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Manpower planning: health manpower planning-hospital manpower planning Seguin, John David 1981

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JVIANPOWER PLANNING HEALTH MANPOWER PLANNING - HOSPITAL MANPOWER PLANNING by JOHN DAVID SEGUIN B.S., University of Utah, 197^  A THESIS SUBMITTED IN PARTIAL RJIFILDVENT OP THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES • Department "of Health Care and Epidemiology Faculty of Medicine We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA December, 1980 .© John David Seguin, 1980 In presenting th i s thes is in pa r t i a l fu l f i lment of the requirements fo an advanced degree at. the Univers i ty of B r i t i s h Columbia., agree that the L ibrary shal l make it f ree ly ava i l ab le for reference and study. I further agree that permission for extensive copying of th i s thesis for scho lar ly purposes may be granted by the Head of my Department or by his representat ives. It is understood that copying or pub l i ca t ion of th is thes i s for f inanc ia l gain sha l l not be allowed without my writ ten permission. John David Seguin Department of Health Care and Epidemiology The Univers i ty of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date March 1. 1981 i i ABSTRACT The main o b j e c t i v e of t h i s t h e s i s i s t o p r e s e n t concepts and knowledge i n v o l v e d i n manpower p l a n -i n g , h e a l t h manpower p l a n n i n g , h o s p i t a l manpower p l a n n i n g , and the development o f manpower and s t a f -f i n g g u i d e l i n e s i n h o s p i t a l s . A l o n g w i t h t h i s ob-j e c t i v e , i t was f e l t n e c e s s a r y t h a t t h i s t h e s i s o f f e r a good r e v i e w of approaches o r t e c h n i q u e s used I n manpower p l a n n i n g , h e a l t h manpower p l a n n i n g , and the development o f manpower and s t a f f i n g g u i d e l i n e s i n h o s p i t a l s . I t was a l s o f e l t t h a t t o r e c e i v e the p r o p e r a t t e n t i o n , a l i s t o f c r i t e r i a o r f u n c t i o n s t h a t are n e c e s s a r y t o develop such g u i d e l i n e s be g i v e n . A l l o f the f o r e g o i n g was a c c o m p l i s h e d t h r o u g h a r e -view o f the l i t e r a t u r e and case s t u d i e s which the a u t h o r has found h e l p f u l . I t i s the main c o n c l u s i o n o f t h i s t h e s i s t h a t b o t h manpower and h e a l t h manpower p l a n n i n g have r e c e i v e d wide r e s p e c t and r e c o g n i t i o n . H o s p i t a l manpower p l a n n i n g f o r the development o f s t a f f i n g g u i d e l i n e s i n h o s p i t a l s has not been so f o r t -u n a te. T h i s type of p l a n n i n g i s s t i l l i n the embryo or i n f a n c y s t a g e . A l t h o u g h i t has not r e c e i v e d the a t t e n t i o n as manpower or h e a l t h manpower p l a n n i n g , r e c o g n i t i o n f o r the importance o f d e v e l o p i n g s t a f f i n g g u i d e l i n e s i s growing r a p i d l y . i i i TABLE OF CONTENTS T i t l e Page i Abstract i i Table of Contents i i i L i s t of Tables v Acknowledgement v i Chapter I , Manpower Planning 1 Defining Manpower Planning 2 Steps i n Manpower Planning 5 Manpower Planning-Private and Public Sectors 10 Methods Used i n Forecasting Manpower Requirements 14 Econometric Methods 15 Productivity Methods 16 Survey Methods 17 Trend Projection Methods 19 Chapter I I , Health Manpower Planning 22 Concepts i n Health Manpower Planning 23 Demand for Health Manpower 28 Cultural and Demographic Factors 30 Economic Factors 33 Health Care Delivery Constraints 36 Methods Used i n Health Manpower Planning 40 Manpower/Population Ratio Approach 43 Service Targets Approach 48 Health Need Approach 53 i v Economic (effective) Demand Approach 56 Functional Analysis Approach 59 Use of Models Approach 6 l Chapter I I I , Hospital Manpower Planning 66 Developing Manpower and St a f f i n g Guidelines 70 Admitting Department 73 Business Office 77 D i e t e t i c Department 8 l Housekeeping Department 86 Medical Records Department 91 Nursing Department 96 Radiology Department 109 S o c i a l Service Department 116 Chapter IV, Review, State-of-the-Art, Conclusions and. Recommendations •• 120 Manpower Planning 121 Health Manpower Planning 124 Hospital Manpower Planning 130 State-of-the-Art 132 Recommendations 135 Bibliography 137 Appendix A - A L i s t of Health Occupations 146 V LIST OP TABLES Table I , Major Methods for Assessing and Projecting Manpower Requirement v i ACKNOWLEDGEMENTS The author would l i k e to thank and show appreciation to the following for t h e i r support, i n s i g h t , - and scholarly guidance i n preparing t h i s thesis. Dr. Larry Moore, Chairman of the Thesis Committee and Associate Professor, Faculty of Commerce and Business Administration, University of B r i t i s h Columbia. Mr. Paulmer Nerland, Committee Member and Director of Business Administration, Office of the Coordinator, Health Sciences; C l i n i c Associate Professor, Department of Health Care and Epidemiology, Faculty of Medicine, University of B r i t i s h Columbia. Dr. Garth Mangum, Committee Member and Director, I n s t i t u t e of Human Resources, College of Business, University of Utah. Mrs. L i l l i a n Gale for her excellent typing of the thesis. Catherine Zylka Olsen f o r her l o y a l support and u n t i r i n g e f f o r t s i n proofreading the thesis. My wife and children f o r t h e i r t o t a l support during the moments of both f r u s t r a t i o n and delight while the thesis was being written. Faculty members from the Department of Health Care and Epidemiology, Faculty of Medicine, University of B r i t i s h Columbia. v i i CHAPTER I Manpower Planning 1 D u r i n g the p a s t s e v e r a l y e a r s t h e r e has been an i n c r e a s e i n demand i n the use o f h o s p i t a l s e r v i c e s . T h i s i n c r e a s e has brought about and produced v a r i o u s changes i n the use o f manpower and s t a f f i n g g u i d e -l i n e s w i t h i n h o s p i t a l s . The k i n d o f care which i s r e -q u i r e d and demanded from such s e r v i c e s as n u r s i n g , d i e t a r y , r a d i o l o g y , l a b o r a t o r y , m e d i c a l r e c o r d s , and o p e r a t i n g rooms has changed d r a s t i c a l l y over the p a s t t e n t o twenty y e a r s . These changes have a f f e c t e d b o t h the n a t u r e o f the work r e q u i r e d and the s t a f f t o meet the demands. Other h o s p i t a l departments i n -c l u d e the b u s i n e s s o f f i c e , h o u s e k e e p i n g , l a u n d r y , and maintenance. V i r t u a l l y e very h o s p i t a l department and s e r v i c e s has undergone changes i n the development o f manpower and s t a f f i n g g u i d e l i n e s . The o b j e c t i v e o f t h i s t h e s i s i s t o p r e s e n t con-c e p t s and knowledge i n v o l v e d i n manpower p l a n n i n g and the development o f s t a f f i n g g u i d e l i n e s f o r major hos-p i t a l departments. A l o n g w i t h the f i r s t o b j e c t i v e , a second one i s t o e s t a b l i s h a l i s t o f c r i t e r i a used i n d e v e l o p i n g such g u i d e l i n e s . B oth o b j e c t i v e s w i l l be cover e d t h r o u g h a r e v i e w o f the l i t e r a t u r e and case s t u d i e s which the a u t h o r has found h e l p f u l . To s e t the stage and a s s i s t the r e a d e r , an a n a l y -s i s on the concept o f manpower p l a n n i n g i n g e n e r a l w i l l 2 be g i v e n . Manpower p l a n n i n g w i l l be d e f i n e d a l o n g w i t h o t h e r manpower terms. A d e s c r i p t i o n o f methods used i n f o r e c a s t i n g manpower r e q u i r e m e n t s w i l l be p r e s e n t e d a l o n g w i t h the s t r e n g t h and weakness o f each method. The need f o r manpower p l a n n i n g i n hos-p i t a l s w i l l be developed and the c h a p t e r w i l l end w i t h a d i s c u s s i o n on the r e m a i n i n g c o n t e n t s o f the t h e s i s . "Manpower p l a n n i n g , s t r i c t l y d e f i n e d , i s the a c t -i v i t y o f management which i s aimed a t c o o r d i n a t i n g the re q u i r e m e n t s f o r , and the a v a i l a b i l i t y o f ... d i f f e r e n t > types o f employee. U s u a l l y t h i s i n v o l v e s e n s u r i n g t h a t the f i r m has enough o f the r i g h t k i n d o f l a b o u r at such times as i t i s needed. I t may a l s o i n v o l v e a d j u s t i n g the r e q u i r e m e n t s t o the a v a i l a b l e s u p p l y . 1 , 1 "Manpower p l a n n i n g i s . a n i m p r e c i s e a r t , based on s h i f t i n g b a s e s . S u c c e s s f u l r e s u l t s depend h e a v i l y on a p p r e c i a t i o n o f the f a c t o r s a t work and s e n s i t i v e e v a l -u a t i o n o f the d a t a . "Manpower p l a n n i n g i s an i n t e r - d i s c i p l i n a r y a c t -i v i t y . . . . T h e range o f s p e c i a l i s m s which can be brought t o b e ar on manpower problems extends from the s t a t i s t -i c a l and m a t h e m a t i c a l s t u d i e s , t o the s o c i o l o g i c a l c o n t r i b u t i o n s . . . n o p a r t i c u l a r d i s c i p l i n e can c l a i m a monopoly o f i n t e r e s t i n the f i e l d . " 3 " ...the use o f the term 'manpower p l a n n i n g ' which has been g a i n i n g c u r r e n c y i n r e c e n t y e a r s may l e g i t i -m a t e l y g i v e r i s e t o s e v e r a l q u e s t i o n s . I t may w e l l be asked i n the f i r s t p l a c e what meaning can be a t t a c h e d t o a term which embraces a c t i v i t i e s so d i v e r s e as math-A n g e l a Bowey, A Guide t o Manpower P l a n n i n g (London,The M a c M i l l a n P r e s s L t d . , 1974, p.1• ^Thomas D. L a r s o n , O r g a n i z a t i o n and Manpower P l a n n i n g (London, B u s i n e s s P u b l i c a t i o n s L t d . , 1966), p. I l l . 3"Aspects o f Manpower P l a n n i n g " : A volume o f papers pub-l i s h e d by the Manpower S o c i e t y , e d i t e d by D. J . Bartholomew and B.R. M o r r i s (London,The E n g l i s h U n i v -e r s i t y P r e s s L t d . , 1971), p. i x . 3 e m a t i c a l work on s t o c h a s t i c models, the ergonomics o f j o b d e s i g n , the s o c i o l o g y of&management d e v e l o p -ment, and the more p r o s a i c but no l e s s d i f f i c u l t problems o f an i n d u s t r i a l p e r s o n n e l department. I t i s , i n f a c t , d i f f i c u l t t o draw up a p r e c i s e d e f i n -i t i o n o f manpower p l a n n i n g which i s broad enough t o cove r a l l t h e s e t y p e s o f a c t i v i t y , but not t o o br o a d as t o become almost m e a n i n g l e s s and, i n t h i s , as i n many o t h e r f i e l d s , the s e a r c h f o r a p r e c i s e d e f i n i -t i o n may be m i s g u i d e d . " ^ R e v i e w i n g the f o r e g o i n g d e f i n i t i o n s , one can r e a d i l y see manpower p l a n n i n g t a k e s i n s e v e r a l dimen-s i o n s . I m p r e c i s e n e s s , i n t e r - d i s c i p l i n a r y a c t i v i t i e s , and supply-demand concepts a l l r e l a t e t o d e f i n i n g manpower p l a n n i n g . I t r e q u i r e s s k i l l , e x p e r i e n c e , and sound judgment. The b a s i c u n d e r l y i n g concept i s tog'see t h a t t h e r e a re t h e r i g h t t y p e s and amounts o f human r e s o u r c e s t o meet the everyday and e v e r changing demands. Manpower p l a n n i n g i s a broad and d i v e r s e term which embraces a wide spectrum o f a c t i v i t i e s . The f o l l o w i n g d e f i n i t i o n o f "manpower" w i l l f u r t h e r show i t s e x t e n d i n g components. "The word 'manpower' i t s e l f connotes many dimen-s i o n s o f human r e s o u r c e development. Both asaa term o f a r t and as an a r e a o f p u b l i c p o l i c y , manpower i n -c o r p o r a t e s a h o s t o f economic and s o c i a l c o n s i d e r -a t i o n s as t h e s e r e l a t e t o p p e o p l e ' s e n t r y i n t o and p r o g r e s s i o n w i t h i n the w o r l d o f work: e d u c a t i o n and t r a i n i n g , h e a l t h and n u t r i t i o n , j o b d i s c r i m i n a t i o n , management o f the n a t i o n a l economy, o p e r a t i o n o f employing i n s t i t u t i o n s , worker p r o d u c t i v i t y , l a b o r m o b i l i t y and m i g r a t i o n , w o r k p l a c e s t a n d a r d s and r e g u l a t i o n , wage d e t e r m i n a t i o n and c o l l e c t i v e b a r -g a i n i n g , and income s e c u r i t y . " 5 ^ I b i d . , p. 1. 5A. Johnson, Knowledge and P o l i c y i n Manpower: A  Study o f the Manpower Research and Development P r o -gram i n the Department o f L a b o r , ( N a t i o n a l Academy of S c i e n c e s , Washington, D.C, 1975) P- 1. 4 Manpower p l a n n i n g I s based on s y s t e m a t i c a t -tempts t o a n t i c i p a t e r e q u i r e m e n t s f o r p e r s o n n e l w i t h p a r t i c u l a r s k i l l s , q u a l i f i c a t i o n s , and a p t i t u d e s . T h i s i s done i n s h o r t (0-2 y e a r s ) , i n t e r m e d i a t e (2-5 y e a r s ) , or l o n g range (beyond 5 y e a r s ) f o r e c a s t i n g p e r i o d s . ' Most commonly t h i s i s done f o r p e r i o d s up t o f i v e y e a r s i n the f u t u r e . S h o r t and i n t e r -m ediate-range manpower f o r e c a s t s o f o c c u p a t i o n a l r e -quirements may be q u i t e a c c u r a t e f o r d e t a i l e d occu-p a t i o n a l groups. Even w i t h t h i s t h e r e i s a s i g n i f -i c a n t t r a d e - o f f between t h e e x a c t n e s s o f the f o r e c a s t and the number o f o c c u p a t i o n a l d e t a i l s p r o v i d e d . The l o n g e r the f o r e c a s t p e r i o d , the more c r i t i c a l t h i s t r a d e - o f f becomes. Long-range f o r e c a s t i n g be-comes more d i f f i c u l t as d e c i s i o n s a re made on vague or u n c e r t a i n f u t u r e c o n d i t i o n s . T h i s can o f t e n be a h i g h l y j u d g m e n t a l p r o c e s s and one t h a t i s based on s p e c i a l r e s e a r c h and s k i l l s . Gordon McBeath, a B r i t i s h c o n s u l t a n t and w r i t e r s t a t e s : " I n my e x p e r i e n c e i t i s p o s s i b l e t o f o r e c a s t f u t u r e s t a f f r e q u i r e m e n t s i n d e t a i l f o r about a y e a r ahead w i t h a r e a s o n a b l y h i g h degree o f a c c u r a c y ; beyond t h i s , the a c c u r a c y l e v e l tends t o f a l l away r a t h e r s h a r p l y , even i n those companies which use r e a s o n a b l y s o p h i s t i c a t e d o r g a n i z a t i o n and manpower-p l a n n i n g t e c h n i q u e s . " 6 ^Thomas D. L a r s o n , O r g a n i z a t i o n and  n i n g (London, B u s i n e s s P u b l i c a t i o n s p. 103. Manpower L i m i t e d , P l a n -196T) , 5 The f o r e c a s t o f o c c u p a t i o n a l r e q u i r e m e n t s i s g e n e r a l l y the f i r s t s t e p i n the manpower p l a n n i n g p r o c e s s . Burack and Walker e x p r e s s : " F o r e c a s t -i n g o f manpower demand and a v a i l a b l e s u p p l y c o n s t i -t u t e s the f i r s t s t e p toward e f f e c t i v e p l a n n i n g and programming o f manpower r e s o u r c e s . " 7 T h i s i n v o l v e s a d e f i n i t i o n o f the b a s i c elements i n manpower p l a n -n i n g : d e f i n i n g the f o r e c a s t i n g needs o f the organ-i z a t i o n and manpower s u p p l y t h a t w i l l be a v a i l a b l e w i t h i n the o r g a n i z a t i o n a t v a r i o u s t i m e s . The second s t e p i n manpower p l a n n i n g i s where management uses the s e f o r e c a s t s t o e s t a b l i s h a s e t o f manpower p o l -i c i e s o r g o a l s which c o r r e s p o n d t o the g o a l s o f the o r g a n i z a t i o n . The t h i r d s t e p i n the manpower p l a n -n i n g i s a d e s i g n and i m p l e m e n t a t i o n o f t h e programs and a c t i v i t i e s used f o r r e c r u i t i n g new employees. These programs i n c l u d e v a r i o u s means o f t r a i n i n g and d e v e l o p i n g p e r s o n n e l a l r e a d y employed e i t h e r t o im-prove t h e i r performances o r p r o v i d e f o r advancement. The programs a l s o i n c l u d e p r o v i s i o n s f o r r e p l a c e -ment o f h i g h l y q u a l i f i e d o r key p e r s o n n e l . Manpower p l a n n i n g produces an a l l o c a t i o n o f the v a r i o u s s k i l l r e q u i r e m e n t s over d i f f e r e n t p e r i o d s o f t i m e . T h i s i s done i n b o t h the f o r e c a s t i n g and 7 E l m e r H. Burack and James W. Wa l k e r , Manpower P l a n - n i n g and Programming ( B o s t o n , A l l y n and Bacon, I n c . 1972), P.89. 6 p o l i c y s t a g e s o f o r g a n i z a t i o n s . Manpower p l a n n i n g then i n v o l v e s the i n s t a l l a t i o n o f the above programs t o i n s u r e t h a t t h e s e r e q u i r e m e n t s are met. The i n -he r e n t d i s t i n c t i o n between t h i s and p a s t p r a c t i c e i s t h a t i t r e p l a c e s i n t u i t i v e o r haphazard p r o c e -dures w i t h a s t r u c t u r e d and m e t h o d i c a l approach t h a t may be r e p e a t e d and t h a t may be improved when new and a d d i t i o n a l i n f o r m a t i o n becomes a v a i l a b l e . Meyer has c l e a r l y p o i n t e d t h i s o u t : " I n summary, companies are r e p l a c i n g i n t u i t i o n and the haphazard approach t o manpower p l a n n i n g and development w i t h h i g h l y s y s t e m a t i c and c a r e f u l l y p l a n n e d programs t o meet a n t i c i p a t e d needs. Com-p a n i e s t h a t c o n t i n u e t o depend upon the i n t u i t i v e approach or upon change alone f o r the development o f t h e i r p e o p l e a re g o i n g t o l o s e out i n the comp-e t i t i o n t o t h e i r more p r o g r e s s i v e c o m p e t i t o r s who are u s i n g s y s t e m i c methods."" I n the post-war p e r i o d , b u s i n e s s e s have devoted i n c r e a s i n g l y l a r g e amounts o f time and t a l e n t t o t e c h -n i c a l and f i n a n c i a l p l a n n i n g p r o c e s s e s . T h i s has i n -c l u d e d much work on the s i z e , d i r e c t i o n and t i m i n g o f i n v e s t m e n t s , l o c a t i o n o f p l a n t s , a n a l y s e s o f so u r c e s and t y p e s o f f i n a n c e , d i v e r s i f i c a t i o n o f sources o f s u p p l y of raw m a t e r i a l s , and p r o d u c t de-velopment and m a r k e t i n g . I t has been o b s e r v e d , how-e v e r , t h a t a l t h o u g h e x p e n d i t u r e s on r e n u m e r a t i o n o f l a b o u r and management manpower account f o r v e r y 8"New D i r e c t i o n s f o r M a n a g e r i a l Manpower P l a n n i n g " , i n I s s u e s and Problems i n M a n a g e r i a l Manpower P l a n n i n g , e d i t e d by L o i s C r o o k s ( P r i n c e t o n , N e w J e r s e y , E d u c a t i o n -a l T e s t i n g S e r v i c e , 1967), p. H 7 -7 l a r g e p r o p o r t i o n s o f the t o t a l budgets of almost a l l o r g a n i z a t i o n s , r e s o u r c e s a l l o c a t e d by b u s i n e s s e s t o the p r o v i s i o n o f p l a n n i n g f o r manpower needs have g e n e r a l l y been modest. The absence o f manpower p l a n n i n g i s e n t i r e l y r e a s o n a b l e i n l o o s e l a b o u r markets when t h e r e are ex-cess s u p p l i e s of unemployed and s k i l l e d p e o p l e a v a i l -a b l e t o the f i r m on demand. I f t h e s e e x c e s s e s are e x p e c t e d t o p e r s i s t t h e n t h e r e i s no need f o r man-agers t o make s p e c i a l p l a n s t o s u p p l y t h e i r f i r m s w i t h q u a l i f i e d p e r s o n n e l . However, such c h r o n i c ex-cesses o f s k i l l e d p e o p l e are not g e n e r a l l y e x p e r -i e n c e d i n the l a b o u r market. I n advanced economies, t e c h n o l o g i c a l change has c r e a t e d an ever i n c r e a s i n g r e q u i r e m e n t f o r h i g h l y s k i l l e d m a n a g e r i a l and t e c h -n i c a l t a l e n t . As i t becomes more c o s t l y t o o b t a i n and m a i n t a i n such people and more c o s t l y s t i l l t o f o r e g o o p p o r t u n i t i e s i n t h e i r absence, i t becomes i n -c r e a s i n g l y i m p o r t a n t f o r f i r m s t o have a good i d e a o f when and where they are g o i n g t o need p a r t i c u l a r s k i l l s and how t o go about g e t t i n g them. There are two f a c t o r s t h a t must be c o n s i d e r e d : 1) G e n e r a l l y , the g r e a t e r the r e q u i r e d s k i l l l e v e l , the l o n g e r the l e a d time