelor's  Master's +  6 y 2 1Nursing Services -- BasicNursing -- Baccalaureate  4 y 2 1Nursing -- Combined RN/BSN  26 m - 3 y / 128 w - 40 m 2 1Nursing -- Diploma  86 w - 2.5 y 2 1Practical Nursing  48 - 52 w 2 1Psychiatric Nursing  90 w 2 1Nursing Services -- Post-basicNursing -- Post-RN Baccalaureate  Diploma  52 w - 2 y 2 1Nutrition & Dietary Services -- BasicDietetics -- Baccalaureate  4 y 3 3,4Human Nutrition -- Baccalaureate  4 y 3 5Nutrition & Food Service Management  1482 h 5 4Pharmaceutical Services -- BasicPharmacy -- Baccalaureate  1 y + 4 y 1 1Pharmacy Technician  324 h - 28 w 5 5Rehabilitation Services -- BasicAudiology and Speech Sciences -- Master's  Bachelor's  13 - 29 m 3 3Massage Therapy  2 y - 104 w 2 1Music Therapy -- Baccalaureate  2 y + 2.5 y 3 3… continuedHealth Human Resources UnitRegional Health Human Resources Planning & Management49Appendix B - continuedField Certificate Diploma Baccalaureate Post-graduatePublic Protection:OccupationalRegulationPublic Protection:Administration ofRegulationOccupational Therapy -- Baccalaureate  1 y + 98 w 3 3Physical Therapy -- Baccalaureate  1 y + 96 w 2 1Prosthetic and Orthotic Technology  70 w 3 3Rehabilitation Assistant  34 - 41 w 5 4Therapeutic Recreation Technician  60 w 5 5Programs Not Offered in BCAcupuncturists 2 1Podiatrists 1 1Chiropractors 2 1Naturopaths 1 1Homeopaths 5 5Midwives 1 1Optometrists 1 1Code Table - Occupational Regulation1  licensure2  certification3  exclusive use of title4  by employer5  noneCode Table - Administration of Occupational Regulation1  self-governance - group-specific legislation2  government body3  professional association - under Society's Act4  facility accreditation5  noneHealth Human Resources UnitRegional Health Human Resources Planning & Management50Appendix C - Identifying and Comparing Categories of Selected Health Services WorkersRollcall ’93CategoriesInventory of Current Health CarePersonnel Classifications (*specialties)Ministry of Health Framework - p. 57)HSCIS - Data Reporting Package:Code Tables - September 1995; NoSenior Management(Union Classifications)Administrative ServicesHealth Services Executive2 Continuing Health Care Administrator2 Health Administrator2 Health Care ManagerHealth Records Personnel1 Health Data TechnologistHealth Information Scientist1 Health Record Administrator Health Record Administrator I - IV (HSA)1 Health Record Technician Medical Records Technician (HEU-AC)Health EpidemiologistPopulation EpidemiologistDental Services - Senior Dental Health Consultant, Dental Health ServicesDental Assistant (Level 1) Dental Assistant (HEU-AC)3 Dental Assistant (Level 2), Certified Dental Asst., Certified (HEU-AC)Certified Dental Asst. Supervisor (HEU)4 Dental Hygienist, Certified5 Dental Technician, Licensed6 Dentist, Licensed Dental Specialist*7 Denturist (Dental Mechanical), LicensedDiagnostic and Therapeutic Technological Services9 Cardiology Technician (/Technologist)Cardiology Technologist (HEU)Cardiovascular Technologist10 Cardiovascular Perfusionist Perfusionist:  I - III (HEU-AC)Perfusionist Asst. (HEU-AC)Combined Technologist (Lab/X-ray), Cert.X-ray Asst:  I - II (HEU-AC)Medical Radiography Tech:  I - VI (HSA)Diagnostic Technician:  I - VI (HSA)Clinical ChemistCytogenetics Laboratory TechnologistCytotechnologist (Diagnostic CT) Cytotechnologist:  I - VI (HSA)12 Diagnostic Medical Sonographer Ultrasonographer:  III - VI (HSA)Cardiac Ultrasound:  III - VI (HSA)Cardiac Ultrasound Technician (HEU)… continuedHealth Human Resources UnitRegional Health Human Resources Planning & Management51Appendix C - continuedRollcall ’93CategoriesInventory of Current Health CarePersonnel Classifications (*specialties)Ministry of Health Framework - p. 57)HSCIS - Data Reporting Package:Code Tables - September 1995; NoSenior Management(Union Classifications)Electron Microscopy TechnologistElectroneurophysiologist Diagnostic Neurophys Tech:  I - VI (HSA)EEG Asst. (HEU-AC)EEG Tech:  I - III (HSA)ECG Tech:  I - VI (HSA)ECG Asst (HEU-AC)Electromyography Tech:  I - VI (HSA)Electronystagmography Tech:  I - VI(HSA)ElectrologistEnterostomal TherapistHealth Human Resources UnitRegional Health Human Resources Planning & Management52Appendix D - Summary of Selected Current Health Care PersonnelClassifications and DatabasesCurrent Health Care PersonnelClassificationsDatabasesRollcall 95 (p.#)Ministry of Health Framework*HSCIS ClassificationsMandatoryRegistration/CertificationVoluntaryMembershipEmployerGroup“A”Payroll/PersonnelEmployerGroup“B”Payroll/PersonnelHSCIS- Union- Non-UnionOtherAdministrative Services2(9) Continuing Health CareAdministrators;Health Care ManagersCCHSE;HAABC;ACHE1(2) Health Data Technologists HRABCHealth Information Scientists1(2) Health Record Administrators HRABC HAS*Health Record Administrator:I-IV1(2) Health Record Technicians*Medical Records TechnicianHRABC HEU-ACHospital EpidemiologistsPopulation EpidemiologistsDental ServicesDental Assistants (Level 1)*Dental Asst.HEU-AC3(17) Dental Assistants (Level 2),Certified*Dental Asst., CertifiedHEU-AC*Certified Dental Asst.SupervisorCDSBC HEU4(25) Dental Hygienists, RegisteredCDHBC CDHBC5(38) Dental Technicians, RegisteredCDTBC6(45) Dentists,Licensed Dental SpecialistCDSBC7(60) Denturists (Dental Mechanic),RegisteredCDBCHealth Human Resources UnitRegional Health Human Resources Planning & Management53Appendix E - Health Personnel in B.C. by Data Available for Publicationin Rollcall ’95 and Place of Graduation ‘95DEMOGRAPHICS EDUCATION REGISTRATION EMPLOYMENT INFORMATIONHealth Group PERSONAL IDENTIFIERHOME ADDRESSAGESEXYEAR OF GRADUATIONPROV/COUNTRY OF GRADUATIONSPECIALTY/LEVEL OF CERTIFICATIONREGISTRATION/LICENCE DATEREGISTRATION/LICENCE STATUSEMPLOYMENT ADDRESSEMPLOYMENT STATUSFULL-TIME/PART-TIME/CASUALTYPE OF INSTITUTIONPOSITIONAREA/FIELD OF SERVICEAdministrative ServicesHealth Record Personnel (HRABC) l l l lHealth Service Executives (Members) l lDental ServicesCertified Dental Assistants l l l l l l l lDental Hygienists l l l l l l l lDental Technicians l l l l lDentists l  l l l l l l l lDenturists l l l l lHealth StandardsPublic Health Inspectors l lLab. & Therapeutic Tech. ServicesCardiology Technologists (CTABC) l l l lClinical Perfusionists (CSCP) l lClinical Eng./Biomedical Eng. Tech. (Survey)l l l l l l l l l lDiagnostic Medical Sonographers ( Survey)l l l l l l l l lMedical Laboratory Technologists (CSLT) l l l lMedical Radiation Technologists (BCAMRT)l l l l l l lRespiratory Therapists (BCSRT) l l l lMedical & Treatment ServicesChiropractors l l lEmergency Medical Assistants l l l