r e q u i r e d t o t r a i n people f o r the j o b s ; 2) As b u s i n e s s o r g a n i z a t i o n s i n c r e a s e i n s i z e and c o m p l e x i t y , the t a s k o f matching p e o p l e ' s s k i l l s , a s p i r a t i o n s and i n t e r e s t s t o the j o b s 8 a v a i l a b l e becomes more d i f f i c u l t . To some e x t e n t , manpower p l a n n i n g must c o n t i n u e t o beaa j u d g m e n t a l p r o c e s s . There i s a r e a l danger t n becoming t o o m e c h a n i s t i c i n the p l a n n i n g p r o c -e s s . What are r e q u i r e d are b a l a n c e d d e c i s i o n s made on the b a s i s o f s t r u c t u r e d e x e r c i s e s which r e f l e c t an awareness o f b o t h the p r e s e n t deployment o f p e r -s o n n e l , as w e l l as a f o r e c a s t o f how the deployment w i l l change i n the f u t u r e . To the e x t e n t t h a t the o v e r a l l p l a n f u n c t i o n s p r o p e r l y i t becomes a s e l f -f u l f i l l i n g p r o c e s s . The f o r e c a s t s c r e a t e a f u t u r e s c e n a r i o and the programs t o r e c r u i t and develop s k i l l s attempt t o make the f o r e c a s t come t r u e . I f the g o a l s o f the f i r m are r e a l i s t i c ( t h e s e g o a l s are s t i l l s u b s t a n -t i a l l y the r e s u l t o f the judgment o f s e n i o r man-agement) and the o p e r a t i o n a l phase o f the p l a n works a d e q u a t e l y , t h e n the a p p r o p r i a t e b a l a n c e be-tween judgment and s t r u c t u r e has been a c h i e v e d . I n t h e p p r i v a t e s e c t o r the demand f o r workers i s a d e r i v e d demand. That i s , the demand f o r l a b o r i s the r e s u l t o f the demand f o r the goods and s e r v i c e s produced by the e f f o r t s o f l a b o r . F o r t h i s r e a s o n , the f i r s t s t e p i n the manpower p l a n n i n g p r o c e s s -the f o r e c a s t s k i l l r e q u i r e m e n t s - i s almost i n v a r i a b l y preceded by a f o r e c a s t of the demand f o r the p r o d u c t s c u r r e n t l y produced by the b u s i n e s s and the demand f o r o t h e r p r o d u c t l i n e s i n t o which the f i r m p l a n s t o 9 move d u r i n g the f o r e c a s t p e r i o d . S k i l l r e q u i r e m e n t s may th e n be f o r e c a s t by u s i n g t e c h n i c a l i n f o r m a t i o n on the a n t i c i p a t e d o c c u p a t i o n a l mix and ou t p u t p e r man at the output l e v e l s e x p e c t e d i n the f o r e c a s t p e r i o d . P r o d u c t and s k i l l demand f o r e c a s t s are o b t a i n e d from m a t h e m a t i c a l models o f v a r y i n g degrees o f s o p h i -s t i c a t i o n . I t s h o u l d be mentioned t h a t i t i s q u i t e p o s s i b l e t o produce a model which i s t o o s o p h i s t i -c a t e d r e q u i r i n g d e t a i l e d and e x p e n s i v e d a t a which c o s t more.to g e n e r a t e t h a n they are worth i n • t e r m s o f performance o f the p l a n . Once a f o r e c a s t i n g model i s s p e c i f i e d , t h e r e -s u l t s o b t a i n e d from i t must be p r e s e n t e d t o s e n i o r management. T h i s i n f o r m a t i o n can th e n be combined w i t h o t h e r r e s e a r c h ( f i n a n c i a l , m a r k e t i n g , e t c . ) so t h a t r e a l i s t i c c o r p o r a t e g o a l s may be e s t a b l i s h e d . Then programs t o a t t a i n t h e s e g o a l s must be d e s i g n e d and put i n t o p l a c e . These i n c l u d e systems t o g a t h e r and a s s e s s i n f o r m a t i o n i n b o t h the e x t e r n a l and i n -t e r n a l l a b o r m arkets. I n f o r m a t i o n on the l a b o r market o u t s i d e the f i r m i s n e c e s s a r y t o o r g a n i z e e f f e c t i v e r e c r u i t m e n t programs. I n f o r m a t i o n on the l a b o r market i n s i d e the f i r m i s r e q u i r e d t o m o n i t o r employees' performance and t o a s s e s s t h e i r p o t e n t i a l f o r p r o m o t i o n . When a l l o f t h e s e elements o f the manpower p l a n 10 are o p e r a t i o n a l , some degree o f m o n i t o r i n g and e v a l u a t i o n a re n e c e s s a r y t o measure performance i n the v a r i o u s e l e m e n t s , i d e n t i f y i n g b o t h the s t r e n g t h s and weaknesses o f the p l a n , and why they d e v e l o p . M o n i t o r i n g and e v a l u a t i o n c o n s t i t u t e a feedback c o l -l e c t i n g p r o c e s s which enables r e v i s i o n and improve-ments o f the o r i g i n a l p l a n as w e l l as a l l o w i n g an a c c u m u l a t i o n o f e x p e r i e n c e so t h a t subsequent p l a n s may p r o f i t from p a s t s u c c e s s e s and m i s t a k e s . U n l i k e t h e i r c o u n t e r p a r t s i n the p r i v a t e . s e c -t o r , manpower p l a n n e r s i n the p u b l i c s e c t o r are not concerned e n t i r e l y w i t h the d e r i v e d demand f o r l a b o u r . They have the added r e s p o n s i b i l i t y o f i d e n t i f y i n g groups which are unable t o o b t a i n s t a b l e employment i n the p r i v a t e s e c t o r and o f p r o v i d i n g a range o f manpower support programs f o r them. These support programs must i n c l u d e the b e s t p o s s i b l e mix o f t r a i n -i n g , placement and j o b c r e a t i o n a c t i v i t i e s . I t i s i n the job c r e a t i o n a c t i v i t i e s t h a t the i n t e r e s t s o f government manpower p l a n n e r s are most s u b s t a n t i a l l y i n d i v e r g e n c e from the i n t e r e s t s o f p l a n n e r s i n the p r i v a t e s e c t o r . F o r government p l a n -n e r s j o b c r e a t i o n presumes t h a t the work, and not the p r o d u c t , i s the main o b j e c t i v e . Placement and t r a i n i n g programs are d e s i g n e d t o i n t e g r a t e d i s a d -vantaged people i n t o the p r i v a t e s e c t o r so t h a t they can compete more s u c c e s s f u l l y . Job c r e a t i o n may do t h i s i n d i r e c t l y by a l l o w i n g people t o g a i n work 11 e x p e r i e n c e and a d a p t t o t h e r e s p o n s i b i l i t i e s o f h o l d i n g a s t e a d y j o b , b u t t h e p r o d u c t s o f t h i s f o r m o f employment a r e n o t n e c e s s a r i l y ones t h a t p e o p l e w o u l d c h o o s e t o buy e i t h e r i n p r i v a t e m a r k e t s o r w i t h t h e i r t a x d o l l a r s . J o b c r e a t i o n i s p r i m a r i l y employment f o r t h e s a k e o f e m p l o y m e n t . F o r g o v e r n m e n t a g e n c i e s , t h e manpower p r o g r a m p l a n n i n g p r o c e s s c a n be o u t l i n e d i n a l i s t o f s p e c i -f i c a r e a s o f c o n c e r n . These a r e a s a r e : 1) i d e n t i f i c a t i o n o f t h o s e c u r r e n t l y i n n e e d o f manpower s e r v i c e s ; 2) d e f i n i t a t i o n o f t h e k i n d o f h e l p t h e d i s a d -v a n t a g e d g r o u p s i d e n t i f i e d r e q u i r e ; 3) f o r e c a s t s o f f u t u r e l a b o u r m a r k e t c o n d i -t i o n s on a r e g i o n a l b a s i s t o a l l o c a t e b u d -g e t s a p p r o p r i a t e l y ; 4) l o c a t i o n o f a c c e s s i b l e j o b s e x i s t i n g i n l o c a l l a b o u r m a r k e t s and f o r e c a s t s o f f u t u r e a r e a s o f employment g r o w t h ; 5) p r o v i s i o n o f v a r i o u s f o r m s o f s k i l l d e v e l -opment o p p o r t u n i t i e s t o f a c i l i t a t e p l a c e -ment f u n c t i o n i n t h e f u t u r e ; 6) p r o v i s i o n o f i n f o r m a t i o n t o i n d i v i d u a l s t o f a c i l i t a t e t h e j o b s e a r c h p r o c e s s and t o i m p r o v e v o c a t i o n a l c h o i c e s ; 7) p r o v i s i o n o f a j o b c r e a t i o n m e c h a n i s m where t h e i n t e r a c t i o n b e t w e e n t r a i n i n g , p l a c e m e n t and t h e p r i v a t e s e c t o r i s c o n s i d e r e d t o be 12 i n a d e q u a t e ; 8) d e t e r m i n a t i o n o f the a p p r o p r i a t e r e s o u r c e mix t o be expended on the a c t i v i t i e s l i s t e d above. L i k e c o r p o r a t e p l a n n i n g , government programs can-not be a l l o w e d t o become too m e c h a n i s t i c . S t a t i s t i c s and models are u s e f u l f o r p r o v i d i n g an u n d e r s t a n d i n g o f the problems t o be a d d r e s s e d and the way i n which these problems can be e x p e c t e d t o develop i n the f u -t u r e . However, e f f e c t i v e p l a n n i n g must i n c l u d e an awareness o f the leeway t h a t e x i s t s i n a l l o c a t i n g r e s o u r c e s among g e o g r a p h i c areas and among a l t e r n a -t i v e a c t i v i t i e s , and must a l s o i n c l u d e knowledge o f the a v a i l a b l e a l t e r n a t i v e s as w e l l as a sense of the impact of the v a r i o u s c h o i c e s on the problems i d e n t i -f i e d . Manpower p l a n n e r s r e q u i r e a c l e a r but not t o o d e t a i l e d p i c t u r e o f c u r r e n t and f u t u r e demand f o r and s u p p l y o f l a b o u r and o f the elements a f f e c t i n g them. P l a n n e r s i n the p r i v a t e s e c t o r r e q u i r e f o r e -c a s t s o f the demand f o r t h e i r p r o d u c t s t o o b t a i n such a p i c t u r e and a knowledge o f the r e l a t i o n s h i p between output l e v e l s and s k i l l r e q u i r e m e n t s . Gov-ernment p l a n n e r s d e a l i n g w i t h aggregate employment and unemployment i n a r e g i o n w i l l want g e n e r a l i n -f o r m a t i o n on economic performance and s p e c i f i c i n -f o r m a t i o n on o c c u p a t i o n s or groups where t h e r e are p a r t i c u l a r l y severe unemployment problems. T h i s 13 s p e c i f i c i n f o r m a t i o n i n c l u d e s d e t a i l on any p e c u l i a r -i t i e s o f p a r t i c u l a r o c c u p a t i o n s such as s e a s o n a l i t y , i n s t i t u t i o n a l f a c t o r s ( u n i o n s , or one of the two dominant employers) as w e l l as i n f o r m a t i o n on the c h a r a c t e r i s t i c s o f the people a f f e c t e d . Manpower p l a n n i n g i s a r e l a t i v e l y new endeavor and must not be a l l o w e d t o become too m e c h a n i c a l . The I s s u e s d e a l t w i t h by manpower p l a n n e r s are ex-t r e m e l y complex. I n c l u d e d are economic, s o c i a l , p o l i -t i c a l and p e r s o n a l f o r c e s which are d i f f i c u l t t o f o r e -c a s t a n d ^ v i r t u a l l y i m p o s s i b l e t o c o n t r o l . D e c i s i o n s s h o u l d be t a k e n on the b a s i s of a r e p l i c a b l e frame-work but must I n c l u d e s u f f i c i e n t f l e x i b i l i t y t o a l l o w f o r the u n f o r e s e e n . D e p a r t u r e s from the models w i l l be f r e q u e n t , but t h e r e must be a b a s i c p r o c e s s from which t o s t a r t and t o which t o r e t u r n . 9 T h i s c h a p t e r w i l l now focus on some of the p r o -cesses from which t o s t a r t and which t o r e t u r n . D i f -f e r e n t methods and t e c h n i q u e s used i n manpower p l a n -n i n g w i l l be p r e s e n t e d . The s t r e n g t h and weakness of each method w i l l a l s o be g i v e n . 9 Reproduced w i t h p e r m i s s i o n : T h i s was a r e p o r t p r e -pared as a r e f e r e n c e t o managers and c o u n s e l o r s on the s u b j e c t o f Manpower P l a n n i n g . The r e p o r t was w r i t -t e n by the Department of Manpower and I m m i g r a t i o n , R e g i o n a l Economic S e r v i c e s B r a n c h , P a c i f i c R e g i o n . S o u r c e s : BURACK, Elmer H. and WALKER, James W.. Man- power P l a n n i n g and Programming ( B o s t o n : A l l y n and Bacon Inc.,1972); KEYS, B.A. and WRIGHT, H. H., Manpower P l a n n i n g i n I n d u s t r y , ( O t t a w a : Queen's P r i n t -er,1966); MANGUM,Garth and SNEDEKER,David, Manpower  P l a n n i n g f o r L o c a l Labour M a r k e t s , ( S a l t Lake C i t y : Olympus P u b l i s h i n g Company, 1974)• 14 -Methods Used i n F o r e c a s t i n g Manpower Requirements There i s no s i n g l e u n i v e r s a l l y a c c e p t e d method f o r p r o j e c t i n g manpower s u p p l i e s and r e q u i r e m e n t s . " F o r e c a s t s may be c a l c u l a t e d i n a wide v a r i e t y o f ways, r a n g i n g i n c o m p l e x i t y from s i m p l y l i n e a r e x t r a p o l a t i o n o f p a s t t r e n d s t o complex e c o n o m e t r i c models. Each t e c h -n i q u e has i t s own s p e c i a l p r o p e r t i e s o f de-t a i l , c o n d i t i o n a l r e s t r a i n t s , and a p p l i c a b i l -i t y t o r e a l i t y . "1-0 Many approaches o r t e c h n i q u e s ' used i n f o r e c a s t i n g may o v e r - l a p and have v a r i o u s p o i n t s i n common. At time s the manpower p l a n n e r may not f i n d a method t o s u i t h i s f o r e c a s t i n g needs. He may be f o r c e d t o l o o k a t a number o f methods and e x t r a p o l a t e those p o i n t s he f e e l s are n e c e s s a r y t o make a more a c c u r a t e man-power f o r e c a s t . The b e s t approach i s o f t e n d e r i v e d from a b o r r o w i n g of s e v e r a l t e c h n i q u e s and i n c o r -p o r a t i n g t h e s e i n t o one's own method o f manpower f o r e c a s t i n g . F o l l o w i n g i s a b r i e f d e s c r i p t i o n o f v a r i o u s - t e c h -n i q u e s o r methods o f f o r e c a s t i n g used i n manpower p l a n -n i n g . These i n c l u d e e c o n o m e t r i c methods, p r o d u c t i v -i t y methods, and survey methods. A f i n a l d i s c u s s i o n w i l l be on t r e n d p r o j e c t i o n methods which take i n fr e e h a n d e x t r a p o l a t i o n , semi-average, and r e g r e s s i o n a n a l y s i s . 1 0Herman S t e k l e r , Economic F o r e c a s t i n g (New York: P r a e g e r , 1970), pp. 3-15, 92-102. 15 E c o n o m e t r i c Methods "The e c o n o m e t r i c method o f manpower f o r e -c a s t i n g i s a t e c h n i q u e f o r d e r i v i n g occupa-t i o n a l l a b o u r r e q u i r e m e n t s from e s t i m a t e d l e v e l s o f f i n a l demand f o r goods and s e r v i c e s i n t he economy i n some f u t u r e y e a r . The n o v e l t y o f the method i s i t s use o f the con-v e n t i o n a l i n p u t - o u t p u t a n a l y s i s as an a n a l y t -i c a l t o o l f o r f o r e c a s t i n g manpower r e q u i r e m e n t s . " There are f o u r b a s i c s t e p s i n c o m p r i s i n g t h i s method. The f i r s t s t e p i s c o n s t r u c t i o n o f an i n p u t -output t a b l e showing the f l o w s o f i n d u s t r y and l e v e l s o f f i n a l demand. The second s t e p i s the r e c a s t i n g o f the i n p u t - o u t p u t t a b l e i n t o a m a t r i x . T h i s i s done t o show the i n p u t r a t i o s o r f i x e d t e c h n i c a l c o e f f i c i e n t s o f each s e c t o r . Step t h r e e i s the f o r m a t i o n o f a l l ( a g g r e g a t e ) manpower r e q u i r e m e n t s from p r o d u c t i o n l e v e l s . The l a s t s t e p i s the c o n s t r u c t i o n o f a s e c t -o r - b y - o c c u p a t i o n m a t r i x which demonstrates the d i s t -r i b u t i o n o f aggregate manpower r e q u i r e m e n t s i n t o p a r t i c u l a r o c c u p a t i o n s and s p e c i f i c o c c u p a t i o n a l r e -quirements . Econ o m e t r i c methods have the advantage o f p r o -d u c i n g r e f i n e d and i n s t r u m e n t a l f o r e c a s t s o f manpower r e q u i r e m e n t s by i n d i v i d u a l o c c u p a t i o n s . A s t r o n g p o i n t i n i t s f a v o r i s t h a t i t does t h i s w i t h i n the framework and r e l a t i o n s h i p s o f the e n t i r e economy. 1 1 0 z e y Mehmet, Methods o f F o r e c a s t i n g Manpower R e q u i r e - ments: With S p e c i a l Reference t o the P r o v i n c e o f O n t a r i o ( C e n t r e f o r I n d u s t r i a l R e l a t i o n s , U n i v e r s i t y o f T o r o n t o , 1965), p.3. 16 I n t h i s s ense, manpower p l a n n i n g and f o r e c a s t i n g be-come a v i t a l p a r t o f a g l o b a l and o v e r - a l l economic p o l i c y . T h i s type o f method a l s o makes p o s s i b l e the o r i g i n o f i n f o r m a t i o n about the s t r u c t u r e and work-i n g o f the economy. I t produces i m p o r t a n t knowledge about i n v e s t m e n t , consumption, p r o d u c t i o n l e v e l s , e t c . . A major draw-back or weakness of the economic method i n manpower p l a n n i n g i s the i n s u f f i c i e n c y o f t r u t h f u l d a t a and i n f o r m a t i o n . Because i t r e q u i r e s s e v e r a l e x p e r t s and a n a l y s t s , the e c o n o m e t r i c method i s b o t h c o s t l y and time consuming. P r o d u c t i v i t y Methods The p r o d u c t i v i t y method, f o r e c a s t s employment f o r v a r i o u s t a r g e t - y e a r s by s e c t o r and o c c u p a t i o n . T h i s i s done c o n c e r n i n g b o t h the change i n l a b o r p r o d u c t -i v i t y and the i n c r e a s e o f o u t p u t . D e t e r m i n i n g the output i n the t a r g e t - y e a r f o r the e n t i r e economy and each s e c t o r i s the f i r s t s t e p i n t h i s method. Output i n any t a r g e t y e a r can gen-e r a l l y be o b t a i n e d from an agency t h a t i s d i r e c t l y r e s p o n s i b l e f o r such f o r e c a s t s . The second s t e p i s a d e r i v a t i o n o f t o t a l employment i n the t a r g e t y e a r and e s t i m a t i o n o f s e c t o r a l manpower r e q u i r e m e n t s on the b a s i s of e s t i m a t e s o f p r o d u c t i v i t y i n the most i m p o r t a n t s e c t o r s . Sources o f o c c u p a t i o n a l r e q u i r e -ments from s e c t o r a l t o t a l s i s s t e p t h r e e . The f o u r t h 17 s t e p e n v o l v e s c o n v e r t i n g rough o r crude labour? r e -quirements i n t o t r a i n e d manpower and d e r i v i n g the e d u c a t i o n a l r e q u i r e m e n t s . Step f i v e i s a comparison of e d u c a t i o n a l r e q u i r e m e n t s w i t h s u p p l y . The f i n a l s t e p i s a g e n e r a l re-assessment and e v a l u a t i o n o f the f i r s t f i v e s t e p s c o n s i d e r i n g a n t i c i p a t e d l a b o u r market i n e q u a l i t i e s . P r o d u c t i v i t y methods have the advantage o f co-o r d i n a t i n g manpower f o r e c a s t w i t h , and i n t e g r a t i n g i n t o , the o v e r a l l economic development p l a n . Re-quirements f o r manpower are worked out on the p r i n c i -p a l of p r e s c r i b e d r a t e s of economic growth. Because of t h i s , r e q u i r e m e n t s a r e , i n e f f e c t , s i g n s o f the type s o f manpower r e q u i r e d t o meet the growth t a r g e t s presumed i n the f i r s t p l a c e . P r o d u c t i v i t y methods g i v e a dynamic b a l a n c e between the e d u c a t i o n system and q u a l i f i e d manpower needs. The weaknesses a s s o c i a t e d w i t h t h i s method are the d i f f i c u l t i e s i n d e t e r m i n i n g t a r g e t y e a r o u t p u t s and d e r i v i n g o c c u p a t i o n a l r e q u i r e m e n t s from aggregate s e c t -o r a l r e q u i r e m e n t s . A f i n a l draw-back o f p r o d u c t i v i t y methods i s the d i f f i c u l t y i n e x p r e s s i n g u n v a r y i n g r e -l a t i o n s h i p s between a s p e c i f i c e d u c a t i o n programme and s p e c i f i c o c c u p a t i o n . Survey Methods The survey method makes p r a c t i c a l use o f manpower r e q u i r e m e n t s o f employers f o r f o r e c a s t i n g manpower 18 demand a t a g i v e n t a r g e t y e a r . S u r v e y s , i n t e r v i e w s , or q u e s t i o n n a i r e s may be used among a sample o f o r g a n i z a t i o n s or f i r m s i n o r d e r t o p r e d i c t the employ-e r ' s f u t u r e manpower needs. The f i r s t s t e p i n t h i s method i s t o f o r m u l a t e b o t h an a n a l y t i c a l l y sound and o p e r a t i o n a l d e f i n i -t i o n o f the o r g a n i z a t i o n s o r f i r m s t o be s t u d i e d . A d e f i n i t i o n o f the t e c h n i q u e o r approach t o be used i n the s e l e c t i o n o f sample f i r m s i s the nex t s t e p . The p r o p o r t i o n o f t o t a l employment o f the sample o r g a n i z a t i o n o r f i r m t o the t o t a l employment i n t h a t i n d u s t r y s h o u l d be h i g h . The r e s u l t s o f the su r v e y are used i n making p r e d i c t i o n s f o r f u t u r e manpower r e q u i r e m e n t s . The main advantage t o t h i s method i s t h a t s u r v e y s and i n t e r v i e w s can be made a t e s t a b l i s h e