l l lFirst Responders l l l l l l lNaturopathic Physicians l lOptometrists l lPharmacists l l l l l l l l l l l lPhysicians l l l l l l l l lPodiatrists l l l l l lNursing ServicesLicensed Practical Nurses l l l l l l l l l l l l l lRegistered Nurses l l l l l l l l l l l l l lLicensed Graduate Nurses l l l l l l l l l l l l l lRegistered Psychiatric Nurses l l l l l l l l l l l lNutrition & Dietary ServicesDietitians & Nutritionists (BCDNA) l l l l l l l l l l l l l lNutrition Managers (PSNM & CSNM) l lPsychological ServicesCounsellors (BCACC & BCAMFT) l l l l lPsychologists l l l l l l l l l l l lSocial Workers in Health Care (Survey) l l l l l l l lRehabilitation ServicesAud. & Speech/Lang. Pathologists (BCASLPA)l l l l l lMassage Therapists l l l l l l l l l l l l l lOccupational Therapists (BCSOT) l l l l l l l l l l l l l lPhysical Therapists l l l l l l l l l l l l l lProsthetists & Orthotists (CBCPO & CAPO)l l lHealth Human Resources UnitRegional Health Human Resources Planning & Management54BibliographyAndru, P.J. (1997). Hospital-community linkages: community information needs, data warehousing,and pilot projects. COACH Conference 22 - General Program Proceedings, COACH, Edmonton,Alberta, 130-135.BC Ministry of Health. Current Initiatives/Programs to Address Rural Physician Recruitment,Retention and Relief Issues.BC Ministry of Health. “Better Teamwork, Better Care” Putting Services for People First,November, 1996.BC Provincial Coordinating Committee on Remote and Rural Health Services, Terms of Reference.British Columbia Provincial Renal Agency Preliminary Conceptualization, November, 1997Health Professions Act, R.S.B.C. 1996, Chapter 183.HHRU 90:2 - Proceedings of the Workshop on Priorities in Health Human Resources Research inCanada, March 1990. Health Human Resources Unit Research Reports. Centre for Health Servicesand Policy Research, University of British Columbia. (A. Kaz njian, K. Friesen).HHRU 92:1 - Information Needed to Support Health Human Resources Management, February1992. Health Human Resources Unit Research Reports. Centre for Health Services and PolicyResearch, University of British Columbia. (A. K zanjian).HPRU 96:14D  Creating a Population-Based Linked Health Database: A New Resource for HealthServices Research. December 1996. (R. Chamberlayne, B. Green, M.L. Barer, C. Hertzman, W.J.Lawrence, S.B. Sheps).Scope of Practice Model Working Paper, Health Professions Council, Province of British Columbia,July 1998.The Practice of Dental Hygiene in Canada, Report of the Working Group on The Practice of DentalHygiene - Part One, Health and Welfare Canada, 1988.Vancouver/Richmond Health Board’s “Inaugural Health Plan, 1997-98.”WHO Study Group on Implementation of Integrated health Systems and Health PersonnelDevelopment (1990).  Coordinated health and human resources development; report of a WHOstudy group.  (World Health Organization. Technical report series; 801.) Geneva, Switzerland:World Health Organization.55Health Human Resources UnitCentre for Health Services and Policy ResearchThe University of British Columbia#429 - 2194 Health Sciences MallVancouver, BC  V6T 1Z3Telephone:  (604) 822-4810            Fax:  (604) 822-5690web site:  www.chspr.ubc.ca/Some of the early reports may not be available for distributionHHRU 98:4 Proceedings of the Second Trilateral Physician Workforce Conference, November 14-16, 1997,Vancouver.  