d o r f r e q u e n t i n t e r v a l s . T h i s means t h a t manpower r e q u i r e m e n t s and demand can be kept m o d e r a t e l y up t o d a t e . The main problem a s s o c i a t e d w i t h t h i s method i s t h a t f i r m s i n c l u d e d i n the sample may not respond t o the s u r v e y . They may be unable t o e s t i m a t e t h e i r manpower r e q u i r e m e n t s o r may even w i s h t o a v o i d mak-i n g any s t a t e m e n t s . Another weakness o f the survey method i s t h a t almost i n v a r i a b l y , e r r o r s may o c c u r i n the r e p l i e s o f the s u r v e y . T h i s can be due t o i n t e r p r e t a t i o n s o f s t a t e m e n t s , terms, or q u e s t i o n s . A f i n a l problem a s s o c i a t e d w i t h t h i s method i s a c c u r -acy o f i n d i v i d u a l employers i n f o r e s e e i n g the e f f e c t s 19 o f t e c h n o l o g i c a l improvements on t h e i r f i r m or organ-i z a t i o n . The Trend P r o j e c t i o n Method The trend, p r o j e c t i o n method i s used, t o p r o j e c t p a s t t r e n d s o f aggregate and o c c u p a t i o n a l l a b o u r f o r c e s t h r o u g h t o the t a r g e t y e a r s . The r e q u i r e m e n t s are t h e n r e a d o f f a graph. There are a v a r i e t y o f v a r i a t i o n s w i t h t h i s method. They r e q u i r e the a v a i l -a b i l i t y o f t i m e - s e r i e s o f the t o t a l l a b o u r f o r c e by s e c t o r s and o c c u p a t i o n s . Trend p r o j e c t i o n s are a l s o done f o r a r e s o n a b l e number of y e a r s . The f o l l o w i n g are v a r i o u s methods of t r e n d p r o j e c t i o n s i n manpower f o r e c a s t i n g : "The Freehand E x t r a p o l a t i o n Method: Of the d i f f e r e n c e v a r i a t i o n s o f the t r e n d p r o j e c t i o n method, the f r e e h a n d e x t r a p o l a t i o n method i s the s i m p l e s t one. I t c o n s i s t s o f p l o t t i n g the graph of the l a b o u r f o r c e s e r i e s on a graph-paper and f i t t i n g a t r e n d t h r o u g h i t by means, of a f r e e h a n d e x t e n s i o n o f the g r a p h , such t h a t the t r e n d appears t o the eye t o d e s c r i b e the l o n g - t e r m growth o f the l a b o u r f o r c e . The weakness of t h i s method i s t h a t i t r e q u i r e s a h i g h degree of s u b j e c t i v e judgment s i n c e the f o r e c a s t e r i s o b l i g e d t o guess the magnitude and c h a r a c t e r o f the f u t u r e course of economic e v e n t s . "The Semi-average Method: There i s a r e l a t i v e l y s i m p l e s t a t i s t i c a l t e c h n i q u e f o r computing t r e n d l i n e s . The d a t a are s p l i t i n t o two e q u a l groups and the f i g u r e s i n each h a l f are t h e n averaged. The averages thus o b t a i n e d are i n t u r n p l o t t e d a g a i n s t the c e n t r e y e a r of the r e s p e c t i v e group, and a s t r a i g h t l i n e i s drawn through the two p o i n t s . E x t e n d i n g t h i s l i n e t o the t a r g e t - y e a r , e s t i -mates o f the l a b o u r f o r c e i n t h a t y e a r may be d e r i v e d . T h i s , as can be o b s e r v e d , i s but a m e c h a n i c a l o p e r a t i o n and t h e r e f o r e s h o u l d be h a n d l e d w i t h c a u t i o n . 20 "The R e g r e s s i o n a l A n a l y s i s Method: T h i s method i s d e s i g n e d t o be used i n d i s t r i b u t i n g the aggregate t a r g e t - y e a r l a b o u r f o r c e i n t o s e c t o r a l and o c c u p a t i o n a l c a t e -g o r i e s . That i s t o say, i t s use.presupposes the knowledge of t o t a l l a b o u r f d r c e i n the t a r g e t - y e a r . U s u a l l y , t h i s i n i t i a l o p e r a t i o n I s e x e c u t e d by a p p l y i n g p a r t i c i p a t i o n r a t e s t o p r o j e c t e d p o p u l a t i o n f i g u r e s . The method i s u s a b l e o n l y i f t h e r e i s a h i g h degree of l i n e a r c o r r e l a t i o n between the aggregate l a b o u r f o r c e and the s p e c i f i c s e c t -o r a l o r o c c u p a t i o n a l s u b d i v i s i o n . " 1 2 The t r e n d p r o j e c t i o n method i s o f t e n used o n l y t o d e r i v e f a i r l y g e n e r a l or t e n t a t i v e manpower f o r e -c a s t s . The major weakness of t h i s method i s t h a t r e s u l t s are d etermined on p a s t t r e n d s t h a t r e q u i r e a c o n s i d e r a b l e amount of d a t a g o i n g back a f a i r number of y e a r s . Now t h a t a d e s c r i p t i o n o f v a r i o u s methods of f o r e c a s t i n g manpower r e q u i r e m e n t s has been g i v e n , t h i s t h e s i s w i l l b r i e f l y a ddress the need f o r manpowe p l a n n i n g i n h o s p i t a l s . Advances i n t e c h n o l o g y , com-p u t e r s , l a b a n a l y z e r s , e t c . , have a l l a f f e c t e d s t a f -f i n g p a t t e r n s i n h o s p i t a l s . A l t h o u g h new and s o p h i s t i c a t e d equipment i m p l y r e d u c t i o n s i n s t a f f , t h i s i s n always the case. E x p e n s i v e equipment b r i n g s w i t h i t p e r s o n n e l f o r maintenance and day-to-day o p e r a t i o n s o such equipment. A c c r e d i t a t i o n and o t h e r p r o f e s s i o n a l b o d i e s c o n t r i b u t e t o . s t a n d a r d s which a l s o change s t a f f i n g needs. Patients', themselves are demanding more Mcbeath, op. c i t . , pp. 22-23. 21 and more s e r v i c e s from h o s p i t a l s . T h i s , t o o , adds t o the numberous manpower needs h o s p i t a l s f a c e each day. Many new and c u r r e n t h o s p i t a l s are now under c o n s t r u c t i o n , r e m o d e l i n g , o r i n the p l a n n i n g s t a g e . The need f o r manpower p l a n n i n g i n h o s p i t a l s i s p r e v -a l e n t . P l a n n e r s must c o n t i n u a l l y s t r i v e f o r methods and t e c h n i q u e s t h a t d e velop a c c u r a t e s t a f f i n g g u i d e -l i n e s . A knowledge o f the p r e v i o u s t e c h n i q u e s used i n manpower planning:.'is not enough. The p l a n n e r must a l s o u n d e r s t a n d methods used i n h e a l t h manpower p l a n n i n g . Once a knowledge o f t h e s e two has been o b t a i n e d , the ro a d t o h o s p i t a l manpower p l a n n i n g can b e g i n t o t a k e i t s c o u r s e . Chapter Two w i l l d i s c u s s h e a l t h manpower p l a n -n i n g . A g a i n , d i f f e r e n t methods, approaches o r t e c h -n i q u e s used i n h e a l t h manpower planning',,will be g i v e n . The s t r e n g t h and weakness o f each method w i l l a l s o be p r e s e n t e d . Chapter Three w i l l address h o s p i -t a l manpower p l a n n i n g and the development o f s t a f f i n g g u i d e l i n e s . The need f o r t h i s t y pe o f p l a n n i n g w i l l be demonstrated. A g e n e r a l d e s c r i p t i o n o f major de-partments w i l l be g i v e n a l o n g w i t h a l i s t o f f u n c t i o n s or c r i t e r i a t o be used i n the development o f such g u i d e l i n e s . Chapter Four w i l l i n c l u d e c o n c l u s i o n s and a r e v i e w o f the t h e s i s . The S t a t e - o f - t h e - A r t and sug-g e s t i o n s f o r f u t u r e r e s e a r c h and study w i l l be g i v e n . 22 CHAPTER I I Health Manpower Planning 23 Concepts i n H e a l t h Manpower P l a n n i n g The concept o f h e a l t h manpower g e n e r a l l y i n c l u d e s : the number o f i n d i v i d u a l s a v a i l a b l e f o r , o r under-g o i n g t r a i n i n g i n the d i f f e r e n t h e a l t h o c c u p a t i o n s ; the demographic c h a r a c t e r i s t i c s o f the s e i n d i v i -d u a l s ; t h e i r s o c i a l c h a r a c t e r i s t i c s i n terms o f educa-t i o n , e x p e r i e n c e , and v a l u e s ; and the changes r e q u i r e d , b o t h i n numbers and q u a l i f i c a t i o n s o f p e r s o n n e l , t o p r o v i d e the h e a l t h s e r v i c e s needed and demanded by a p o p u l a t i o n . As g e n e r a l l y u n d e r s t o o d , t h e r e f o r e , h e a l t h manpower i n c l u d e s : 1) Those a l r e a d y w o r k i n g i n the f i e l d o f h e a l t h s e r v i c e s ; 2) P o t e n t i a l h e a l t h w o r k e r s , i . e . , those who have the a b i l i t y t o engage i n a p a r t i c u l a r h e a l t h o c c u p a t i o n but are not a t p r e s e n t d o i n g so; and, 3) P r o s p e c t i v e manpower, i . e . , those who are at p r e s e n t u n d e r g o i n g e d u c a t i o n and t r a i n -i n g t h a t w i l l p e r m i t them t o j o i n the h e a l t h s e r v i c e s . 1" H e a l t h manpower p l a n n i n g i s the p r o c e s s o f e s t i m a t i n g the q u a n t i t y and type o f knowledge, s k i l l s , and a b i l i t i e s needed t o i n t r o d u c e p r e -d e termined a l t e r a t i o n s i n the f u n c t i o n i n g o f a h e a l t h system so as t o make i t more p r o b a b l e t h a t the d e s i r a b l e changes i n the h e a l t h o f a x World H e a l t h O r g a n i z a t i o n , T e c h n i c a l Report S e r i e s No. 4 8 l , The Development o f S t u d i e s i n H e a l t h Manpower, (Geneva, S w i t z e r l a n d : World H e a l t h O r g a n i z a t i o n 1971), pp. 9-10. 24 p o p u l a t i o n w i l l be a c h i e v e d . Such p l a n n i n g i n v o l v e s s p e c i f y i n g who i s g o i n g t o do what, and a l s o where, when, how and f o r what p a t i e n t s or p o p u l a t i o n group, so t h a t knowledge and s k i l l s n e c e s s a r y f o r adequate performance can be e s t a b l i s h e d and made a v a i l a b l e a c c o r d i n g t o a p r e d e t e r m i n e d s c h e d u l e . T h i s must be a con-t i n u i n g , not a s p o r a d i c p r o c e s s . " 2 H e a l t h manpower p l a n n i n g i m p l i e s the g e n e r a t i o n and u t i l i z a t i o n o f v a r i o u s s k i l l s . T h i s type of man-power p l a n n i n g a n a l y z e s and p r o j e c t s h e a l t h needs a l o n g w i t h the p o p u l a t i o n ' s demands f o r h e a l t h s e r v -i c e s . The measurement of p r e s e n t h e a l t h manpower, p a t t e r n s o f u t i l i z a t i o n and e s t i m a t i o n o f f u t u r e manpower r e q u i r e m e n t s are a l l c o n s i d e r e d . E d u c a t i o n , t r a i n i n g needs, and the d e t e c t i o n o f any i mbalances between the e s t i m a t e d r e q u i r e m e n t s and the e x p e c t e d s u p p l y are elements c r u c i a l l y i n v o l v e d i n the p l a n -n i n g s t a g e s . "Manpower i s a major key t o meeting our n a t i o n ' s h e a l t h problems. There i s i m p o r t a n t s t a t i s t i c a l i n f o r m a t i o n t h a t can i d e n t i f y , q u a l i f y , and a s s i s t i n e v a l u a t i n g the s t a t u s o f t h e i r t r e n d s i n t r a i n i n g , employment, u t i l i z a -t i o n , and demand f o r h e a l t h manpower. C l a s s -i f i c a t i o n by h e a l t h o c c u p a t i o n i d e n t i f i e s t h o s e i n d i v i d u a l s p o s s e s s i n g knowledge and s k i l l un-i q u e t o the h e a l t h f i e l d , the range and d i v e r s -i t y o f h e a l t h c a r e e r s , and the employment of persons f o r the p r o g e s s i o n o f h e a l t h s e r v i c e s , f o r e n v i r o n m e n t a l c o n t r o l and p r o t e c t i v e s e r v -i c e s , and f o r t e a c h i n g , r e s e a r c h , and a d m i n i -s t r a t i o n i n the h e a l t h f i e l d . " 3 2 I b i d . , p.1. 3Maryland Y. P e n n e l l and D a v i d B. Hoover, H e a l t h Man-power Source Book 21 - A l l i e d H e a l t h Manpower Supply  and Requirements: 1950-1980 (Washington, D.C: U.S. Government P r i n t i n g O f f i c e , 1970), p . l . 25 I d e a l l y , h e a l t h p l a n n i n g s h o u l d be i n t e g r a t e d i n t o b r oad s o c i o - e c o n o m i c p l a n n i n g f o r a n a t i o n as a whole, w i t h i n the c o n t e x t o f a c t i v i t i e s i n s e c t o r s such as a g r i c u l t u r e , e d u c a t i o n and i n d u s t r y . W i t h -i n h e a l t h p l a n n i n g i t s e l f t h e r e are a number of sub-s e c t o r s , e.g., manpower p l a n n i n g , p l a n n i n g f o r f a c -i l i t i e s and equipment, and o r g a n i z a t i o n p l a n n i n g , a l l o f which are i n t e r d e p e n d e n t . I t i s not always pos-s i b l e t o draw sharp d i v i d i n g l i n e s between the s e c t -ors o f n a t i o n a l s o c i o - e c o n o m i c p l a n n i n g ; a g r i c u l t u r e and h e a l t h o b v i o u s l y o v e r l a p i n the a r e a o f n u t r i -t i o n ; and e d u c a t i o n a f f e c t s the u t i l i z a t i o n o f h e a l t h r e s o u r c e s . The same i s t r u e o f the s u b s e c t o r s . P l a n n i n g f o r the l o c a t i o n o f f a c i l i t i e s can p r o f o u n d -l y a f f e c t the d i s t r i b u t i o n o f manpower and the organ-i z a t i o n o f s e r v i c e s , and v i c e v e r s a . D e s p i t e the i n t e r d e p e n d e n c e , p l a n n i n g f o r educa-t i o n i s no s u b s t i t u t e f o r p l a n n i n g f o r h e a l t h , and f a c i l i t i e s p l a n n i n g i s no s u b s t i t u t e f o r manpower p l a n n i n g . The p r o p e r r e l a t i o n s h i p o f h e a l t h man-power p l a n n i n g t o o v e r a l l h e a l t h p l a n n i n g must be r e c o g n i z e d , as must the r e l a t i o n s h i p o f o v e r a l l h e a l t h p l a n n i n g t o n a t i o n a l s o c i o - e c o n o m i c p l a n n i n g . I t i s r a r e t h a t s u f f i c i e n t r e s o u r c e s are com-, m i t t e d t o a l l o w h e a l t h p l a n n i n g t o advance on a l l f r o n t s s i m u l t a n e o u s l y . However, because o f e x t e n s -i v e i n t e r d e p e n d e n c e i t i s q u i t e f e a s i b l e t o approach p l a n n i n g o f the h e a l t h s e c t o r w i t h c o n s i d e r a b l e 26 b r e a d t h — a l t h o u g h not c o m p r e h e n s i v e l y — t h r o u g h one of I t s s u b s e c t o r s . Thus, h e a l t h manpower p l a n n i n g may move d e e p l y i n t o q u e s t i o n s o f f i n a n c i n g and org a n -i z i n g h e a l t h s e r v i c e s . S i m i l a r l y , c e n t r a l problems of h e a l t h p l a n n i n g can be approached from the s t a n d -p o i n t o f f i n a n c i n g or o f o r g a n i z a t i o n . The s u b s e c t o r approach i s a p r a c i t c a l e x p e d i e n t t h a t has been adop-t e d 'in a number o f c o u n t r i e s . Manpower has o f t e n been chosen as the p r i n c i p a l f o c a l p o i n t o f such s t u d i e s because of the c r i t i c a l i m p o r t a n c e o f man-power problems i n h e a l t h p l a n n i n g . There are no p r e c i s e c r i t e r i a f o r d e t e r m i n i n g what h e a l t h manpower p l a n n i n g s h o u l d encompass and what problems i t s h o u l d t r y t o s o l v e . There appears t o be agreement t h a t i t s h o u l d i n c l u d e an e x a m i n a t i o n of the e x i s t i n g s u p p l y o f h e a l t h w o r k e r s , the s o u r c e s of s u p p l y , and the p r o s p e c t s f o r f u t u r e s u p p l y . Be-yond t h i s , p o l i c y q u e s t i o n s a r i s e t h a t may or may not l i e w i t h i n the purview o f a manpower s t u d y . To be-g i n w i t h , a p l a n n e r needs t o know what the h e a l t h problems are i n o r d e r t o s e t g o a l s and t o p l a n s o l u -t i o n s . A l t h o u g h i t may be conceded t h a t p l a n n e r s do not s e t g o a l s t h e m s e l v e s , but o n l y make recommend-a t i o n s t o p o l i t i c a l a u t h o r i t i e s , p l a n n e r s s t i l l need some g u i d e s t o enable them t o proceed w i t h t h e i r work. The e x t e n t t o which manpower p l a n n e r s s h o u l d p a r t i c i p a t e i n h e a l t h g o a l - s e t t i n g p r o c e s s e s would 27 appear t o be a f f e c t e d by the amount o f o t h e r p l a n -n i n g machinery t h a t e x i s t s . S i m i l a r l y , the r e o r g a n i z a t i o n - o f h e a l t h s e r v -i c e s i n v o l v e s not o n l y means but a l s o ends, o r g o a l s . I t i s v i r t u a l l y i m p o s s i b l e f o r manpower p l a n n e r s t o a v o i d o r g a n i z a t i o n a l q u e s t i o n s . Manpower s p e c i a l -i s t s u s u a l l y d e l i n e a t e two major dimensions t o man-power problems: (a) s u p p l y , w h i c h concerns the number o f a v a i l a b l e workers h a v i n g v a r i o u s k i n d s o f s k i l l s ; and (b) o r g a n i z a t i o n , w h i c h concerns the d i s t r i b u t i o n o f w o r k e r s , the d i s t r i b u t i o n o f t a s k s among w o r k e r s , and t h e i r i n t e r - r e l a t i o n s h i p s . ^ Through optimum u t i l i z a t i o n o f a v a i l a b l e and the f u t u r e s u p p l y o f manpower we can p r o v i d e the most e c o n o m i c a l mix o f p r o f e s s i o n and a u x i l i a r y h e a l t h w o r k e r s . The u t i l i z a t i o n , d e l i v e r y , and q u a l i t y o f h e a l t h s e r v i c e s can be improved by e f f e c t i v e and e f f i c i e n t manpower p l a n n i n g . P r o p e r manpower p l a n -n i n g c o n s i s t s not o n l y o f p e o p l e , but a l s o a know-ledge o f the v a r i o u s j o b s and s k i l l s t h ey must pos-s e s s . Appendix A p r o v i d e s a l i s t o f h e a l t h occupa-t i o n s which the p l a n n e r must be f a m i l i a r w i t h . Ap-p r o x i m a t e l y 375 t i t l e s are l i s t e d . The l i s t i s r e -s t r i c t e d t o tho s e f o r which s p e c i a l e d u c a t i o n o r t r a i n -4H. P. H i l l e b o e , A. Barkhuss and W. C. Thomas, J r . , Approaches t o N a t i o n a l H e a l t h P l a n n i n g (Geneva, S w i t z e r l a n d : World H e a l t h O r g a n i z a t i o n , 1 9 7 2 ) , pp. 8 7 - 8 8 . 28 i n g i s needed t o pr e p a r e the worker t o f u n c t i o n i n a h e a l t h s e t t i n g . One o f the d i f f i c u l t i e s i n h e a l t h manpower p l a n n i n g i s the d i f f i c u l t y t h a t a r i s e s from the l o n g " l e a d t i m e " r e q u i r e d t o b r i n g about changes t h r o u g h some e d u c a t i o n and t r a i n i n g programs. The e d u c a t i o n , t r a i n i n g and p r o f e s -s i o n a l p r e p a r a t i o n o f p h y s i c i a n s t a k e s n e a r l y 20 y e a r s . "For a p r o f e s s i o n such as m e d i c i n e , even a t e n - y e a r p l a n n i n g p e r i o d i s i n s u f -f i c i e n t . D e c i s i o n s made i n y e a r one can b e g i n t o a f f e c t s u p p l y o n l y by y e a r e i g h t and nine. " 5 B e f o r e p r e s e n t i n g a d e t a i l e d d e s c r i p t i o n o f methods and t e c h n i q u e s used i n h e a l t h manpower p l a n -n i n g , a d i s c u s s i o n on the c h a r a c t e r i s t i c s o f the demand f o r h e a l t h manpower s e r v i c e s i s needed. Two typ e s o f h e a l t h care demands p l a c e d on manpower s e r v i c e s a re those which are p l a c e d d i r e c t l y on p r i -v a t e p r a c t i t i o n e r s and t h e i r employees, and those which are p l a c e d on h e a l t h c a r e i n s t i t u t i o n s ( e . g . , h o s p i t a l s , n u r s i n g homes, p s y c h i a t r i c care f a c i l i -t i e s , e t c . ) which i n t u r n e s t a b l i s h r e q u i r e m e n t s f o r h e a l t h p e r s o n n e l . Both types o f demand are u s u a l l y preceded by the h e a l t h consumer d e c i s i o n t o seek some form o f h e a l t h s e r v i c e . Thus, the a n a l y s i s of 5T. L. H a l l , H e a l t h Manpower i n Pe r u : A Case Study  i n P l a n n i n g , ( B a l t i m o r e , John H o p k i n s , 1974), p . 