December 1998.  (M L. Barer, L. Wood).  ISBN 1-894066-99-5.HHRU 98:3 PLACE OF GRADUATION 97.  A Status Report on Place of Graduation for Selected HealthPersonnel in the Province of British Columbia.  August 1998.ISBN 1-896459-99-4.  ISSN 1200-0701.HHRU 98:2 INVENTORY 97.  A Regional Analysis of Health Personnel in the Province of British Columbia.June 1998.  ISBN 1-896459-98-6.HHRU 98:1 ROLLCALL 97.  A Status Report of Health Personnel in the Province of British Columbia.  June1998.  ISBN 1-896459-97-8.  ISSN 0707-3542.HHRU 97:4 Common Problems, Different 'Solutions': Learning from International Approaches to ImprovingMedical Services Access for Underserved Populations.  October 1997.  (M.L. Barer, L. Wood).ISBN 1-896459-96-X.  Also listed as Health Policy Research Unit Report  HPRU 97:12D.HHRU 97:3 INVENTORY UPDATE 96.  A Regional Analysis of Health Personnel in the Province of BritishColumbia.  July 1997.  ISBN 1-896459-95-1.  ISSN  1196-9911.HHRU 97:2 ROLLCALL UPDATE 96.  A Status Report of Selected Health Personnel in the Province ofBritish Columbia.  July 1997.  ISBN 1-896459-94-3.  ISSN 0828-9360.HHRU 97:1 PLACE OF GRADUATION 95.  A Status Report on Place of Graduation for Selected HealthPersonnel in the Province of British Columbia.  April 1997.ISBN 1-896459-93-5.  ISSN 1200-0701.HHRU 96:5 INVENTORY 95.  A Regional Analysis of Health Personnel in the Province of British Columbia.December 1996.  ISBN 1-896459-92-7.HHRU 96:4 PRODUCTION 95.  A Status Report on the Production of Health Personnel in the Province ofBritish Columbia.  October 1996.  ISBN 1-896459-91-9.  ISSN 1199-4010.HHRU 96:3 ROLLCALL 95.  A Status Report of Health Personnel in the Province of British Columbia.October 1996.  ISBN 1-896459-90-0.  ISSN 0707-3542.HHRU 96:2R Identifying the Population of Health Managers in one Canadian Province: A Two-StageApproach.  April 1996.  (A. Kazanjian, N. Pagliccia).  ISBN 1-896459-89-7.HHRU 96:1R Key Factors in Physicians’ Choice of Practice Location - Level of Satisfaction and SpousalInfluence.  March 1996.  (A. Kazanjian, N. Pagliccia).  ISBN 1-896459-88-9.56HHRU 95:6E Fee Practice Medical Services Expenditures Per Capita, and Full-Time-Equivalent Physiciansin British Columbia, 1993-1994.  December 1995.  (A. Kazanjian, P. Wong Fung, L. Wood).Only available in an electronic format at:  www.chspr.ubc.ca/feepract/.HHRU 95:5R The Impact of Professional and Personal Satisfaction On Perceptions of Rural and Urban:Some Analytic Evidence.  D cember 1993.  (N. Pagliccia, L. Apland, A. Kazanjian).  ISBN 1-896459-87-0.HHRU 95:4 PRODUCTION UPDATE 94.  A Status Report on the Production of Selected Health Personnelin the Province of British Columbia.  May 1995.  ISBN 1-896459-86-2.ISSN 1199-4010.HHRU 95:3 Health Personnel Modelling 1975-1994: An Updated Bibliography with Abstracts. March1995.  (N. Pagliccia, K. McGrail, L. Wood).  ISBN 1-896459-85-4.HHRU 95:2 INVENTORY UPDATE 94.  A Regional Analysis of Health Personnel in the Province of BritishColumbia.  March 1995.  ISBN 1-896459-84-6.  ISSN  1196-9911.HHRU 95:1 ROLLCALL UPDATE 94.  A Status Report of Selected Health Personnel in the Province ofBritish Columbia.  