7 • 29 the demand f o r h e a l t h manpower s e r v i c e s r e q u i r e s an u n d e r s t a n d i n g of the f a c t o r s which i n f l u e n c e the consumer's h e a l t h , h i s b e h a v i o r , and h i s consumption of h e a l t h manpower s e r v i c e s . F a c t o r s which i n f l u -ence the consumer's b e h a v i o r i n c l u d e an i n d i v i d u a l ' s c u l t u r a l b e l i e f s , a t t i t u d e s toward h e a l t h c a r e , p s y c h o l o g i c a l c o n d i t i o n , and p e r c e p t i o n o f i l l n e s s , as w e l l as the r e l a t i v e u t i l i t y , c o s t and q u a l i t y o f h e a l t h c a r e which he p e r c e i v e s . S i n c e d a t a d e s c r i b -i n g t h e s e parameters are d i f f i c u l t i f not i m p o s s i b l e t o o b t a i n , most a n a l y s e s attempt t o d e s c r i b e v a r i a -t i o n s i n h e a l t h s e r v i c e u t i l i z a t i o n i n terms o f s o c i o -economic, demographic, o r o t h e r d i f f e r e n t i a b l e a t t r i -b u t e s o f the p o p u l a t i o n , as w e l l as changes i n epidem-i o l o g i c a l c o n d i t i o n s , p r i c e , and o t h e r h e a l t h system parameters. These p a t t e r n s o f h e a l t h s e r v i c e u t i l i -z a t i o n are th e n used t o d e s c r i b e the i n f l u e n c e o f consumer d i s c r e t i o n a r y b e h a v i o r on the demand f o r h e a l t h s e r v i c e s . F o r the r e s u l t s o f t h e s e a n a l y s e s o f h e a l t h consumer demands t o be u s e f u l i n h e a l t h manpower p l a n n i n g , they must be t r a n s l a t e d i n t o r e q u i r e m e n t s f o r manpower s e r v i c e s . The way i n which t h e s e r e -quirements are met w i l l depend not o n l y on the mag-n i t u d e and type o f s e r v i c e s d e s i r e d , but a l s o on the s t a f f i n g p a t t e r n s and manpower r e s o u r c e l e v e l s as d e t e r m i n e d by the o p e r a t i o n a l and f u n c t i o n a l l i m i t a t i o n s o f h e a l t h care d e l i v e r y o r g a n i z a t i o n s . 30 V a r i a t i o n s i n type o f s e r v i c e s o f f e r e d and the s i z e of the h e a l t h s e r v i c e f a c i l i t i e s u t i l i z e d , as w e l l as d i f f e r e n c e s i n the a l l o c a t i o n and mix o f p e r s o n n e l , w i l l have a compound e f f e c t on h e a l t h manpower r e -qu i r e m e n t s . These h e a l t h care d e l i v e r y f a c t o r s a c t as c o n s t r a i n t s which a f f e c t the re q u i r e m e n t f o r man-power a t a g i v e n l e v e l o f u t i l i z a t i o n . They a l s o shape and mold the type o f care sought by i n f l u e n c i n g the p r i c e s , a c c e s s i b i l i t y and a v a i l a b i l i t y o f s e r v i c e s o f f e r e d . Thus, i n o r d e r t o s i m p l i f y the d i s c u s s i o n o f t h e s e h i g h l y i n t e r r e l a t e d a n l y s i s f a c t o r s , the d e s c r i p t i o n o f the s e areas f o r a n a l y s i s i s o r g a n i z e d i n t o t h r e e c a t e g o r i e s — c l u t u r a l - d e m o g r a p h i c f a c t -o r s , economic f a c t o r s , and h e a l t h c a r e d e l i v e r y con-s t r a i n t s . C u l t u r a l and Demographic F a c t o r s The type and magnitude of h e a l t h care s e r v i c e s demanded are o f t e n s t r a t i f i e d f o r a n a l y s i s i n terms of paremeters such as age, s e x , m a r i t a l s t a t u s , f a m i l y s i z e , e d u c a t i o n , and r e s i d e n c e (urban v s . r u r a l ) . F o r example, the i n c i d e n c e o f i l l n e s s , m o r b i d i t y p a t t e r n s , d i s e a s e r e c o v e r y r a t e s , and m o r t a l i t y r a t e s a l l v a r y w i t h age. Females i n d i f -f e r e n t age groups r e q u i r e d i f f e r e n t q u a n t i t i e s o f o b s t e t r i c a l s e r v i c e , and men r e q u i r e none. M a r i t a l s t a t u s and f a m i l y s i z e r e f l e c t the a v a i l a b i l i t y o f home r e c u p e r a t i v e c a r e , and hence can be used t o 31 c h a r a c t e r i z e t o t a l amounts of s e r v i c e demanded. D i f f e r e n c e s i n c u l t u r a l b e l i e f s and s o c i a l a t t i t u d e s toward u t i l i z a t i o n o f h e a l t h care might be d i s t -i n g u i s h e d by an i n d i v i d u a l ' s e d u c a t i o n and/or l o c a -t i o n o f r e s i d e n c e . Data d e s c r i b i n g the above (and o t h e r ) c u l t u r a l / demographic p o p u l a t i o n a t t r i b u t e s and h e a l t h s e r v -i c e s consumption are used as a b a s i s f o r d e t e r m i n -i n g h e a l t h s e r v i c e u t i l i z a t i o n b e h a v i o r . P r e d i c t i o n s o f the r e l a t i v e numbers of persons i n each p o p u l a -t i o n c a t e g o r y c o u p l e d w i t h d e s c r i p t i o n s o f the h e a l t h s e r v i c e u t i l i z a t i o n b e h a v i o r p r o v i d e f o r a mechanism f o r e s t i m a t i n g f u t u r e s e r v i c e consump-t i o n , and hence r e q u i r e m e n t s . These e s t i m a t e s a r e , howerer, o f t e n c o n s t r a i n e d by l i m i t a t i o n s i n h e r e n t i n the a v a i l a b l e d a t a . R e l a t i o n s h i p s between d i f f e r e n t t y p e s of u t i l i z a t i o n and the d e s i r e d s e t o f demograph-i c f a c t o r s are d i f f i c u l t , I f - n o t i m p o s s i b l e , t o a s -c e r t a i n s i n c e the c r o s s - s e c t i o n a l and/or l o n g i t u d i n a l u t i l i z a t i o n d a t a r e q u i r e d i s o f t e n u n a v a i l a b l e , i n -complete, or i n c o n s i s t e n t . However, t h e s e d a t a con-s t r a i n t s can be overcome under c e r t a i n c i r c u m s t a n c e s , e i t h e r t h r o u g h s t a t i s t i c a l m a n i p u l a t i o n or e x i s t i n g d a t a or e x t e n s i v e d a t a g a t h e r i n g and/or i d e n t i f i c a -t i o n a c t i v i t i e s . A l t h o u g h the a n a l y s i s o f c u l t u r a l - d e m o g r a p h i c f a c t o r s may i n c r e a s e u n d e r s t a n d i n g of h e a l t h con-sumer b e h a v i o r p a t t e r n s , i t o f f e r s a few a r e a s where 32 h e a l t h a g e n c i e s can i n t e r v e n e and improve h e a l t h s e r v i c e u t i l i z a t i o n . One such p o l i c y a c t i o n which c o u l d a f f e c t u t i l i z a t i o n i s the e d u c a t i o n of the consumer, p a r t i c u l a r l y i n the a r e a o f h e a l t h or h e a l t h - r e l a t e d s u b j e c t m a t e r i a l . H e a l t h e d u c a t i o n , f o r example, c o u l d change c u l t u r a l a t t i t u d e s and I n c r e a s e p u b l i c awareness of a l t e r n a t i v e forms of t r e a t m e n t and s e r v i c e d e l i v e r y . G r e a t e r u n d e r s t a n d i n g of d i s e a s e symptoms and t r e a t m e n t o f s e l f - l i m i t i n g i l l n e s s c o u l d r e s u l t i n e a r l i e r d e t e c t i o n and hence tr e a t m e n t o f s e r i o u s i l l n e s s e s and a r e d u c t i o n i n the u t i l i z a t i o n of h e a l t h s e r v i c e s f o r minor a i l m e n t s . An educated consumer c o u l d p o s s i b l y d i f f e r e n t i a t e l e v e l s of s e r v i c e q u a l i t y b e i n g o f f e r e d and s e l e c t the type o f s e r v i c e most c o s t / b e n e f i c i a l t o him. F u r t h e r m o r e , a p a r t of t h i s e d u c a t i o n a l a c t i v i t y c o u l d be devoted t o d i s s e m i n a t i o n of i n f o r m a t i o n on the a v a i l a b i l i t y of f r e e p r e v e n t i v e t r e a t m e n t s such as x - r a y s , pap smears, and v a c c i n a t i o n s , as w e l l as t o i n f o r m the p u b l i c o f impending e p i d e m i c s ( e . g . , f l u or s y p h i l i s ) or h e a l t h h azards ( e . g . , e n v i r o n m e n t a l p o l l u t i o n , s e v e r e weather, o r danger-ous w o r k i n g c o n d i t i o n s ) . A l t h o u g h t h e r e are o t h e r c u l t u r a l - d e m o g r a p h i c f a c t o r s which c o u l d be i n f l u -enced by governmental i n t e r v e n t i o n such as m a r i t a l s t a t u s , f a m i l y s i z e and r e s i d e n c e — e d u c a t i o n a l i n -f o r m a t i o n d i s s e m i n a t i o n programs appear t o be the o n l y a c t i o n s c ontemplated i n the near f u t u r e . 33 I n a d d i t i o n t o the a f o r e m e n t i o n e d l i m i t a t i o n s , a n a l y s i s o f the i n f l u e n c e o f c u l t u r a l - d e m o g r a p h i c f a c t o r s on h e a l t h s e r v i c e u t i l i z a t i o n w i l l not r e -v e a l the e f f e c t s o f economic f a c t o r s on the demand f o r s e r v i c e s , nor does i t r e f l e c t the c o n s t r a i n t s p l a c e d on the consumer by the h e a l t h s e r v i c e s y s -tem. The a n a l y s i s o f the e f f e c t of t h e s e l a t t e r f a c t o r s on h e a l t h s e r v i c e demands i s the t o p i c o f the next two s u b s e c t i o n s . Economic F a c t o r s Two economic f a c t o r s which a f f e c t the demand f o r h e a l t h s e r v i c e s a re the p r i c e o f s e r v i c e s ( i . e . , t h e c o s t o f h e a l t h care t o the consumer) and the income a b i l i t y o f the consumer t o pay f o r s e r v i c e s o f f e r e d . The c o s t o f m e d i c a l care t o the consumer c o n s i s t s o f not o n l y the f e e s charged and/or p r i c e s demanded by p h y s i c i a n s and h e a l t h I n s t i t u t i o n s , but a l s o o t h e r i n t a n g i b l e c o s t s such as l o s s o f l e i s u r e t i m e , d i f -f i c u l t i e s i n o b t a i n i n g h e a l t h c a r e , and o t h e r i n c o n -v e n i e n c e s which c o n f r o n t the h e a l t h consumer. S i n c e most o f the nonmonetary c o s t s are the r e s u l t o f r e -s t r i c t i o n s p l a c e d on the consumer by the h e a l t h de-l i v e r y system, d i s c u s s i o n o f t h e s e c o s t s w i l l be l e f t t o the subsequent s u b s e c t i o n . T h i s w i l l c o n c e n t r a t e on d i r e c t and i n d i r e c t ( e . g . , l o s s of income) mone-t a r y c o s t s o f h e a l t h care s e r v i c e , and the e f f e c t s o f t h e s e c o s t s on the u t i l i z a t i o n o f h e a l t h s e r v i c e s . 34 P r i c e s of h e a l t h care a f f e c t not only an i n -d i v i d u a l ' s d e c i s i o n to seek h e a l t h s e r v i c e s , but a l s o the amount and type of s e r v i c e he uses. For ex-ample, the p r i c e of h e a l t h s e r v i c e s may i n f l u e n c e whether or not a person decides to have e l e c t i v e surgery to improve a c h r o n i c c o n d i t i o n , to remain i n a h o s p i t a l f o r a longer r e c u p e r a t i v e p e r i o d , or to seek the s e r v i c e s of a m e d i c a l s p e c i a l i s t or a gen-e r a l p r a c t i t i o n e r . The outcome of such d e c i s i o n s may a l s o be i n f l u e n c e d by the consumer's a b i l i t y to pay, a combination of h i s income and coinsurance. A n a l y s i s of the e f f e c t s of these f a c t o r s , o n the u t i l i z a t i o n of s e r v i c e s i s necessary to assess the impact of economic programs aimed at d e c r e a s i n g the cost of h e a l t h care of r e d u c i n g h e a l t h economic bar-r i e r s c o n f r o n t i n g low income groups. The e f f e c t s of programs designed to decrease the cost of c a r e . t o s e l e c t e d groups (e.g., Medicare and Medicaid) are proposed programs aimed at a m e l i o r a t i n g the t o t a l cost of care on the o v e r a l l demands f o r h e a l t h s e r v -i c e s need to be examined. S i g n i f i c a n t r e d u c t i o n s i n cost of h e a l t h care to the consumer co u l d i n c r e a s e the q u a n t i t y of care demanded which may, i n t u r n , es-c a l a t e the p r i c e of care i n the short run. W i t h i n these programs, a l t e r n a t i v e reimbursement systems (e.g., p r o s p e c t i v e vs. r e t r o s p e c t i v e payment) should be examined with r e s p e c t to t h e i r p o s s i b l e moderation 35 of e s c a l a t i n g h e a l t h care costs.' The r e l a t i o n s h i p between income and the consump-t i o n of h e a l t h s e r v i c e s should be examined to d e t e r -mine the e f f e c t s of t h i s f a c t o r on the o v e r a l l u t i l -i z a t i o n of h e a l t h s e r v i c e s . Different-'*' income groups may consume d i f f e r i n g q u a n t i t i e s and types of h e a l t h s e r v i c e . Persons with h i g h e r incomes may s e l e c t more comprehensive forms of care (e. g., y e a r l y phy-s i c a l s and e l e c t i v e s u r g e r y ) , have longer lengths of stay i n h e a l t h i n s t i t u t i o n s , u t i l i z e more s p e c i a l i z e d s e r v i c e s , and pay h i g h e r p r i c e s f o r s i m i l a r s e r v i c e s . Furthermore, the consumer's a b i l i t y to pay f o r care could i n f l u e n c e a p h y s i c i a n ' s s e l e c t i o n of treatment modality and p a r t i a l l y account f o r the amount and type of h e a l t h s e r v i c e s u t i l i z e d . .-. A t h i r d f a c t o r which must be s p e c i f i c a l l y taken i n t o account i n a n a l y z i n g the economics of h e a l t h care u t i l i z a t i o n i s h e a l t h i n s u r a n c e . H e a l t h insurance not only d i s t o r t s the impact of costs and income f a c t -ors on u t i l i z a t i o n , but a l s o i n f l u e n c e s the q u a n t i t y and type of medical care demanded. Insurance pro-t e c t s the i n d i v i d u a l consumer from unexpected expenses by d i s t r i b u t i n g the cost of medical care across the i n s u r e d p o p u l a t i o n . By l e s s e n i n g the cost of h e a l t h care, p a t t e r n s of consumption are a l t e r e d . I n d i v i -duals confronted with " b a r g a i n " care are more l i k e l y to i n c r e a s e t h e i r demand f o r care, p a r t i c u l a r l y those types of care which o f f e r the g r e a t e s t insurance 36 coverage. For example, h o s p i t a l care may be sought i n s t e a d of ambulatory care because of s p e c i f i c i n s u r -ance p r o v i s i o n s . S i m i l a r l y , there may be i n c r e a s e d demands f o r s p e c i a l i s t s vs. g e n e r a l p r a c t i t i o n e r s s i n c e t h e i r s e r v i c e s are more completely i n s u r e d . Health insurance programs sponsored by the f e d e r a l government (e.g., Medicaid and Medicare) and by other t h i r d p a r t y c o n t r i b u t i o n s (e.g., company insurance programs) can be viewed as e f f e c t i v e l y i n c r e a s i n g an i n d i v i d u a l ' s income and s e l e c t i v e l y changing h i s a b i l i t y to pay f o r h e a l t h care s e r v i c e s . The i n t e r r e l a t i o n s h i p s between the above f a c t -ors — h e a l t h s e r v i c e u t i l i z a t i o n and a l t e r n a t i v e economic p o l i c i e s and programs of governmental p l a n -ning agencies — need to be i d e n t i f i e d to develop, implement, and assess these a l t e r n a t i v e courses of a c t i o n . The impact of tax i n c e n t i v e s d i r e c t e d toward i n c r e a s i n g i n d i v i d u a l and employer expenditures f o r h e a l t h i n s u r a n c e , f e d e r a l and s t a t e w e l f a r e pro-grams aimed at d e c r e a s i n g the medical costs of i n -c r e a s i n g the income of the i n d i g e n t (e.g., M e d i c a i d ) , and government-supported h e a l t h care c l i n i c s which provide low cost or f r e e s e r v i c e s (e.g., neighbor-hood h e a l t h c l i n i c s ) a d d i t i o n a l l y should be ad-dressed i n t h i s a n a l y s i s . H ealth Care D e l i v e r y C o n s t r a i n t s In a d d i t i o n t o the economics and c u l t u r a l -37 demographic f a c t o r s which i n f l u e n c e and c h a r a c t -e r i z e an i n d i v i d u a l ' s d e c i s i o n t o seek h e a l t h s e r v -i c e s , e x t e r n a l h e a l t h care d e l i v e r y c o n s t r a i n t s may l i m i t and mold the choice of a l t e r n a t i v e s a v a i l a b l e t o the h e a l t h consumer. The a c c e s s i b -i l i t y of d i f f e r e n t s e r v i c e s may not only i n f l u e n c e the type of care sought, but a l s o c o n t r i b u t e t o the d e c i s i o n to seek care. The d i s u t i l i t y asso-c i a t e d with consumption of s e r v i c e s which r e q u i r e encumbering appointment procedures, long t r a v e l or w a i t i n g times, or other s i m i l a r inconveniences, may s i g n i f i c a n t l y i n f l u e n c e a consumer's d e c i s i o n pro-cess. S i m i l a r l y , the r e l a t i v e a c c e s s i b i l i t y of a l -t e r n a t i v e h e a l t h d e l i v e r y forms may a f f e c t the type of care u t i l i z e d . A l t e r n a t i v e modes of h e a l t h care d e l i v e r y such as p r e p a i d vs. feer-f o r - s e r v i c e care; group v s. s o l o p r a c t i c e ; and p r e v e n t i v e vs. e p i s o d i c medical care, a f f e c t the manner i n which these s e r v i c e s are u t i l i z e d and hence i n f l u e n c e the manpower s e r v i c e requirements f o r p a t i e n t care. For example, group p r a c t i c e s may p l a c e . g r e a t e r dependence on a u x i l i a r y p ersonnel t o provide c o n t i n u i t y of care f o r c h r o n i c i l l n e s s e s than would a s o l o p r a c t i t i o n e r ; or pr e -v e n t i v e medical s e r v i c e s may r e q u i r e fewer i n p a t i e n t s e r v i c e s ( i . e . , s h o r t e r lengths of s t a y , fewer admis-s i o n s , or both) and more o u t p a t i e n t v i s i t s than i t s e p i s o d i c c o u n t e r p a r t s ; or p r e p a i d p a t i e n t s may demand 38 more s e r v i c e s t h a n f e e - f o r - s e r v i c e p a t i e n t s . I n h e r e n t i n the h e a l t h care d e l i v e r y system are a complex s e t o f p r o c e d u r e s which f u r t h e r con-s t r a i n the a c t i o n space o f the h e a l t h s e r v i c e con-sumer. Foremost among the s e i s the r e s t r i c t i o n t h a t a l l but t h e most s i m p l e o f m e d i c a l ca r e s e r v -i c e s . r e q u i r e s some i n t e r a c t i o n w i t h a p h y s i c i a n . As a consequence, the p h y s i c i a n a a c t s , i n p a r t , as a buyer o f h e a l t h s e r v i c e s f o r the consumer. The p a t i e n t - p h y s i c i a n r e l a t i o n s h i p r e s u l t s i n the phys-i c i a n r a t h e r than the consumer placing-demands f o r many k i n d s o f h e a l t h s e r v i c e s . P h y s i c i a n s not o n l y s e l e c t the method and l o c a t i o n o f t r e a t m e n t , but a l s o as aoconsequence o f the s e d e c i s i o n s , determine the o v e r a l l magnitude and type o f h e a l t h s e r v i c e r e -q u i r e d f o r each i l l n e s s e p i s o d e . F a c t o r s whcih i n -f l u e n c e the p h y s i c i a n ' s d e c i s i o n p r o c e s s i n c l u d e : t r a i n i n g and s p e c i a l i z e d o r i e n t a t i o n ( e . g . , a surgeon may t r e a t s p e c i f i c h e a l t h problems I n a d i f f e r e n t manner than-an i n t e r n i s t o r a g e n e r a l p r a c t i t i o n e r ) ; s p e c i a l i n s t i t u t i o n a l agreements and arrangements ( e . g . , h o s p i t a l a p p o i n t m e n t s , c l i n i c a l t e s t i n g and l a b o r a t o r y arrangements, e t c . ) ; p a t i e n t s ' i n t e r e s t ( i . e . , c o s t and q u a l i t y o f a l t e r n a t i v e t r e a t m e n t m o d a l i t i e s ) ; and the p h y s i c i a n ' s p e r s o n a l b e n e f i t s ( e . g . , income, l e i s u r e t i m e , u t i l i t y , e t c . ) . The p h y s i c i a n ' s d e c i s i o n space i s a l s o c o n s t r a i n e d by 39 the l i m i t s of p r e f e r r e d medical p r a c t i c e and pro-f e s s i o n a l or o r g a n i z a t i o n a l s a n c t i o n s which p r e -clude c e r t a i n a c t i o n s , such as p r o l o n g i n g a pa-t i e n t ' s h o s p i t a l stay or a d m i t t i n g p a t i e n t s to a h o s p i t a l u n n e c e s s a r i l y . Other p r o c e d u r a l con-s t r a i n t s which are o u t s i d e the spectrum o f p h y s i -c i a n c o n t r o l are those p r i n c i p a l l y imposed by f a c i l i t y and p ersonnel l i m i t a t i o n s (e.g., number of beds, type of l a b o r a t o r y f a c i l i t i e s , s i z e of h o s p i t a l s t a f f , e t c . ) . In a d d i t i o n , the decrease i n the r e l a t i v e number of p h y s i c i a n s o f f e r i n g what i s c u r r e n t l y r e f e r r e d to as primary h e a l t h c a r e . ( i . e . , g e n e r a l or f a m i l y p r a c t i c e ) may r e s u l t i n i n c r e a s e d d i f f i -c u l t y i n o b t a i n i n g t h i s type of care and subse-quently cause i n a p p r o p r i a t e u t i l i z a t i o n of medical s p e c i a l i s t s f o r s e l f - l i m i t i n g or n o n - s p e c i f i c i l l -n esses. This i n c r e a s i n g u t i l i z a t i o n of s p e c i a l i s t s f o r i n i t i a l treatment r e q u i r e s g r e a t e r consumer medical knowledge ( i . e . , h e a l t h education) to s e l e c t the c o r r e c t medical d i s c i p l i n e and i s s u b j e c t to g r e a t e r misuse of h e a l t h manpower t a l e n t and a r e -s u l t i n g i n c r e a s e i n t o t a l demand f o r manpower s e r v -°U.S. Department of H e a l t h , E d u c a t i o n and Welfare, Bureau of Health Resources Development, An A n a l y s i s  of Health Manpower Models: Volume 1, DHEW P u b l i c a t i o n No. (HRA) 75-19, 1974, pp. 11-20. 40 How does one s e l e c t the proper number or s t a t i s t i c to meet the demands f o r h e a l t h manpower? This s e c t i o n of the t h e s i s w i l l p rovide a d e s c r i p -t i o n of v a r i o u s such methods used i n h e a l t h man-power-planniiigg• Along with the d e s c r i p t i o n , s t r e n g t h , weaknesses, and questions posed by each method w i l l be g i v e n . A comparison of the d i f f e r e n t methods w i l l a l s o be g i v e n showing the advantages and d i s -advantages of each approach. Before d i s c u s s i n g the v a r i o u s methods or techniques, i t i s w e l l to remem-ber t h a t j u s t as i n manpower p l a n n i n g , each method i n h e a l t h manpower pl a n n i n g a l s o has i t s own s p e c i a l p r o p e r t i e s and m e r i t s . Again, the best method may be d e r i v e d from a borrowing of d i f f e r e n t approaches and b l e n d i n g them i n t o one. "...no s i n g l e method of measuring r e -quirements has proven e n t i r e l y s a t i s f a c t o r y or u n i v e r s a l l y a p p l i c a b l e , and no simple g u i d e l i n e s or concensus e x i s t about the most a p p r o p r i a t e methodology. The l a c k of agreement r e f l e c t s the g e n e r a l l a c k of knowledge about the f o r c e s i n f l u e n c i n g the demand f o r h e a l t h care, about the con-v e r s i o n of that demand i n t o manpower r e -quirements, and about the supply responses to changing circumstances. I t a l s o r e -f l e c t s d i f f e r i n g o p i n i o n s about concepts and d e f i n i t i o n s . Even when there i s agree-ment on f a c t o r s t hat must be measured, there i s a gap i n our knowledge of how best to proceed. For example, we know that "head counts" by d i s c r e t e occupations are m i s l e a d -i n g ; t h a t the h e a l t h p r o f e s s i o n s f u n c t i o n i n a complex web of complementarity and sub-s t i t u t a b i l i t y . There i s a l s o no accepted method f o r measuring the output of h e a l t h workers, or even agreement on the output to be measured — v i s i t s , hours, e x p e n d i t u r e s , 41 income, e t c . In other words, there are inadequate input and output measures to t r a n s l a t e i n an accurate way the manpower demand and supply i n t o the demand and supply of s e r v i c e s and v i c e versa. " 7 • As d i s c u s s e d e a r l i e r , manpower.planning i s a process whereby g o a l s , o b j e c t i v e s , p r i o r i t i e s , and a c t i v i t i e s f o r h e a l t h manpower development are determined i n a systematic f a s h i o n , i n order to ensure that h e a l t h manpower r e s o u r c e s , both cur-rent and f u t u r e , are adequate.to meet the r e q u i r e -ments f o r the d e l i v e r y of h e a l t h s e r v i c e s to a pop-u l a t i o n . ^  In s h o r t , one major .concern of h e a l t h planners i s to ensure the proper "manning" of the h e a l t h care d e l i v e r y system. They must see to i t that the r i g h t number- and types of h e a l t h manpower are a v a i l a b l e when and where they-are needed. They must p l a n f o r the human resources to meet the r e -q u i r e m e n t s — w h i c h i n c l u d e t i m e l i n e s s and accept-able c o s t — g e n e r a t e d by the d e c i s i o n s of h e a l t h care p r o v i d e r s to d e l i v e r h e a l t h s e r v i c e s to a de-f i n e d , p o p u l a t i o n group. To accomplish these g o a l s , h e a l t h planners must gather two kinds of i n f o r m a t i o n . The f i r s t concerns 7u.S. Department of H e a l t h , E d u c a t i o n and Welfare, Bureau of Health Manpower, Review of H e a l t h Manpower  P o p u l a t i o n Requirements Standards, DHEW P u b l i c a t i o n No. (HRS) 77-22, 1976, p . l . ^U.S. Department df H e a l t h , E d u c a t i o n and Welfare, Health,Manpower Planning Process, H.E.W. Document No. H.R.A. 76-14013, p.3. 42 the e x i s t i n g stock of manpower i n terms of t h e i r number and type. The second k i n d of i n f o r m a t i o n concerns present or "projected requirements f o r h e a l t h manpower. Complicating the planner's job i s the f a c t that p l a n n i n g i s , g e n e r a l l y speaking, a f u t u r e - o r i e n t e d a c t i v i t y . Thus, care must be taken to account f o r the i n e v i t a b l e time l a g between p l a n -n i n g and implementation. There are many questions which the h e a l t h planner must c o n s i d e r i n t h i s con-n e c t i o n . For example, how long does i t take to educate a h e a l t h p r o f e s s i o n a l ? What are the l i k e l y changes i n u t i l i z a t i o n or p r o d u c t i v i t y standards that w i l l r e s u l t from pending or a n t i c i p a t e d l e g i s -l a t i o n ? What are the p o t e n t i a l demographic changes w i t h i n the plann i n g area or p o p u l a t i o n that w i l l a f f e c t requirements f o r a balance between the r e -sources a v a i l a b l e and the resources r e q u i r e d ? ^ A l t e r n a t i v e methodologies f o r e s t i m a t i n g r e -quirements are a v a i l a b l e to the l o c a l p l anner, but . no one method i s u n i v e r s a l l y a p p l i c a b l e and e r r o r f r e e . ' Experience has shown.that d i f f e r e n t methods produce d i f f e r e n t e s t i m a t e s . A 1 9 7 0 i n v e s t i g a t i o n of s i x e a r l i e r p r o j e c t i o n s of 1 9 7 5 p h y s i c i a n r e -quirements based on d i f f e r e n t methodologies found the estimates vary s i g n i f i c a n t l y , r a nging from 9 l b i d . , p.4. 305,000 to 425,000 and that the f i n d i n g s l e d to opposing c o n c l u s i o n s concerning the adequacy of the p r o j e c t e d supply of p h y s i c i a n s . D i f f e r e n t methodological approaches d i s c u s s e d i n t h i s t h e s i s w i l l i n c l u d e the manpower popula-t i o n r a t i o approach, the s e r v i c e t a r g e t s approach, the h e a l t h need approach and the economic ( e f f e c t -i v e ) demand approach. These f o u r approaches to e s t i m a t i n g manpower requirements are the most com-monly used i n h e a l t h manpower s t u d i e s . Two other methods that c a n . e i t h e r be i n t e g r a t e d with the other approaches or used by themselves w i l l a l s o be d i s c u s s e d . These are the f u n c t i o n a l a n a l y s i s approach and the use of models approach. The l a t -t e r two techniques have been used i n numerous s t u d i e s of s p e c i f i c h e a l t h occupations or communi-t i e s , but have not as yet been widely used on a n a t i o n a l s c a l e . MANPOWER/POPULATION RATIO APPROACH This i s the most popular and widely used ap-proach f o r determining h e a l t h manpower requirements. This method i s used to c h a r a c t e r i z e c u r r e n t man-power s i t u a t i o n s and to assess the adequacy of the 1 0Hansen, Lee W., "An A p p r a i s a l of P h y s i c i a n Man-power P r o j e c t i o n s , " I n q u i r y , March 1970. 44 present supply of h e a l t h manpower. The method i s a l s o used to study the geographic d i s t r i b u t i o n of h e a l t h workers and to determine the number of p e r s -onnel that w i l l be r e q u i r e d to provide the community with h e a l t h s e r v i c e s i n the f u t u r e . The b a s i c i d e a of the manpower/population r a t i o approach i s that p o p u l a t i o n s i z e i s the main determinant of manpower requirements. Area pop-u l a t i o n s t a t i s t i c s and the d e s i r e d r a t i o of h e a l t h manpower to p o p u l a t i o n are the two elements essen-t i a l to apply t h i s method. A r a t i o of the number of h e a l t h manpower to the t o t a l p o p u l a t i o n served i s s e l e c t e d . The simplest method of e s t i m a t i n g and f o r e c a s t i n g manpower requirements i s to c a l -c u l a t e the a c t u a l r a t i o of manpower to p o p u l a t i o n and then compute the manpower r e q u i r e d to meet t h i s s t a n d a r d . f o r another p o p u l a t i o n . In the formula to c a l c u l a t e manpower requirements, the r a t i o i s a p p l i e d to the t a r g e t year p o p u l a t i o n . Manpower Estimated manpower Po p u l a t i o n x t a r g e t p o p u l a t i o n = requirements The numerator i n the r a t i o , manpower, may r e f e r to d i s c r e t e occupations (e.g., r a d i o l o g i c a l t e c h -n o l o g i s t ) or to g e n e r i c c a t e g o r i e s (e.g., a l l i e d h e a l t h o c c u p a t i o n s ) . The term may be l i m i t e d to h e a l t h personnel p r o v i d i n g s e r v i c e i n a p a r t i c u l a r s e t t i n g (e.g., n u r s i n g homes) or to a p a r t i c u l a r type of care (e.g., p e d i a t r i c ) , or i t may be a l l -45 i n c l u s i v e encompassing the t o t a l i t y of workers i n the h e a l t h i n d u s t r y . The denominator of the r a t i o , p o p u l a t i o n , may be d e f i n e d i n d i f f e r e n t terms depending upon the planner's concerns: t o t a l community p o p u l a t i o n , i f the problem deals with environmental h e a l t h ; c i t -i z e n s 60 years of age and o l d e r , i f the concern i s to s t a f f n u r s i n g homes and t r e a t c h r o n i c i l l n e s s ; the r e s i d e n t s of a g e o g r a p h i c a l l y d e f i n e d s e r v i c e area, i f the i s s u e i s adequate ambulatory c a r e . H The r a t i o of one area can be used f o r another p o i n t i n time, or a comparison can be made across both time and space. A l s o , other types of p o p u l a t i o n standards can be employed, such as p r o v i d e r s per po p u l a t i o n from a t y p i c a l HMO. S i m i l a r l y , v i s i t s or some other measure can a l s o be r e l a t e d to popu-l a t i o n . 1 2 . I f the t a r g e t r a t i o i s s e l e c t e d c o r r e c t l y , the amount of s e r v i c e s s u p p l i e d w i l l be adequate when the a c t u a l r a t i o i s equal to the t a r g e t r a t i o . I f ^-Mj.S. Department of Heal t h , Education and Welfare, Bureau of Heal t h Planning and Resource Development, M e t h o d o l o g i c a l Approaches f o r Determining H e a l t h  Manpower Supply and Requirements: Volume 1 A n a l y t i -c a l P e r s p e c t i v e , DHEW P u b l i c a t i o n No. (HRA) 76-14511, 1976, p. 33-1 2U.S. Department of He a l t h , E d u c a t i o n and Welfare, Bureau of Health Manpower, E s t i m a t i n g Manpower Re-quirements : A Background Paper, Report No. 76-114, Washington, D.C: U. S. Government P r i n t i n g O f f i c e , 1977, PP. 12-13. 4f>. the r a t i o i s not based on c o n d i t i o n s i n the country or area concerned, but i s simply taken over from another country at a more advanced stage of develop-ment or from a more favored r e g i o n w i t h i n the same country, i t i s not c l e a r how i t s adequacy can be e s t a b l i s h e d . I t must a l s o be borne In mind t h a t , because of dramatic t e c h n o l o g i c a l changed t h a t are t a k i n g p l a c e , the v a l i d i t y of any p a r t i c u l a r r a t i o i s of l i m i t e d duration.13 STRENGTHS AND WEAKNESSES OF THE MANPOWER/POPULATION  APPROACH The s i m p l i c i t y of the method i s I t s g r e a t e s t advantage. R e l a t i v e to other methods, data r e -quirements are minimal, and the s t a t i s t i c s are e a s i -l y o btained; the estimates can be prepared i n short order at low c o s t ; the methodology r e q u i r e s modest s t a f f e x p e r t i s e . I t i s u s e f u l as a d e s c r i p t i v e de-v i c e , as an input to m o r e . s o p h i s t i c a t e d methodolo-g i e s , as a v a l i d a t i o n of estimates d e r i v e d by other means, and as a datum to be used i n producing more t h o u g h t f u l judgments. The weaknesses of the method are s e r i o u s and may be o v e r r i d i n g . I n e v i t a b l e changes i n the f u t u r e i n -l^World H e a l t h O r g a n i z a t i o n , T e c h n i c a l Report S e r i e s No. 481, The Development of Studies i n H e a l t h Man-power (Geneva, S w i t z e r l a n d : World H e a l t h Organiza-t i o n 197D, pp. 12-13. in-v o l v i n g socioeconomic c o n d i t i o n s , t e c h n o l o g i c a l and bi o m e d i c a l advances in» h e a l t h care and the c o n f i g u -r a t i o n of the d e l i v e r y system are ig n o r e d , although they a f f e c t the amount of s e r v i c e s h e a l t h p e r s o n n e l w i l l p r o v i d e . To • ignore.these changes and focus on p o p u l a t i o n growth may be f e a s i b l e i n the very short run, but i t i s p e r i l o u s . f o r long-term p r o j e c t i o n s . I t has been p o i n t e d out that "manpower/population r a t i o s do not take i n t o account the v a r i a t i o n s i n the s i z e of s e r v i c e areas f o r a p a r t i c u l a r type of manpower as the p o p u l a t i o n d e n s i t y changes."-^ Furthermore, i t i s untenable to assume t h a t a f i x e d r e l a t i o n s h i p of manpower to p o p u l a t i o n i s a p p r o p r i a t e f o r any l e n g t h of time other than the immediate. But even i f the assumption about a f i x e d r a t i o of manpower to p o p u l a t i o n i s r e l a x e d and changes i n the standard r a t i o are allowed d u r i n g the p r o j e c t i o n p e r i o d , thus o b v i a t i n g some o b j e c t i o n a b l e aspects of t h i s m e t h o d o l o g i c a l approach, the p a r t i c u l a r r a t i o choseri may be suspect — whether i t be designated by expert o p i n i o n or by the standard found i n another area. In f a c t , i f the designated r a t i o i s based on a standard h i g h e r than that e x i s t i n g i n the planner's 1 4U.S. Department of Hea l t h , E d u c a t i o n and Welfare, Bureau of Health Resources and Development, The  D e l i n e a t i o n of Economic and Health S e r v i c e Areas  and the L o c a t i o n of Health Manpower Educat i o n Pro-grams , Washington, D.C: U. S. Government P r i n t i n g O f f i c e , 1974, p. 149. 4f community j the c o n c l u s i o n t h a t a s h o r t a g e e x i s t s i s b u i l t i n t o the methodology and i s i n e v i t a b l e . A s i d e from the u n r e a l i s t i c n a t u r e o f the under-l y i n g a s s u m p t i o n s , l o c a l h e a l t h p l a n n e r s may encount-e r a d a t a problem. P o p u l a t i o n and manpower d a t a may not be p u b l i s h e d f o r the r e l e v a n t l a b o r market o r h e a l t h s e r v i c e d e l i v e r y a r e a . A v a i l a b l e data-may not a p p l y t o the manpower.categories under s t u d y , or may use v a r y i n g o c c u p a t i o n a l t i t l e s and d i f f e r -ent j o b d e s c r i p t i o n s . I n a d d i t i o n , d a t a gaps may make i t d i f f i c u l t o r i m p o s s i b l e t o dev e l o p a time s e r i e s from which t o study h i s t o r i c a l r e l a t i o n s h i p s i n o r d e r t o s e l e c t a r a t i o . W i t h t h i s m e t h o d o l o g i c a l approach, as w i t h the o t h e r s , the s t r e n g t h s and weaknesses must be weighed i n terms o f t h e o p t i o n s and c i r c u m s t a n c e s t h a t f a c e each p l a n n e r . Severe c r i t i c i s m s can be l e v e l e d a g a i n s t the r a t i o method, but i t s use i n many i n -s t a n c e s r e f l e c t s t he f a c t t h a t more s a t i s f a c t o r y ap-proaches may not be f e a s i b l e . I n f a c t , .most s t u d i e s use the manpower/population r a t i o at some p o i n t . SERVICE TARGETS APPROACH T h i s approach addresses the q u e s t i o n as t o how Department o f H e a l t h , E d u c a t i o n and W e l f a r e , Bureau o f H e a l t h P l a n n i n g and Resource Development, M e t h o d o l o g i c a l Approaches f o r D e t e r m i n i n g H e a l t h Man-power Supply and Requirements: Volume 11 P r a c t i c a l ' P l a n n i n g Manual, DHEW P u b l i c a t i o n No. (HRA)•76-14512, 1976, pp. 39-40. 49 many s e r v i c e s of each k i n d should be produced to meet expected requirements f o r h e a l t h care,and^what manpower w i l l be r e q u i r e d to provide these s e r v i c e s or t a r g e t s . The " t a r g e t s " must be c l e a r l y s p e c i f i e d and d e r i v e d from statements made by p u b l i c l e a d e r s , p r o f e s s i o n a l a s s o c i a t i o n s , or other q u a l i f i e d auth-o r i t i e s . 16 Data e s s e n t i a l f o r the s e r v i c e t a r g e t s approach are: (1) p o p u l a t i o n , (2) q u a n t i t a t i v e standards or norms f o r h e a l t h s e r v i c e s , (3) work assignments and s t a f f i n g p a t t e r n s f o l l o w e d i n the p r o v i s i o n of s e r v -i c e s , and (4) manpower productivity."'" 7 The f i r s t step i n a p p l y i n g the method i s to set the t a r g e t of the types of q u a n t i t y of s e r v i c e s r e q u i r e d by the p o p u l a t i o n i n the l o c a l area. The c o n s t r a i n t s of the p a r t i c u l a r program and of the h e a l t h d e l i v e r y system are taken i n t o account i n s e l e c t i n g the s e r v -i c e g o a l s . With the s e r v i c e t a r g e t s q u a n t i f i e d , man-power requirements are d e r i v e d by a p p l y i n g f a c t o r s r e l a t e d to manpower s t a f f i n g and p r o d u c t i v i t y . N e i t h -er of these f a c t o r s i s e a s i l y q u a n t i f i e d . l^World H e a l t h O r g a n i z a t i o n , T e c h n i c a l Report S e r i e s , No. 481, The Development of Studies i n Health Man-power, (Geneva, S w i t z e r l a n d : World He a l t h O r g a n i z a t i o n , 197D, p. 13. 1 7U.S. Department of He a l t h , Education and Welfare, Bureau of Hea l t h Planning and Resource Development, M e t h o d o l o g i c a l Approaches f o r Determining H e a l t h  Manpower Supply and Requirements: Volume 11 P r a c t i -c a l P l anning Manual, DHEW P u b l i c a t i o n No. (HRA) 76-14512, 1976, p. 41. 5© "To i l l u s t r a t e the methodology o f the s e r v -i c e t a r g e t s approach w i t h a s i m p l e example, l e t us suppose t h a t the q u e s t i o n t h e p l a n n e r needs t o answer i s , 'How many emergency m e d i c a l t e c h n i c i a n s (EMT's) are r e q u i r e d f o r adequate s e r v i c e i n our community?' F i r s t , we d e f i n e the s e r v i c e t a r g e t : say t h a t the number o f ambulances r e q u i r e d i s e s t a b l i s h e d as one ambulance per 10,000 p e o p l e , based on the a n a l y s i s o f the p a s t y e a r ' s emergency c a l l s and the o r g a n i z a t i o n o f ambulance s e r v i c e s i n v t h e a r e a . The s e r v i c e t a r g e t i s v a l i d a t e d by the e x p e r t j u d g -ment o f emergency m e d i c a l p h y s i c i a n s . Thus, t h i s community, with, a p o p u l a t i o n o f 50,000, would r e -q u i r e f i v e ambulances. Second, we determine the s t a f f i n g p a t t e r n : l e t us assume i t i s agreed t h a t each ambulance s h o u l d c a r r y two EMT's, and s h o u l d be manned 24 hours a day, seven days a week. T h i r d , we d e c i d e upon the l e v e l o f p r o d u c t i v -i t y : i n t h i s c a s e , the output o f emergency p e r s o n -n e l i s measured by the hours they are a v a i l a b l e t o r e s p o n d t o emergency c a l l s . Each EMT w i l l man the ambulance f o r an 8-hour day, 40-hour week. F i n a l l y , we c a l c u l a t e the manpower r e q u i r e m e n t s : each, ambulance w i l l o p e r a t e r o u n d - t h e - c l o c k , a 168-hour week. D i y i d i n g 168 hours by a 40-hour week f o r each, man eq u a l s • f o u r men. M u l t i p l y i n g by two men per s h i f t e q u a l s e i g h t men, w h i c h , when m u l t i p l i e d by f i v e ambulances e q u a l s 40 men. Adding one. EMT as- a r e l i e f man g i v e s the community's t o t a l man-power r e q u i r e m e n t f o r EMT's — 4 l men. n l° STRENGTHS. AND WEAKNESSES OF THE SERVICE TARGETS  APPROACH The s t r e n g t h o f the s e r v i c e t a r g e t s approach t o e s t i m a t i n g r e q u i r e m e n t s i s i t s f o c u s on the c e n t r a l l-^u.S. Department of He a l t h , E d u c a t i o n and Welfare, Bureau of H e a l t h Planning and Resource Development, M e t h o d o l o g i c a l Approaches f o r Determining H e a l t h Man-power Supply and Requirements: Volume 1 A n a l y t i c a l Perspective,DHEW P u b l i c a t i o n No.