March 1995.  ISBN 1-896459-83-8.  ISSN 0828-9360.HHRU 94:5 PLACE OF GRADUATION 93.  A Status Report on Place of Graduation for Selected HealthPersonnel in the Province of British Columbia.  October 1994.  (K. McGrail, K. Kerluke, A.MacDonald, L. Wood).  ISBN 1-896459-82-X.  ISSN 1200-0701.HHRU 94:4 PRODUCTION 93.  A Status Report on the Production of Health Personnel in the Province ofBritish Columbia.  August 1994.  ISBN 1-896459-81-1.  ISSN 1199-4010.HHRU 94:3 ROLLCALL 93.  A Status Report of Health Personnel in the Province of British Columbia.  May1994.  ISBN 1-896459-80-3.  ISSN 0707-3542.HHRU 94:2 Interpreting the Historical Difficult-to-Fill Vacancy Trends - A Multivariate Analysis.  April1994.  (N. Pagliccia, A. Kazanjian, L. Wood).  ISBN 1-896459-79-X.HHRU 94:1 Social Work Personnel in British Columbia:  Defining the population and describingdeployment patterns in 1993. January 1994.  (J. Finch, A. Kazanjian, L. Wood)ISBN 1-896459-78-1.HHRU 93:8R Health Care Managers in British Columbia  Part I: Who Manages Our System?, Part II:Exploring Future Directions.  December 1993.  (A. Kazanjian, N. Pagliccia).ISBN 1-896459-77-3.HHRU 93:7 Fee Practice Medical Services Expenditures Per Capita, and Full-Time-Equivalent Physiciansin British Columbia, 1991-1992.  December 1993.  (A. Kazanjian, P. Wong Fung, L. Wood).ISBN 1-896459-76-5.HHRU 93:6 Social Workers in Health Care in British Columbia, 1991.  July 1993.  (L.E. Apland,L. Wood, A. Kazanjian).  ISBN 1-896459-75-7.HHRU 93:5 Difficult-to-Fill Vacancies in Selected Health Care Disciplines in British Columbia, 1980-1991.June 1993.  (A. MacDonald, A. Kazanjian).  ISBN 1-896459-74-9.57HHRU 93:4 ROLLCALL UPDATE 92.  A Status Report of Selected Health Personnel in the Province ofBritish Columbia.  April 1993.  ISBN 1-896459-73-0.  ISSN 0828-9360.HHRU 93:3 Nursing Resources in British Columbia: Trends, Tensions and Tentative Solutions.  February1993.  (A. Kazanjian, L. Wood).  ISBN 1-896459-72-2.  Also listed as Health Policy ResearchUnit Report     HPRU 93:5D.HHRU 93:2 Nursing Resources Models: Part I: Synthesis of the Literature and a Mod lli g Strategy forB.C.  February 1993.  (N. Pagliccia, L. Wood, A. Kazanjian).  ISBN 1-896459-71-4.HHRU 93:1 Study of Rural Physician Supply: Perceptions of Rural and Urban. Janua y 1993.(N. Pagliccia, L.E. Apland, A. Kazanjian).  ISBN 1-896459-70-6.HHRU 92:8 Diagnostic Medical Sonographers in British Columbia, 1991.  December 1992.(L.E. Apland, A. Kazanjian).  ISBN 1-896459-69-2.HHRU 92:7 Fee Practice Medical Service Expenditures per Capita, and Full-Time-Equivalent Physicians inBritish Columbia, 1989-1990.  November 1992.  (A. Kazanjian, P. Wong Fung, M.L. Barer).ISBN 1-896459-68-4.HHRU 92:6 PLACE OF GRADUATION 91.  A Status Report on Place of Graduation for Selected HealthPersonnel in the Province of British Columbia.  November 1992.(A. MacDonald, K. erluke, L.E. Apland, L. Wood).  ISBN 1-896459-67-6.ISSN 1200-0701.HHRU 92:5R Health "Manpower" Planning or Gender Relations?  The Obvious and the Oblique.  June 1992.(A. Kazanjian).  ISBN 1-896459-66-8.HHRU 92:4R A Human Resources Decision Support Model: Nurse Deployment Patterns in One CanadianSystem.  November 1992.  (A. Kazanjian, I. Pulcins, K. Kerluke).ISBN 1-896459-65-X.HHRU 92:3 PRODUCTION 91.  