(HRA) 76-14511, 1976, PP. 35-37-51 i s s u e o f p r o v i d i n g s e r v i c e s , and t h e r e f o r e , on the i m p o r t a n c e o f the e f f i c i e n t and e f f e c t i v e o r g a n -i z a t i o n o f the d e l i v e r y o f c a r e . A t t e n t i o n i s d i -r e c t e d t o manpower u t i l i z a t i o n and i t s impact on p r o d u c t i v i t y . The i m p l i c a t i o n s o f the h e a l t h team can be s t u d i e d , a l l o w i n g the p l a n n e r t o t h e o r e t i c ca.ll.yy. t e s t the e f f e c t o f a l t e r n a t i v e manpower mixes on manpower r e q u i r e m e n t s . The p l a n n e r i s d i r e c t e d by t h i s method t o do an i n - d e p t h a n a l y s i s of each s e r v i c e component o f h e a l t h care and o f the s t a f f t o j ' p r o v i d e the s e r v i c e . T h i s d i s a g g r e g a t i o n e n a b l e s the p l a n n e r t o t a i l o r h i s methodology a c c o r d i n g t o the unique c h a r a c t e r -i s t i c s o f the p a r t i c u l a r s e r v i c e s e c t o r . I n the a r e a o f manpower r e q u i r e m e n t s f o r pharm-a c e u t i c a l s e r v i c e s . , f o r example, one must e s t i m a t e , the impact o f the expanded use o f drugs i n m e d i c a l p r a c t i c e ; the s h i f t i n g r o l e o f p h a r m a c i s t s away from drug compounding and d i s p e n s i n g , and toward a d v i s i n g and m a i n t a i n i n g drug p r o f i l e s ; the r e l a t i v e i mportance o f d i f f e r e n t employment s e t t i n g s — p h a r m a c e u t i c a l houses, drug s t o r e s , h o s p i t a l s , HMO's; and the p o t e n t i a l use o f a u x i l i a r y p e r s o n n e l . A c o m p l e t e l y d i f f e r e n t s e t o f c o n s i d e r a t i o n s must be q u a n t i f i e d i n d e t e r m i n i n g manpower r e q u i r e m e n t s f o r r a d i o l o g i c t e c h n o l o g i s t s . F i r s t , t he r a d i o l o g i s t d e t e r m i n e s the d i a g n o s t i c and c u r a t i v e use o f X-ray and o t h e r r a d i a t i o n t e c h n i q u e s . The use o f r a d i o -52 l o g i c s e r v i c e s and o f r a d i o l o g i c t e c h n o l o g i s t s de-pends upon the d o c t o r s ' o r d e r s . New t e c h n o l o g y — B - s c a r i j h o l o g r a p h y , xerography — expands the h o r i -zon, but the concern about h e a l t h h a z a r d s w i l l s u r e l y l i m i t the use o f r a d i o l o g i c s e r v i c e s . The s e a r c h f o r u n d e r s t a n d i n g of the u n d e r l y i n g f a c t o r s and r e l a t i o n s h i p s t h a t i s r e q u i r e d i n the s e r v i c e t a r g e t s approach i s one o f ; l i t s g r e a t e s t s t r e n g t h s . The p l a n n e r i s f a c e d w i t h the A c h i l l e s ' h e e l o f t h i s method when he a t t e m p t s t o q u a n t i f y the v a r i a b l e s d e a l i n g w i t h J s e r v i c e t a r g e t s , manpower s t a f f i n g and p r o d u c t i v i t y . He w i l l almost c e r t a i n l y f i n d i m p o r t a n t d a t a gaps. S h o u l d he d e c i d e t o c o l -l e c t p r i m a r y d a t a , he. must be p r e p a r e d f o r a l o n g -term e f f o r t , c o n s i d e r a b l e expense and t h e need f o r e x p e r t t e c h n i c a l a s s i s t a n c e . The p l a n n e r s h o u l d be wary o f t h e t e m p t a t i o n t o e l a b o r a t e the study t o such an e x t e n t t h a t the de-t a i l e d f i n d i n g s are o n l y o f academic i n t e r e s t and o f no p r a c t i c a l v a l u e i n the l i g h t o f h i s p o l i c y o p i n -i o n s . By f a r the g r e a t e s t danger of' t h i s method i s the use o f improper c r i t e r i a f o r s e t t i n g the s e r v i c e s t a n d a r d s — i n terms of the demand f o r s e r v i c e s and t h e p r o d u c t i v i t y of l a b o r . I f the s t a n d a r d s used are not v a l i d , the e s t i m a t e s may be g r o s s l y u n r e a l i s t i c . I n t h i s , as i n e v e r y o t h e r method-o l o g i c a l approach, the f i n a l outcome i s o n l y as 53 good as the judgment and s t a t i s t i c a l d a t a t h a t are used.19, HEALTH NEEDS APPROACH The h e a l t h needs approach i s used t o a s c e r t a i n what h e a l t h s e r v i c e s are needed by people t o make - and keep them h e a l t h y . The d e t e r m i n a t i o n o f "need" i s made by h e a l t h p r o f e s s i o n a l s i n accordance w i t h t h e i r b e s t judgment as t o what i s r e q u i r e d a c c o r d i n g t o modern m e d i c a l s c i e n c e . Needed s e r v i c e s are then c o n v e r t e d i n t o manpower r e q u i r e m e n t s . 2 ^ The d a t a r e q u i r e m e n t s are e x t e n s i v e : the ex-t e n t o f h e a l t h needs must be i d e n t i f i e d ; agreement on'the p r o p e r modes o f care and type of ^'treatment f o r each h e a l t h need must be re a c h e d ; the a p p r o p r i -ate t r e a t m e n t must be d e f i n e d i n terms o f v t h e p e r -s o n n e l t o d e l i v e r the s e r v i c e and the time needed f o r t r e a t m e n t ; and the amount o f s e r v i c e t h a t the i n d i v i d u a l h e a l t h worker can be ex p e c t e d t o p r o v i d e must be s e t . The f i r s t s t e p d e t e r m i n e s the h e a l t h s t a t u s o f Department o f H e a l t h , E d u c a t i o n and W e l f a r e , Bureau o f H e a l t h P l a n n i n g and Resource Development, M e t h o d o l o g i c a l Approaches f o r D e t e r m i n i n g H e a l t h  Manpower Supply and Requirements: Volume 11 P r a c t -i c a l P l a n n i n g Manual, DHEW P u b l i c a t i o n No.(HRA) 76-14512, 1976, pp. 4 8 - 4 9 . 2 (- )World H e a l t h O r g a n i z a t i o n , Pan American Conference on H e a l t h Manpower P l a n n i n g , (Washington, D.C, 1973), p. 62. 5'U the community; t h a t i s , the. number and. c h a r a c t e r i s t -i c s o f peop l e w i t h s p e c i f i c i n c i d e n c e s o f p r e v a l -ences o f i l l n e s s or d i s e a s e -- or o t h e r r e q u i r e m e n t s f o r h e a l t h care s e r v i c e s — are q u a n t i f i e d . I n the second, the a p p r o p r i a t e t r e a t m e n t o f each d i s e a s e and i l l n e s s i s s p e c i f i e d i n q u a n t i t a t i v e terms. The t h i r d s p e c i f i e s the amount o f time i t t a k e s f o r the t y p i c a l p r a c t i t i o n e r t o p r o v i d e each s e r v i c e ; and the f o u r t h c a l c u l a t e s the number o f hours i n a P1 y e a r t h a t the p r a c t i t i o n e r works. With q u a n t i t a t i v e s t a t i s t i c s on the s i z e o f p o p u l a t i o n , the f r e q u e n c y o f - i l l n e s s , o t h e r h e a l t h c o n d i t i o n s , the s e r v i c e s t o be p r o v i d e d and the time r e q u i r e d t o d e l i v e r t h e s e s e r v i c e s , the h e a l t h needs can be d e f i n e d ascLa b a s i s f o r e s t i m a t i n g manpower. The approach i s sometimes viewed as an e x t e n s i o n o f the s e r v i c e t a r g e t s approach i n which t a r g e t s are s e t by b i o l o g i c a l needs o f the community. These needs f o r h e a l t h s e r v i c e s are t r a n s l a t e d i n t o manpower r e q u i r e m e n t s . STRENGTH AND WEAKNESSES OF HEALTH NEEDS APPROACH The l o g i c a l coherences oft'fc.he h e a l t h needs method — t h a t manpower needs are determined by -^•-U.S. Department o f H e a l t h , E d u c a t i o n and W e l f a r e , Bureau o f H e a l t h P l a n n i n g and Resource Development, M e t h o d o l o g i c a l Approaches f o r D e t e r m i n i n g H e a l t h  Manpower Supply and Requirements: Volume 11 P r a c t i -c a l P l a n n i n g Manual, DHEW P u b l i c a t i o n No. (HRA) 76-14512, 1976, p. 50. h e a l t h c a r e r e q u i r e d — are ve r y s a t i s f y i n g f o r h e a l t h r e s o u r c e s p l a n n e r s . One can e a s i l y con-c e p t u a l i z e the a n a l y t i c a l framework: t y p e s o f h e a l t h c o n d i t i o n s , such as a c u t e , c h r o n i c , p r e v e n t i v e ; r e -q u i r e d t y p e s o f c a r e , such as a m b u l a t o r y , h o s p i t a l -b a sed, l o n g - t e r m ; h e a l t h o c c u p a t i o n s p r o v i d i n g the c a r e , such as p h y s i c i a n s , n u r s e s , t h e r a p i s t s . When the community's needs are the p r o p e r c r i t e r i a , and d a t a on h e a l t h s t a t u s and a p p r o p r i a t e t r e a t m e n t are o b t a i n a b l e , t h i s approach i s e x c e l l e n t . The p l a n n e r s h o u l d be aware t h a t the t e c h n i c a l d i f f i c u l t i e s i n d e f i n i n g and q u a n t i f y i n g h e a l t h needs, " a c c e p t a b l e " modes o f care and manpower's output are f o r m i d a b l e . P r o f e s s i o n a l s do not agr e e ; the h e a l t h s t a t u s o f a p o p u l a t i o n changes over t i m e ; m e d i c a l p r a c t i c e advances; assignments o f r e s p o n s -i b i l i t y and f u n c t i o n s o f h e a l t h o c c u p a t i o n s h i f t ; and l a s t , but not l e a s t , p u b l i s h e d s t a t i s t i c s are out o f d a t e , i n a p p l i c a b l e o r i n c o m p l e t e . Most s e r i o u s o f a l l , c r i t i c i s m i s d i r e c t e d at the method's f a i l u r e t o ta k e i n t o account the pa-t i e n t ' s w i l l i n g n e s s t o seek care and the community's a b i l i t y t o pay f o r h e a l t h s e r v i c e s . The assumption i s t h a t t h e r e are no f i n a n c i a l , p s y c h o l o g i c a l o r s o c i a l c o n s t r a i n t s t o s e e k i n g c a r e . The concept o f "demand as need" has the...inherent danger o f 5.6 o v e r e s t i m a t i n g manpower requirements.22 The m e t h o d o l o g i c a l and p r a c t i c a l d i f f i c u l t -i e s i n h e r e n t i n t h i s approach l i m i t i t s use t o t i g h t l y c o n t r o l l e d h e a l t h systems w i t h an e l a b o r a t e s t a t i s t i c a l base. L i t t l e i s kno'wn about how v a r i -ous h e a l t h manpower "mixes" i n d i f f e r e n t n a t i o n s r e -l a t e t o the p r e v a l e n t m o r b i d i t y i n the p o p u l a t i o n , and about the r e l a t i v e e f f e c t i v e n e s s o f the s e s y s -tems i n a l l e v i a t i n g disease.23 The approach i s comp-l i c a t e d , c o s t l y , r e q u i r e s s o p h i s t i c a t e d d a t a , and i s apt t o r e s u l t i n c o s t l y p r o j e c t i o n s o f ^ s e r v i c e r e -quirements f a r i n exc e s s o f a b i l i t y t o p p r o v i d e them. ECONOMIC (EFFECTIVE) DEMAND APPROACH The economic ( e f f e c t i v e ) demand approach con-s i d e r s what h e a l t h s e r v i c e s are I n d i v i d u a l s and/or the government w i l l i n g and a b l e to^pay f o r ? T h i s d e t e r m i n a t i o n i s g e n e r a l l y based on p a s t and p r e s -ent p a t t e r n s o f h e a l t h e x p e n d i t u r e s . 2 ^ 2^U.S. Department o f H e a l t h , E d u c a t i o n , and W e l f a r e , Bureau o f H e a l t h P l a n n i n g and Resource Development, M e t h o d o l o g i c a l Approaches f o r D e t e r m i n i n g H e a l t h  Manpower Supply and Requirements: Volume 11 P r a c t -i c a l P l a n n i n g Manual, DHEW P u b l i c a t i o n No. (HRA) 76-14512, 1976, p. 55. 23world H e a l t h O r g a n i z a t i o n , T e c h n i c a l Report S e r i e s No. 481, The Development o f S t u d i e s i n H e a l t h Man- power (Geneva, S w i t z e r l a n d : World H e a l t h O r g a n i z a -t i o n , 1971) p. 17. 2^World H e a l t h O r g a n i z a t i o n , Pan American C o n f e r - ence on H e a l t h Manpower P l a n n i n g , (Washington, D.C., 1973, p. 62. Manpower requirements are d e r i v e d from an e s t i -mate of the m o n i e s • a v a i l a b l e from a l l sources to pay f o r care, i n c l u d i n g wages and s a l a r i e s , or from an estimate of the s e r v i c e s consumers are w i l l i n g to buy, t a k i n g i n t o account the tasks performed and the p r o d u c t i v i t y of h e a l t h p e r s o n n e l . E f f e c t -i v e demand f o r manpower may be e l i c i t e d from em-p l o y e r s or a n a l y t i c a l l y deduced from h e a l t h expend-i t u r e s or s e r v i c e u t i l i z a t i o n data. Manpower requirements are d e r i v e d from an e s t i -mate of the monies a v a i l a b l e from a l l sources t o pay f o r care, i n c l u d i n g wages and s a l a r i e s , or from an estimate of the s e r v i c e s consumers are w i l l i n g to buy, t a k i n g i n t o account the tasks performed and the p r o d u c t i v i t y of h e a l t h p e r s o n n e l . E f f e c t i v e demand f o r manpower may be e l i c i t e d from employers or a n a l y t i c a l l y deduced from h e a l t h expenditures or s e r v i c e u t i l i z a t i o n data. A v a r i e t y of techniques may be used to c a l c u l a t e the economic e f f e c t i v e demand and to ' c o n v e r t t h i s demand f o r s e r v i c e s i n t o manpower requirements. A survey o f employers or an area s k i l l survey i s one approach. Another i s to analyze e m p i r i c a l evidence of the u t i l i z a t i o n of s e r v i c e s by p o p u l a t i o n groups i n r e l a t i o n to measures o f ' d i s e a s e or i l l n e s s , per-sona l income and other,.•health system determinants. The most s o p h i s t i c a t e d techniques employ mathemat-i c a l models, u s i n g r e g r e s s i o n a n a l y s i s , mathematical 58 programming and s i m u l a t i o n m e t h o d o l o g i e s . 2 5 STRENGTHS AND WEAKNESSES OF THE ECONOMIC (EFFECTIVE)  DEMAND APPROACH The s t r o n g s u i t s o f t h i s method are i t s r e l i -ance on measures o f e f f e c t i v e demand — the u t i l i z -a t i o n r a t e — and i t s d e t a i l e d study o f the behav-i o r o f groups of peopl e s e e k i n g h e a l t h c a r e . The degree o f d i s a g g r e g a t i o n i n h e r e n t i n i t h i s method p e r m i t s the p l a n n e r t o base h i s manpower e s t i m a t e on the h e a l t h c a r e demands o f each segment o f the p o p u l a t i o n , r e f l e c t i n g the c u l t u r a l and p h y s i c a l c h a r a c t e r i s t i c s of each group o f p e o p l e . T h i s e s -t i m a t e r e p r e s e n t s the change l i k e l y t o o o c c u r as a r e s u l t o f one.Important dynamic f a c t o r , namely, the change I n p o p u l a t i o n over t i m e . However, the assumption t h a t other:.important economic f a c t o r s , such as income, p r i c e and t h i r d p a r t y f i n a n c i n g , remain unchanged i s v e r y l i m i t i n g and u n l i k e l y t o r e p r e s e n t r e a l i t y . The assumption t h a t p o p u l a t i o n and the demand f o r s e r v i c e s are so r e l a t e d t h a t a change i n p o p u l a t i o n b r i n g s a p r o -p o r t i o n a t e response i n the demand f o r s e r v i c e s i s v e r y r e s t r i c t i v e and needs to'.-be v a l i d a t e d . F u r -Department o f H e a l t h , E d u c a t i o n and W e l f a r e , Bureau o f H e a l t h P l a n n i n g and Resource Development, M e t h o d o l o g i c a l Approaches f o r D e t e r m i n i n g H e a l t h  Manpower Supply and Requirements: Volume 1, A n a l y t -i c a l P e r s p e c t i v e , DHEW P u b l i c a t i o n No. (HRA) 76-14511, 1976, pp. 41-42. 59 thermore, the assumption t h a t p r e s e n t u t i l i z a t i o n p a t t e r n s are the p r o p e r s t a n d a r d f o r the f u t u r e i s q u e s t i o n a b l e . 2 ^ Other apparent weaknesses i n c l u d e a f a i l u r e of t a k i n g i n t o account the q u a l i t y o f s e r v i c e s or t h e i r r e l e v a n c e t o the h e a l t h problems o f the c o u n t r y . Even though t h i s approach i s concerned w i t h econom-i c s , i t can o f t e n be c o m p l i c a t e d , c o s t l y , and r e q u i r e e x t e n s i v e d a t a . FUNCTIONAL ANALYSIS APPROACH Based i n p a r t on the assumptions o f the c o s t -b e n e f i t and supply-and-demand approaches, f u n c t i o n a l a n a l y s e s o f h e a l t h manpower have been concerned w i t h ways i n which t h e q u a l i f i c a t i o n s o f p e r s o n n e l can be s y s t e m a t i c a l l y matched t o the r e q u i r e m e n t s o f job performance. A l t h o u g h t h e r e have beemmumerous s t u d i e s o f what d o c t o r s , n u r s e s , and a l l i e d h e a l t h workers do i n h o s p i t a l s , o f t e n s l o w i n g down the work i n the hosp-i t a l — the r e l a t i o n s h i p between the t a s k s p e r -formed and t h e i r u l t i m a t e purpose has r a r e l y been e x p l o r e d , and the e x t e n t t o which programs have been d e s i g n e d o r systems r e d e s i g n e d as a r e s u l t o f 2 f % . S . Department o f H e a l t h , E d u c a t i o n and W e l f a r e , Bureau o f H e a l t h P l a n n i n g and Resource Development, M e t h o d o l o g i c a l Approaches f o r D e t e r m i n i n g H e a l t h  Manpower Supply and Requirements: Volume 11 P r a c t i c a l P l a n n i n g Manual, DHEW Pub.No.(HRA) 76-14512,1976, p.71. 6.0 a c t i v i t y s t u d i e s i s not known. A n a l y s i s of the a c t i v i t i e s and f u n c t i o n s of h e a l t h workers a l s o presupposes an e s t a b l i s h e d work r o u t i n e and o f t e n a high l e v e l of s k i l l i n sampling to allow f o r i n s t i t u t i o n a l and temporal ( d a i l y and seasonal) v a r i a t i o n s — c o n d i t i o n s t h a t are seldom met. Where they are met, i t may not always be necessary to repeat such s t u d i e s i n de-t a i l because of the growing s i m i l a r i t y i n work r o u t -i n e s . In other i n s t a n c e s , i t may be more important to i n c r e a s e the o v e r a l l l e v e l of p r o f i c i e n c y i - t h a n to develop e x t e n s i v e p r o f i l e s of a c t i v i t i e s . Con-d i t i o n s vary g r e a t l y a c c o r d i n g to the type of h e a l t h worker concerned; f o r some c a t e g o r i e s r e l a t i v e l y few s t u d i e s have been undertaken as y e t , and none has been thoroughly s t u d i e d from the viewpoint of the f u n c t i o n a l d i v i s i o n of l a b o r i n a g i v e n s e t t i n g . Another problem i n f u n c t i o n a l and a c t i v i t y a n a l -yses of h e a l t h workers i s to decide what norms to use i n e v a l u a t i o n , how to e s t a b l i s h them, and who should c o l l e c t the i n f o r m a t i o n . Data c o l l e c t i o n procedures used have i n c l u d e d s e l f - c o m p l e t e d t o t a l estimates of a c t i v i t i e s , continuous s e l f - l o g g i n g of a c t i v i t i e s f o r a s p e c i f i e d time, a "shadowing" or o b s e r v a t i o n a l approach by an o u t s i d e observer, and p e r i o d i c spot checks on a c t i v i t i e s . These approaches may y i e l d d i f f e r e n t p r o f i l e s of•• work r o u t i n e s , and where two or more have been undertaken s i d e by s i d e , there has 61 not o f t e n been a high c o r r e l a t i o n of r e s u l t s . 2 7 USE OF MODELS APPROACH The uses and l i m i t a t i o n s of models i n h e a l t h manpower pl a n n i n g i s only beginning to develop. In essence, a model i s a low-cost and r e a d i l y modi-f i a b l e s u b s t i t u t e f o r the r e a l t t h i n g . To the ex-t e n t that the v a r i a b l e s used w i t h i n the model ac-c u r a t e l y r e f l e c t and encompass the most important components of"'the system under c o n s i d e r a t i o n , wheth-er the system be a h e a l t h c e n t e r , h o s p i t a l , h e a l t h r e g i o n or h e a l t h s e c t o r , m a n i p u l a t i o n o f one or more v a r i a b l e s can g i v e the planner or a d m i n i s t r a t -or important i n d i c a t i o n s as to how the r e s t of the s y s t e m . w i l l r e a c t . In t h i s way, i t i s p o s s i b l e to assess the i m p l i c a t i o n s f o r the system of a l t e r -n a t i v e h e a l t h p o l i c i e s . Although e x t e n s i v e l y used i n other d i s c i p l i n e s , p a r t i c u l a r l y i n e n g i n e e r i n g , economics, and the p h y s i c a l and mathematical s c i e n c e s , models have not yet been widely a p p l i e d i n the h e a l t h s e c t o r . The types of model t h a t have so f a r been used i n c l u d e m o r b i d i t y models, demographic demand models,queue-i n g models, and Markovian models. The i n f o r m a t i o n 2?World Health O r g a n i z a t i o n , T e c h n i c a l Report S e r i e s No. 481, The Development of Studies i n H e a l t h Man-power (Geneva, S w i t z e r l a n d : World Health O r g a n i z a t i o n , 197D , p. 18. 62 base f o r a model may be o b t a i n e d d i r e c t l y from the •system • t h a t I s under study ( e . g . , m o r b i d i t y r a t e s , u t i l i z a t i o n r a t e s )•••-• o r , i n the absence o f o t h e r s o u r c e s , may r e p r e s e n t l i t t l e more than i n f o r m e d e s t i m a t e s . I n . e i t h e r e v e n t , the f i n a l model w i l l be no more a c c u r a t e t h a n the d a t a used, so i t i s i m p o r t a n t t o c o n s i d e r not o n l y the a b s o l u t e v a l u e s o f t h e s e d a t a , but a l s o the p r o b a b l e margin o f e r r o r . By examining a l t e r n a t i v e models based on the upper and lower l i m i t s ofT.the more i m p o r t a n t d a t a i t e m s , the p l a n n e r can a p p r e c i a t e the p o t e n -t i a l margin o f e r r o r o f the f i n a l r e s u l t s . Models have been used i n c r e a s i n g l y i n t h e gen-e r a l f i e l d o f manpower p l a n n i n g , and on o c c a s i o n i n h e a l t h manpower s t u d i e s . U s u a l l y , o n l y a p o r t i o n o f the h e a l t h s e c t o r i s i n c l u d e d i n the model; i t i s e v i d e n t t h a t much r e f i n e m e n t and a d d i t i o n a l ex-p e r i e n c e w i l l be n e c e s s a r y b e f o r e the maximum po-t e n t i a l o f models can be r e a l i z e d . ^ 8 Table One (pages 6 3 - 6 4 ) o f f e r s a comparison. o f the f o u r most common approaches t o h e a l t h manpower p l a n n i n g . The name and d e s c r i p t i o n o f each method i s g i v e n a l o n g w i t h advantages and d i s a d v a n t a g e s . 2 9 w o r l d H e a l t h O r g a n i z a t i o n , T e c h n i c a l Report S e r i e s No. 481, The Development o f S t u d i e s i n H e a l t h Man-power, (Geneva, S w i t z e r l a n d : World H e a l t h O r g a n i z a -t i o n , 1971), pp. 18-19. 63 P r e r e q u i s i t e s and a p p r o p r i a t e s i t u a t i o n s where each method should be used are i n c l u d e d i n the t a b l e . 2 9 29Thomas L. H a l l , E s t i m a t i n g Requirements and Supply: Where Do We Stand, Address g i v e n at Pan American Con-ference on Health Manpower Planning, 10-14 September 1973, Ottawa, Canada, P u b l i s h e d by World Health Or-g a n i z a t i o n , Washington, D.C. 1974, pp. 64-65-Table I Ma.ior Methods f o r A s s e s s i n g and P r o j e c t i n g Manpower Requirements. 29.  Name and description of the method'/, principal variants Potential advantages Potential disadvantages Prerequisites and appropriate country situations Health manpower: population ratios (ratio method); This method involves the identification of a suitable health manpower: population ratio for a future point in time and then the applica-tion of this ratio to the projected population to derive manpower requirements. Many different methods have been used to derive the desired ratios. These include: 1. International comparisons. 2. Maintaining the current, situation. 3. Use of "recognized" standards. 4. Adoption of the ratio currently observed in a favored portion of the country. 5. Construction of a model using one of the other methods, conversion of the require-ments into a ratio, and adoption of this as the standard. 6. Extrapolation of past ratio trend lines. Easy to use and to interpret. Data requirements usually modest and not very sensitive to errors within the validity of the underlying assumptions. If current situation is judged adequate, main-tenance of status quo is a defensible policy. Easy to select unrealistic ratios resulting in major errors in economic and manpower policies. Tends to be used with single occupational categories with risk of ignoring potential improvements in utilization through changed interpersonnel ratios. Some methods of selecting a ratio cannot help but show a manpower shortage. Provides little insight into the dynamics of demand. With primary emphasis on manpower, little attention may be given to services (kind, quality, volume, frequency, distribution, and relevance). Realism and candor, even more than with the other methods. Of greatest use in countries with: public or private sectors; reasonably adequate health services delivery system, and health situation; limited planning resources; passive or active health policies, though the latter requires fairly strong control over the health system. Service targets approach {normative approach): This method emphasizes the development of detailed standards for the provision of different kinds of services, standards which are then used to derive targets for the production of these services. Manpower staffing and pro-ductivity standards are then used to convert service targets into the manpower required to attain them. Various methods can be used to develop the service standards, including those used in the health needs and to a lesser extent, the manpower: population ratio methods. Other techniques for developing standards include: 1. Task and functional analysis. 2. Empirical experience. 3. Professional judgment. 4. Internationally recommended standards. 5. International comparisons. Permits a disaggregated approach in which thv; most suitable methods and standards are used for each component activity of the sector. With primary emphasis on "services," not "manpower," attention is naturally directed toward productivity, interpersonnel ratios and efficient resource utilization. Facilitates closer adjustment of delivery to needs and demands. Relatively easy to interpret rationale to others. Cost estimation relatively easy. Method is prone to having standards based more on desires than on reality, leading to major policy errors. The logic of the method invites excessively detailed planning for segments of the sector not subject to tight control. Modest data and planning capability require-ments. Of greatest use in countries with: dominant public sector: activist government policies toward development and provision of health services; adequate governmental control over health services delivery system. Can be readily used in conjunction with other methods. 29 Source: Thomas L. H a l l , E s t i m a t i n g Requirements and Sup p l y : Where Do We S t a n d , Address g i v e n at Pan American Conference on H e a l t h Manpower P l a n n i n g , 10 - 14 Sept-ember 1973, Ottawa, Canada. P u b l i s h e d by World H e a l t h O r g a n i z a t i o n , Washington, D.C. 1974, 6 4 - 6 5 . Table I ( c o n t i n u e d ) Major Methods f o r A s s e s s i n g and P r o j e c t i n g Manpower Requirements 29 Name and description of the method's principal variants Potential advantages Potential disadvantages Prerequisites and appropriate country situations Economic demand (or, "effective economic demand"): This method concerns the measure-ment and projection of what health services people are willing and able to pay for, irrespec-tive of the quality of the specific services obtained or of their need for them. The services demanded tend to be curative in nature and to be provided predominantly through the private sector, with or without the intervention of third party reimbursement mechanisms. The method consists of correlating the receipt of services with selected economic and other vari-ables, and then of projecting the changes likely to occur regarding these variables in order to derive the impact of theae changes on the demand for services, and ultimately on health manpower requirements. Variants include: 1. Constant utilization rates for a changing population. 2. Population and income. 3. Trend in expenditures. 4. Job vacancies. 5. Relative earnings. 6. Rate of return. Helps describe dynamics and determinants of health services utilization. Tends to produce economically realistic projections. Allows for disaggregation of various com-ponents of demand. Probably provides a good estimate of the minimum growth in demand and ensures that the level of future satisfaction at least equals present satisfaction. Some variants of this approach are quite simple. May provide useful information for comparing returns from training for health occupations with those of other sectors. May be complicated, costly and require sophisticated data. Ignores many political and societal reasons for improving the distribution of health services. Does not necessarily take into account the quality of services or their relevance to the health problems of the country. May neglect consideration of ways to improve manpower productivity. Hard to interpret to health sector authorities and to the public. Requires sophisticated data and technical expertise in some cases. Of greatest use in countries with: large private sector; relatively limited and/or passive govern-ment involvement in the provision of health services; relatively small urban-rural, rich-poor, and other imbalances in the utilization rate of services. Can usefully com piemen t other methods of manpower estimation. Health needs (or, biologic needs): This method seeks to determine, based on expert opinion and taking into account available technology, what kinds, amounts, and quality levels of services are required to attain and maintain a healthy population. Service targets are then converted into manpower requirements by means of staffing and productivity standards. Considera-tions of service costs and distribution are of secondary importance. Appealing logic of method. Permits allocation of resources where they will have greatest effect on health; can focus on ways to improve utilization. Fulfills health ethic of providing services according to need and not to social or economic condition of consumers. Provides ultimate or maximum goal for the provision of services. Particularly suited to high priority categorical programs. Complicated, costly, and requires sophisticated data. Logic of method may require excessively detailed planning and frequent updating of standards in accord with developing tech-nology. Continued wide divergence among experts on "best" methods to treat many disease con-ditions. Apt to result in costly projections of service requirements, far in excess of ability to provide them. Presupposes tight governmental control over health services delivery system and high level of health consciousness in the population. Requires sophisticated data and technica expertise. Of greatest use in countries with: relatively large public sector; active government com-mitment to improving and shaping health services delivery; tight government control over health system; high level of health con-sciousness of people. Useful in defined public health or other cate-gorical health programs. 29 K i d . 66 CHAPTER I I I H o s p i t a l Manpower P l a n n i n g ( D e v e l o p i n g Manpower and S t a f -f i n g G u i d e l i n e s i n H o s p i t a l s ) 67 H o s p i t a l v i s i t s are i n c r e a s i n g at a r a t e unsur-passed i n almost every province and s t a t e i n both Canada and the United S t a t e s . Today, the h o s p i t a l i s America's f a s t e s t growing b u s i n e s s . 1 P a r a l l e l with t h i s i s the r i s i n g cost of *: s u p p l i e s , equipment, e t c . From 1966 to 1977, the cost of a p a i r of band-age s c i s s o r s almost t r i p l e d , from $5.00 to $ 1 4 . 0 0 . H o s p i t a l and h e a l t h care personnel are no e x c e p t i o n . Between 75 and 80 per cent of a h o s p i t a l ' s budget goes to s t a f f s a l a r i e s and p a i d working hours i n the h o s p i t a l . 3 The cost of l a b o r i n h o s p i t a l s has r i s e n s h a r p l y over the past ten years. The s t a r t i n g s a l a r y f o r a Nursing A s s i s t a n t working f o r the V e t -erans A d m i n i s t r a t i o n H o s p i t a l System (America's l a r g e s t chain of h o s p i t a l s ) i n 1968 was $5,565.00. Today, that f i g u r e reads $10 ,049 .00. Ten years ago, a D i e t i t i a n ' s s t a r t i n g s a l a r y was $6,734.00. Today,. D i e t i t i a n s s t a r t between $13,925.00 and $17,035 . 00 . ^ The cost has n e a r l y doubled duri n g the past decade. 1 H o s p i t a l A f f i l i a t e s I n t e r n a t i o n a l , Inc., "How to . Cope with Running the Toughest Business i n America," Tr u s t e e , May 1 9 7 8 , V o l . 3 1 , No, 5, p. 4 2 . 2 I b i d . 3u.S. Department of H e a l t h , Education and Welfare, S o c i a l S e c u r i t y B u l l e t i n , V o l . 4 0 , . N o . 1 , 1 9 7 7 , Wash-in g t o n , D.C: U.S. Government P r i n t i n g O f f i c e , 1 9 7 7 , p. 3 8 . ^U.S. C i v i l S e r v i c e Commission, S a l a r y Table No. 4 8 , Washington, D.C: U.S. Government P r i n t i n g O f f i c e , 1 9 8 0 . ' . 68 Not only have budgets f o r s t a f f i n c r e a s e d , but the number of s t a f f to operate a h o s p i t a l has a l s o i n c r e a s e d . As d i s c u s s e d i n Chapter One, s o p h i s t i c a t e d equipment, h o s p i t a l a c c r e d i t a t i o n , and p a t i e n t s them-se l v e s have a l l a f f e c t e d manpower and s t a f f i n g guide-l i n e s i n h o s p i t a l s . Not only.', newly b u i l t f a c i l i t i e s , but h o s p i t a l s undergoing extensive remodeling and c o n s t r u c t i o n a l s o r e q u i r e p l a n n i n g i n terms of man-power. We can take the example of a h o s p i t a l p l a n -ning to open up one or two wings or p l a n n i n g to add an e n t i r e new b u i l d i n g . The manpower planner i s faced with many d e c i s i o n s . He must know how many new p a t i e n t beds he w i l l have. He must be able to f o r e c a s t or a n t i c i p a t e the number of new lab r e q u e s t s , X-rays, e t c . t h a t the new a d d i t i o n w i l l r e q u i r e . The planner must be able to co n s i d e r how many nurses w i l l be r e q u i r e d f o r the e x t r a beds; he must know i f he w i l l need more ward o r d e r l i e s , ward c l e r k s , c l e a n i n g p e r s o n n e l , e t c . . One of the more d i f f i c u l t questions the manpower planner must co n s i d e r is,how f a s t w i l l the number of p a t i e n t s i n c r e a s e to f i l l the new beds? W i l l the i n c r e a s e be slow and begin with only a t r i c k l e of p a t i e n t s , or i s the expansion needed so much that the new beds w i l l be f i l l e d r a p i d l y ? The planner must co n s i d e r the p o s s i b i l i t y of d i f f i c u l t i e s i n r e -c r u i t i n g new s t a f f f o r the a d d i t i o n . I f - d i f f i c u l t i e s a r i s e , should the s t a f f be b u i l t up p r i o r to the open-69 ing? Should the ward - or b u i l d i n g open u n d e r - s t a f f e d and only run at p a r t c a p a c i t y ? How long w i l l i t take before a f u l l complement of s t a f f i s obtained and the h o s p i t a l i s able to operate at f u l l c a p a c i t y ? I f the planner e l e c t s to b u i l d up the s t a f f p r i o r to the opening, he must co n s i d e r the l o s s of employing s t a f f who are u n d e r - u t i l i z e d . He must not only look at the monetary f a c t o r s , but others as w e l l . I f s t a f f are t e m p o r a r i l y deployed, morale may drop and f a l s e e x p e c t a t i o n s of the f u t u r e workload may develop. Looking at the s i t u a t i o n i n another d i r e c -t i o n , i f the manpower planneroopens the new ward or b u i l d i n g without the proper number of s t a f f , he w i l l be u n d e r - u t i l i z i n g the expansion. I f the expansion took l a r g e amounts of c a p i t a l investment, the costs of u n d e r - u t i l i z i n g the expansion may outweigh the costs of employing s t a f f - p r i o r to the opening. Another problem the planner must consid e r i s the p o s s i b i l i t y of a h i g h wastage or turnover r a t e of new employees to a ward u n d e r - s t a f f e d . T h i s can.pro-duce high costs and i n e f f i c i e n c y . 5 Manpower pl a n n i n g i n h o s p i t a l s i s a v i t a l i s s u e i n today's world of h e a l t h care. With the r a p i d l y growing number of new and expanding h o s p i t a l s , and as h o s p i t a l departments become more p r o d u c t i v e , the ^ E s t i m a t i n g Manpower Requirements - A Background Paper by the U.S. Department or H e a l t h , E d u c a t i o n and Wel-f a r e , Washington, D.C: U.S. Government P r i n t i n g Of-f i c e , 1977, p. 19. 70 need i s f u r t h e r enhanced. With the i n c r e a s i n g u t i l -i z a t i o n of h o s p i t a l s by the Un i t e d States (and Can-adian) p o p u l a t i o n and the impact of Medicare f o r persons 65 years of age and over, current knowledge of the demand f o r h e a l t h manpower i n h o s p i t a l s has become c r i t i c a l . ^ The purpose of t h i s chapter i s to take a c l o s e look at manpower p l a n n i n g and the development of s t a f f i n g g u i d e l i n e s i n h o s p i t a l s . The f o l l o w i n g departments w i l l be g i v e n a t t e n t i o n : A d m i t t i n g , Business O f f i c e , D i e t a r y , Housekeeping, M e d i c a l Records, Nursing, Radiology, and S o c i a l Work. A b r i e f d e s c r i p t i o n of each department's purpose and r e s p o n s i b i l i t i e s w i l l be g i v e n . The d i s c u s s i o n on each department w i l l i n c l u d e a l i s t of f u n c t i o n s , procedures, e t c . , that one must pay a t t e n t i o n t o when e s t a b l i s h i n g manpower and s t a f f i n g g u i d e l i n e s . A l i s t of p o s s i b l e s t a f f or p o s i t i o n t i t l e s w i l l a l s o be i n c l u d e d f o r each department. The main c r i t e r i a i n developing these g u i d e l i n e s i s to develop l a b o r performance standards. This i s accomplished by l i s t i n g a l l procedures, examinations, f u n c t i o n s , e t c . , (both constant and non-constant) performed i n each department. A l i s t of f u n c t i o n s b G a r r i e J . Losee and Marion E. A l t e n d e r f e r , H e a l t h Manpower i n H o s p i t a l s , Washington, D.C: U.S. Govern-ment P r i n t i n g O f f i c e , 1970, p. 1. .71 or a c t i v i t i e s performed by c l e r i c a l , f i l e room, and r e l a t e d s t a f f i s necessary to determine s t a f f i n g needs f o r the e n t i r e t y of each department. This l i s t should i n c l u d e not only c u r r e n t a c t i v i t i e s , but goals and f u t u r e plans that may .increase or decrease f u n c t i o n s of each department. A standard completion time f o r each f u n c t i o n , t ask, examination, e t c . i s determined. Adjustments to times can be set by developing an ag-gregate standard. T h i s aggregate then becomes the standard time allowed to complete the examination, f u n c t i o n , e t c . . Time standards are.Vneeded to e s t a b l i s h guide-l i n e s and provide adequate s t a f f i n g f o r a l l workload s i t u a t i o n s . S t a f f i n g f o r peak workloads, as w e l l as other p e r i o d s i n c l u d i n g absences and v a c a t i o n s , are l i k e l y to be more accurate i f l a b o r performance stand-ards are s e t . In d e v e l o p i n g s t a f f i n g g u i d e l i n e s , the f o l l o w i n g p o s i t i o n s and tours of duty should not be overlooked to make the g u i d e l i n e s more meaningful: 1. Supervisory p e r s o n n e l 2. T e c h n i c a l s t a f f a. Weekday day s h i f t b. Weekday evening s h i f t c. Weekend s h i f t s 3. N o n - t e c h n i c a l s t a f f a. R e c e p t i o n i s t - c l e r k t y p i s t b. P i l e room personnel 72 c. T r a n s c r i p t i o n i s t A s i x to eight-week p e r i o d of studying f r e -quency data i s normal f o r job e n g i n e e r i n g p r o j e c t s i n h o s p i t a l s . ? Time standards f o r the m a j o r i t y of a c t i v i t i e s or procedures can be developed through d i r e c t o b s e r v a t i o n . Frequency data f o r lower v o l -ume f u n c t i o n s can be d e r i v e d from past records and logs t hat are maintained. Appropriate allowances w i l l probably be necessary i n c e r t a i n circumstances. Once the a c t i v i t y f r e q u e n c i e s have been determined, they are m u l t i p l i e d by the corresponding time stand-ards to determine the workload by day and s h i f t . T h i s i s then converted i n t o the a c t u a l manpower and s t a f f i n g g u i d e l i n e . "^Personnel i n t e r v i e w with L a r r y Grandia, D i r e c t o r of Management Systems, Intermountain H e a l t h Care, S a l t Lake C i t y , Utah, J u l y 6 , 1 9 7 8 . 73 THE ADMITTING DEPARTMENT The Admitting O f f i c e i s r e s p o n s i b l e f o r d e t e r -mining the p a t i e n t ' s e l i g i b i l i t y f o r admission to the h o s p i t a l . The Admitting O f f i c e evaluates each a p p l i c a n t i n terms of s t a t e d purposes of the h o s p i -t a l ; c o n t r o l s numbers of p a t i e n t s admitted and room assignments; admits p a t i e n t s to v a r i o u s s e r v i c e s promptly, g r a c i o u s l y and i n an o r d e r l y manner; main-t a i n s r e c ords o f p a t i e n t s a w a i t i n g admission and those a l r e a d y i n the h o s p i t a l ; and develops c o n f i -dence i n and understanding of a c t i v i t i e s o f t t h e h o s p i t a l by the p a t i e n t and the g e n e r a l p u b l i c . Admitting f u n c t i o n s r e v o l v e around a d m i t t i n g , t r a n s f e r r i n g , and d i s c h a r g i n g p a t i e n t s . Preadmis-s i o n r e s e r v a t i o n s f o r accommodation are made atCthe the request of a member of the medical s t a f f , except f o r emergency p a t i e n t s who are admitted i n ac c o r d -ance with e x i s t i n g p o l i c y . P e r s o n a l , f i n a n c i a l and s t a t i s t i c a l i n f o r m a t i o n are obtained from the p a t i e n t or r e l a t i v e . The p a t i e n t i s informed about a c t i v i -t i e s and r u l e s of the h o s p i t a l , and i s r e f e r r e d or es c o r t e d t o accommodations. A l l departments con-cerned with care, treatment, d i a g n o s i s , or r e c o r d -keeping are n o t i f i e d of the p a t i e n t ' s admission. I t may be the assigned r e s p o n s i b i l i t y o f the Admitting n O f f i c e to schedule use of o p e r a t i n g room f a c i l i -t i e s , and give r o u t i n e i n f o r m a t i o n concerning c o n d i t i o n of p a t i e n t s . 