A Status Report on the Production of Health Personnel in the Province ofBritish Columbia.  May 1992.  ISBN 1-896459-64-1.  ISSN 1199-4010.HHRU 92:2 ROLLCALL 91.  A Status Report of Health Personnel in the Province of British Columbia.  May1992.  ISBN 1-896459-63-3.  ISSN 0707-3542.HHRU 92:1 Information Needed to Support Health Human Resources Management.  February 1992.(A. Kazanjian).  ISBN 1-896459-62-5.HHRU 91:4R A Single Stochastic Model For Forecasting Nurse Supply and For Estimating Life-CycleActivity Patterns.  May 1991.  (A. Kazanjian).  ISBN 1-896459-61-7.HHRU 91:3 ROLLCALL UPDATE 90.  A Status Report of Selected Health Personnel in the Province ofBritish Columbia.  March 1991.  ISBN 1-896459-60-9.  ISSN 0828-9360.HHRU 91:2 Study of Rural Physician Supply: Practice Location Decisions and Problems in Retention.Volume I.  March 1991.  (A. Kazanjian, N. Pagliccia, L. Apland, S. Cavalier, L. Wood).  ISBN1-896459-59-5.HHRU 91:1 Registered Psychologists in British Columbia, 1990: A Status Report. March 1991.(C. Jackson, L. Wood, K. Kerluke, A. Kazanjian).  ISBN 1-896459-58-7.58HHRU 90:7 Place of Graduation for Selected Health Occupations - 1989.(HMRU 90:7) November 1990.  (S. Cavalier, K. Kerluke, L. Wood).  ISBN 1-896459-57-9.HHRU 90:6 Health Managers in B.C.  Part II: Who Manages Our System? - ociodemographic(HMRU 90:6) Characteristics, Employment Patterns, Educational Background and Training of HealthManagers.  June 1990.  (A. Kazanjian, C. Jackson, N. Pagliccia).  ISBN 1-896459-56-0.HHRU 90:5 Health Personnel Modelling: A Bibliography With Abstracts.(HMRU 90:5) June 1990.  (N. Pagliccia, C. Jackson, A. Kazanjian).  ISBN 1-896459-55-2.HHRU 90:4 PRODUCTION 89.  A Status Report on the Production of Health Personnel in(HMRU 90:4) the Province of British Columbia.  March 1990.  ISBN 1-896459-54-4.ISSN 1199-4010.HHRU 90:3 ROLLCALL 89.  A Status Report of Health Personnel in the Province of British(HMRU 90:3) Columbia.  March 1990.  ISBN 1-896459-53-6.  ISSN 0707-3542.HHRU 90:2 Proceedings of the Workshop on Priorities in Health Human Resources Research in(HMRU 90:2) Canada.  March 1990.  (A. Kazanjian, K. Friesen).  ISBN 1-896459-52-8.HHRU 90:1 Nurse Deployment Patterns:  Examples for Health Human Resources Management.(HMRU 90:1) February 1990.  (A. Kazanjian, I. Pulcins, K. Kerluke).  ISBN 1-896459-51-X.HHRU 89:4 Providers of Vision Care in British Columbia: A Report on the Status of(HMRU 89:4) Ophthalmologists and Optometrists, and On the Utilization of Ophthalmological andOptometric Services, 1975-1988.  July 1989.  (I. Pulcins, P. Wong Fung, C. Jackson,    K.Kerluke, A. Kazanjian).  ISBN 1-896459-50-1.HHRU 89:3  Fee Practice Medical Service Expenditures Per Capita, and Full-Time-Equivalent(HMRU 89:3) Physicians in British Columbia, 1987-88.  August 1989.  (A. Kazanjian, P. Wong Fung, M.L.Barer).  ISBN 1-896459-49-8.HHRU 89:2 Health Managers in B.C.  Part I: Methods and Preliminary Findings From Survey of(HMRU 89:2) Chief Executive Officers.  July 1989.  (A. Kazanjian, N. Pagliccia, C. Jackson).ISBN 1-896459-48-X.HHRU 89:1 ROLLCALL UPDATE 88.  A Status Report of Selected Health Personnel in the Province(HMRU 89:1) of British Columbia.  March 1989.  ISBN 1-896459-47-1.  ISSN 0828-9360.

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