75 FUNCTIONS, ACTIVITIES OR PROCEDURES  ADMITTING DEPARTMENT Number o f Adm i s s i o n s Number o f C l i n i c s Number o f C l i n i c Appointments P a t i e n t s t r a n s f e r r e d t o o t h e r h o s p i t a l s Number of o u t p a t i e n t v i s i t s Number o f Emergency Room v i s i t s '76 POSITION OR STAFF TITLES  ADMITTING DEPARTMENT A d m i t t i n g S u p e r v i s o r A d m i t t i n g C l e r k s P r e - A d m i t t i n g C l e r k s S w i t c h b o a r d O p e r a t o r s C a s h i e r s C l i n i c C l e r k s S c h e d u l i n g C l e r k s 77 BUSINESS OFFICE The purpose of the Business O f f i c e i s to man-age the h o s p i t a l ' s f i n a n c i a l a c t i v i t i e s and keep a d m i n i s t r a t i o n informed of f i n a n c i a l c o n d i t i o n s f o r purposes of h o s p i t a l p l a n n i n g and c o n t r o l . The Business O f f i c e a l s o works c l o s e i n r e l a t i o n t o ad-m i t t i n g p a t i e n t s i n accordance with f i s c a l p o l i c i e s and r e g u l a t i o n s e s t a b l i s h e d by the governing auth-o r i t y of the h o s p i t a l . The Business O f f i c e i s r e s p o n s i b l e f o r the f i n -a n c i a l a c t i v i t i e s of the h o s p i t a l which encompass r e c e i p t of revenues, expenditure of funds, and con-s e r v a t i o n of h o s p i t a l a s s e t s . As a b a s i s f o r p er-forming these and r e l a t e d a d m i n i s t r a t i v e func-t i o n s , t h i s department maintains e x t e n s i v e account-i n g and s t a t i s t i c a l r e c o r d s . I t records a l l f i n a n -c i a l t r a n s a c t i o n s i n c l u d i n g c o n t r o l of cash, income and expense, purchase and d i s p o s a l of c a p i t a l a s s e t s , estimates cost of f r e e s e r v i c e rendered i n d i g e n t p a t i e n t s , and r e l a t e d t r a n s a c t i o n s . The r e s p o n s i b -i l i t y i n c l u d e s development of p a y r o l l records and payment of s a l a r i e s . Another f u n c t i o n of the Business O f f i c e i s to prepare budgets f o r ensuing f i s c a l p e r i o d s . Many f a c t o r s are considered i n the p r e p a r a t i o n of a 78 budget i n c l u d i n g estimated needs of v a r i o u s d e p a r t -ments, departmental expenses of previous p e r i o d s , a n t i c i p a t e d p a t i e n t census and income, and g e n e r a l economic and market c o n d i t i o n s . S i m i l a r l y , the Business O f f i c e i s r e s p o n s i b l e f o r p r e p a r a t i o n of r e p o r t s of departmental income and expenses, and comparisons of gross earnings and costs of revenue-producing departments. Such r e -views and r e p o r t s are of a s s i s t a n c e i n s e t t i n g r a t e s . The department i s a l s o r e s p o n s i b l e f o r p r e p a r a t i o n of a l l r e p o r t s to o u t s i d e agencies. Most important, are r e p o r t s f o r cost reimbursement purposes which can derermine the h o s p i t a l ' s f i n a n c i a l p o s i t i o n . The department may have r e s p o n s i b i l i t y f o r de-v e l o p i n g a d m i n i s t r a t i v e systems and procedures; t h i s can i n c l u d e r e s p o n s i b i l i t y f o r the data p r o c e s s i n g f u n c t i o n , i f one e x i s t s . In. most h o s p i t a l s , the Business O f f i c e has the r e s p o n s i b i l i t y f o r determining a p a t i e n t ' s a b i l i t y to pay e s t a b l i s h e d r a t e s f o r s e r v i c e s , and making necessary f i n a n c i a l adjustments i f p a t i e n t cannot meet h i s f u l l o b l i g a t i o n . T h i s c r e d i t f u n c t i o n i n -cludes the r e s p o n s i b i l i t y f o r c o l l e c t i n g unpaid b i l l s . .79 FUNCTIONS, ACTIVITIES OR PROCEDURES  BUSINESS OFFICE Vouchers p r o c e s s e d I n v o i c e s p r o c e s s e d P a y r o l l c a r d s p r o c e s s e d Pay checks p r o c e s s e d B i l l s p r o c e s s e d t o : I n d i v i d u a l s I n s u r a n c e Companies Medicare M e d i c a i d Other 80 POSITION OR STAFF TITLES  BUSINESS OFFICE C o n t r o l l e r B u s i n e s s O f f i c e Manager Manager f o r C r e d i t and C o l l e c t i o n C o l l e c t i o n C l e r k C h i e f Accountant Accountant A u d i t C l e r k Bookkeeper C a s h i e r A c c o u n t i n g C l e r k A c c o u n t s - R e c e i v a b l e C l e r k I n v o i c e - C o n t r o l C l e r k I n s u r a n c e C l e r k P a y r o l l C l e r k .81 DIETETIC DEPARTMENT The purpose o f the D i e t e t i c Department i s t o p r o v i d e complete d i e t e t i c t r e a t m e n t t o a l l p a t i e n t s , i n c l u d i n g p a t i e n t e d u c a t i o n ; and t o p l a n , p r e p a r e and s e r v e n u t r i t i o u s and a p p e t i z i n g f o o d f o r pa-t i e n t s , p e r s o n n e l and v i s i t o r s ; t o t r a i n d i e t e t i c and o t h e r h o s p i t a l p e r s o n n e l , and t o m a i n t a i n c l o s e w o r k i n g r e l a t i o n s h i p s w i t h o t h e r h o s p i t a l a c t i v i t i e s and community a g e n c i e s . R e s p o n s i b i l i t y f o r t h i s department i n c l u d e s p l a n n i n g , o r g a n i z i n g and d i r e c t i n g a l l phases o f the d i e t e t i c o p e r a t i o n which i n c l u d e s menu p l a n n i n g ; f o o d p r e p a r a t i o n and s e r v i c e ; budget e s t i m a t e s ; c o s t c o n t r o l and a d m i n i s t r a t i v e r e c o r d - k e e p i n g ; p a t i e n t e d u c a t i o n ; a n a l y s i s and a p p r a i s a l o f p e r s o n n e l r e -q u i r e m e n t s ; and s a f e t y and s a n i t a t i o n programs. The department i s r e s p o n s i b l e f o r k e e p i n g i n f o r m e d of advancements and changes i n equipment and food f o r p o s s i b l e a p p l i c a t i o n . I t i s the r e s p o n s i b i l i t y o f the D i e t e t i c D e part-ment t o s p e c i f y q u a n t i t y and q u a l i t y o f food t h r o u g h use o f commodity s p e c i f i c a t i o n s . Meals must s u p p l y b a s i c p h y s i o l o g i c a l needs and a l s o have a e s t h e t i c a p p e a l t o the p a t i e n t . F o r e f f i c i e n c y i n o p e r a t i o n s , a l l d i e t s can be b u i l t around g e n e r a l d i e t s by ad-82 d i t i o n s and m o d i f i c a t i o n s . P i l e s of r e c i p e s f o r q u a n t i t y c o o k i n g are main-t a i n e d t o f a c i l i t a t e p r e p a r a t i o n and c o s t c o n t r o l . The r e c i p e s s h o u l d c o n t a i n f o r m u l a s t o be f o l l o w e d and i n d i c a t e y i e l d s I n terms of number and s i z e o f s e r v i n g s , and c o s t s o f b o t h t o t a l r e c i p e and s i n g l e s e r v i n g s . A d i e t manual p r e p a r e d or recommended by the department and approved by the m e d i c a l s t a f f , must be a v a i l a b l e f o r use by p h y s i c i a n s and n u r s e s . Food p r e p a r a t i o n and s e r v i c e c o n s t i t u t e a l a r g e p a r t o f the work of the D i e t e t i c Department. A l l foods s h o u l d be p r e p a r e d under s t r i c t l y s a n i t a r y c o n d i t i o n s , i n accordance w i t h l o c a l and S t a t e p u b l i c h e a l t h r e g u l a t i o n s . Poods s h o u l d be p r e p a r e d p r e s e r v i n g f u l l c o l o r , f l a v o r , and n u t r i t i o n a l v a l u e ; meals s h o u l d be a t t r a c t i v e l y s e r v e d . Trays must be i n s p e c t e d so t h a t p a t i e n t s on m o d i f i e d d i e t s w i l l r e c e i v e p r o p e r meals. Dishwashing and housekeep-i n g I n main k i t c h e n , f l o o r k i t c h e n , and o t h e r d i e t -e t i c a r e a s u s u a l l y are a l s o f u n c t i o n s o f t h i s d e p a r t -ment . Another f u n c t i o n i s t h a t o f f o r m a l and i n f o r m a l e d u c a t i o n . D i e t e t i c i n t e r n s are t r a i n e d i n many h o s p i t a l s . N u r s e s , m e d i c a l and d e n t a l s t u d e n t s , and i n t e r n s and r e s i d e n t s are i n s t r u c t e d i n p r i n c -i p l e s o f n u t r i t i o n and d i e t t h e r a p y . The d e p a r t -ment i s a l s o r e s p o n s i b l e f o r t e a c h i n g p a t i e n t s and 83 t h e i r f a m i l i e s n u t r i t i o n and m o d i f i e d d i e t r e q u i r e -ments . I n f a n t f o r m u l a s may be p r e p a r e d by the D i e t -e t i c Department or p r e - p r e p a r e d f o r m u l a s purchased from vendors. Other d i e t e t i c s e r v i c e s i n c l u d e v i s i t i n g pa-t i e n t s I n n u r s i n g u n i t s t o determine t h e i r f o o d p r e f -erences b o t h as t o type o f f o o d and manner i n which i t i s p r e p a r e d ; a d v i s i n g p a t i e n t s w i t h s p e c i a l d i e t -e t i c problems p r i o r t o t h e i r d i s c h a r g e from the h o s p i t a l , or as r e f e r r e d from the o u t p a t i e n t c l i n i c ; c o o p e r a t i n g w i t h m e d i c a l s t a f f i n p l a n n i n g , p r e p a r -i n g and s e r v i n g m e t a b o l i c r e s e a r c h d i e t s . D i e t e t i c s i s an i m p o r t a n t a s p e c t o f the h o s p i t a l m e d i c a l c a r e . To be e f f e c t i v e , the D i e t e t i c D e p a r t -ment must de v e l o p a p l a n n e d program, e f f i c i e n t o r -g a n i z a t i o n and a d m i n i s t r a t i o n , and c l o s e c o o r d i n a -t i o n w i t h o t h e r h o s p i t a l a c t i v i t i e s . The program must be f l e x i b l e enough t o t a k e advantage o f c u r -r e n t developments i n m e d i c i n e , d i e t e t i c s , and the f o o d s e r v i c e i n d u s t r y . 84 FUNCTIONS, ACTIVITIES OR PROCEDURES  DIETETIC DEPARTMENT Number o f meal days p r o v i d e d by h o s p i t a l Number o f meal days purchased from p r i v a t e s o u r c e s Type o f h o s p i t a l s e r v i c e s Number o f h o s p i t a l s e r v i c e s Number o f I n t e r n s Number o f R e s i d e n t s Number o f V o l u n t e e r s Number o f D i n i n g Rooms Number o f o u t p a t i e n t s r e q u i r i n g d i e t e t i c c o u n s e l i n g Number o f i n p a t i e n t s r e q u i r i n g d i e t e t i c c o u n s e l i n g . 85 POSITION OR STAFF TITLES  DIETETIC DEPARTMENT D i r e c t o r , Food S e r v i c e s C h i e f D i e t i t i a n D i e t i t i a n - Teaching D i e t i t i a n - A d m i n i s t r a t i v e D i e t i t i a n - T h e r a p e u t i c D i e t e t i c C l e r k s Food P r o d u c t i o n S u p e r v i s o r D i n i n g S e r v i c e Manager D i n i n g S e r v i c e Worker Baker Cook S a l a d P r e p a r e r D e s s e r t P r e p a r e r P a t i e n t Food - S u p e r v i s o r P a t i e n t Food - Worker Pot Scrubber D i s h - s o r t e r and Washer 86 HOUSEKEEPING DEPARTMENT The p u r p o s e o f t h e H o u s e k e e p i n g D e p a r t m e n t i s t o m a i n t a i n t h e h o s p i t a l f a c i l i t i e s i n a c l e a n , s a n -i t a r y , o r d e r l y , and a t t r a c t i v e c o n d i t i o n ; t o p r o v i d e a s u i t a b l e e n v i r o n m e n t f o r t h e c a r e o f p a t i e n t s a n d f o r t h e work o f t h e h o s p i t a l s t a f f a n d e m p l o y e e s . C l e a n , s a n i t a r y , p l e a s a n t e n v i r o n m e n t a nd f a c -i l i t i e s a r e e s s e n t i a l t o m e d i c a l a n d n u r s i n g c a r e o f p a t i e n t s and t o h o s p i t a l s t a f f . The r e s p o n s i b i l -i t y f o r p r o v i d i n g s u c h s u r r o u n d i n g s i n as e c o n o m i c a manner as p o s s i b l e f a l l s i n a l a r g e m e a s u r e upon t h e h o u s e k e e p i n g s t a f f o f t h e h o s p i t a l . H o u s e k e e p -i n g i s a c o m p l e x a c t i v i t y r e q u i r i n g c o n s t a n t a t t e n -t i o n t o many d i f f e r e n t d e t a i l s , and t o an o v e r a l l p l a n w h i c h p r o v i d e s f o r t h e u t i l i z a t i o n o f p e r s o n n e l , p r o c e d u r e s , and m a t e r i a l i n an e f f i c i e n t and e f f e c t -i v e manner. More s p e c i f i c a l l y , r e s p o n s i b i l i t i e s o f t h e H o u s e k e e p i n g D e p a r t m e n t i n c l u d e : 1. E s t a b l i s h and m a i n t a i n a r e g u l a r l y s c h e d u l e d c l e a n i n g p r o g r a m t h r o u g h o u t t h e h o s p i t a l c o m p l e x . P a t i e n t - c a r e a r e a s , i n t e n s i v e c a r e u n i t s , s u r g i c a l s u i t e s , and o t h e r s p e c i a l i z e d a r e a s r e q u i r e t h a t a h i g h l e v e l o f s a n i t a t i o n and s t e r i l i -•87 z a t i o n be m a i n t a i n e d . 2. R e c r u i t , s e l e c t and t r a i n p e r s o n -n e l f o r t h i s p u r p o s e . 3. S t u d y new t e c h n i q u e s f o r i m p r o v i n g h o u s e k e e p i n g s e r v i c e s ; e v a l u a t e , s e l e c t , and p r o v i d e p r o p e r e q u i p m e n t and s u p p l i e s f o r e f f i c i e n t and e c o n o m i c a l o p e r a t i o n o f t h e h o u s e k e e p i n g s e r v i c e s . 4. P r o v i d e . q u a l i f i e d s u p e r v i s i o n a nd d i r e c t i o n t o s c h e d u l e d work a c t i v i t i e s r e s u l t i n g i n t h e most e f f e c t i v e u t i l -i z a t i o n o f manpower. 5. E s t a b l i s h a n d m a i n t a i n p r o c e d u r e s w h i c h w i l l i n s u r e a c c e p t a b l e s t a n d a r d s o f q u a l -i t y . T h i s i n c l u d e s r o u t i n e c l e a n i n g o f w i n d o w s , w a l l s , f l o o r s , f i x t u r e s , a n d f u r -n i s h i n g s , as w e l l as r e s p o n s i b i l i t y f o r d i s p o s a l o f o r d i n a r y and c o n t a m i n a t e d r e f u s e ; d i s i n f e c t i o n o f c o n t a m i n a t e d a r e a s ; p e s t a nd r o d e n t c o n t r o l ; t a k i n g b a c t e r i o l o g i c a l s u r f a c e s a m p l i n g s ; and c a r r y i n g o u t p e r t i n e n t i n f e c t i o n - c o n t r o l p r o c e d u r e s . 6. U t i l i z e g o o d i n t e r i o r d e s i g n p r i n c -i p l e s w i t h r e g a r d t o d e c o r a t i n g and c h o i c e o f f u r n i t u r e a n d f u r n i s h i n g s , a nd a t t e n d t o f u r n i t u r e r e p a i r s , r e f i n i s h i n g , a n d u p h o l s t e r i n g , o r r e p l a c e m e n t o f e q u i p m e n t 88 and s u p p l i e s . May move and r e l o c a t e f u r n i t u r e . 7. M a i n t a i n l i n e n s e l e c t i o n , d i s t r i b u -t i o n , c o n t r o l and r e p a i r . 8. Be aware of common s a f e t y p r e c a u -t i o n s and c o r r e c t or r e p o r t s a f e t y h a z ards t o the c o r r e c t a u t h o r i t y . 9. C o o r d i n a t e department a c t i v i t i e s w i t h those o f a l l o t h e r departments. 10. Report b u i l d i n g r e p a i r needs t o the E n g i n e e r i n g and Maintenance Department. The Housekeeping Department may a l s o be r e s p o n s -i b l e f o r the f o l l o w i n g s e r v i c e s : h o s p i t a l s e c u r i t y ; e l e v a t o r o p e r a t i o n ; o p e r a t i o n o f the l a u n d r y ; and c o n t r o l o f s e r v i c e c o n t r a c t s f o r s e r v i c e s p r o v i d e d by n o n - h o s p i t a l p e r s o n n e l . §9 FUNCTIONS, ACTIVITIES OR PROCEDURES  HOUSEKEEPING DEPARTMENT Number o f square f o o t a g e Frequency o f c l e a n i n g Types o f c l e a n i n g : Dust mop Damp mop Waxing Vacuum P o l i s h i n g S i z e and number o f i n d i v i d u a l o f f i c e s S i z e and number o f c o r r i d o r s Number o f windows Number o f r e s t rooms Number o f bed changes and c l e a n i n g S i z e and f r e q u e n c y o f w a l l washing Number o f s t a f f d r e s s i n g rooms Frequency and areas where p e s t c o n t r o l i s un d e r t a k e n ,90 POSITION QR STAFF TITLES  HOUSEKEEPING DEPARTMENT D i r e c t o r , Housekeeping Housekeeping S u p e r v i s o r Housekeeping A t t e n d a n t Housekeeping A i d e W a l l Washer Window Washer Linen-Room Aide Seamstress Dusting-Vacuuming Aide E l e c t r i c S c r u b b e r / P o l i s h e r O p e r a t o r Pest C o n t r o l l e r Bed C l e a n e r 91 MEDICAL RECORDS DEPARTMENT The main purpose o f the M e d i c a l Records D e p a r t -ment i s t o p r o v i d e a c e n t r a l f i l e f o r m e d i c a l r e c o r d s , which document the course o f a p a t i e n t ' s i l l n e s s and tre a t m e n t d u r i n g a p a r t i c u l a r e p i s o d e as an i n p a t i e n t our o u t p a t i e n t . As suc h , i t i s an i m p o r t a n t g o a l i n the p r a c t i c e o f m e d i c i n e s i n c e i t s e r v e s as a b a s i s f o r p l a n n i n g p a t i e n t c a r e , e v a l u a t i n g c a r e , and p r o -v i d i n g a means o f communication between the p h y s i c i a n and o t h e r p r o f e s s i o n a l groups i n c o n t r i b u t i n g t o the p a t i e n t ' s c a r e . The secondary purpose may be t o p r o -t e c t the l e g a l i n t e r e s t s o f the h o s p i t a l and the p h y s i -c i a n , and t o p r o v i d e c l i n i c a l d a t a o f i n t e r e s t t o r e -s e a r c h e r s and c l i n i c a l d a t a r e s e a r c h systems. The department i s r e s p o n s i b l e f o r m a i n t a i n i n g a m e d i c a l r e c o r d , which i s a complete case h i s t o r y or w r i t t e n r e p o r t p e r t a i n i n g t o each p a t i e n t . The r e c o r d s h o u l d i n c l u d e I d e n t i f i c a t i o n d a t a , c h i e f c o m p l a i n t , past m e d i c a l h i s t o r y , f a m i l y h i s t o r y , h i s t o r y o f p r e s e n t i l l n e s s , r e s u l t s o f p h y s i c a l e x a m i n a t i o n , and p r o v i s i o n a l d i a g n o s i s ; c o n s u l t a -t i o n s and o t h e r s p e c i a l r e p o r t s ; c l i n i c a l l a b o r -a t o r y , p a t h o l o g y , and X^ray f i n d i n g s ; m e d i c a l and s u r g i c a l t r e a t m e n t ; p h y s i c i a n s ' o r d e r s ; p r o g r e s s n o t e s ; f i n a l d i a g n o s i s ; c o n d i t i o n on d i s c h a r g e and .92 f o l l o w u p r e c o r d s ; r e p o r t of a u t o p s y , i f pe r f o r m e d ; and n u r s e s - g r a p h i c c h a r t s . The department r e c e i v e s the m e d i c a l r e c o r d s , performs a q u a n t i t a t i v e a n a l y s i s on the c o n t e n t , and r e f e r s i n c o m p l e t e r e c o r d s t o r e s p o n s i b l e phy-s i c i a n or department head f o r c o m p l e t i o n . I t a l s o r e v i e w s c l i n i c a l r e c o r d s r e c e i v e d from p a t i e n t s t r a n s f e r r e d from o t h e r h o s p i t a l s and r e c o r d s r e -c e i v e d from p a t i e n t s t r a n s f e r r e d from o t h e r h o s p i -t a l s , a n d i n i t i a t e s a c t i o n t o o b t a i n m i s s i n g d a t a . The department m a i n t a i n s and i n d e x e s r e c o r d s i n accordance w i t h s t a n d a r d s e s t a b l i s h e d by the J o i n t Commission on A c c r e d i t a t i o n o f H o s p i t a l s of the American H o s p i t a l A s s o c i a t i o n . These i n c l u d e a p a t i e n t s i n d e x , f i l e d a l p h a b e t i c a l l y by p a t i e n t s ' names, c o n t a i n i n g name o f the p a t i e n t , a t t e n d i n g p h y s i c i a n , date o f a d m i s s i o n and f i l e number; i n d e x o f d i s e a s e s , f i l e d a c c o r d i n g t o the St a n d a r d Nomen-c l a t u r e o f D i s e a s e s and O p e r a t i o n s , or by an o t h e r a c c e p t e d system; i n d e x o f o p e r a t i o n s , which p e r m i t s study o f a l l p a t i e n t s i n the h o s p i t a l f o r any spec-i f i c type o f o p e r a t i o n ; p h y s i c i a n s ' i n d e x , c o n t a i n -i n g p h y s i c i a n ' s name, f i l e number o f the p a t i e n t , and end r e s u l t s ; and an i n d e x o f end r e s u l t s which can be a r r a n g e d a c c o r d i n g t o c l a s s i f i c a t i o n s such as e l e c t i v e , emergency, and p a l l i a t i v e . The M e d i c a l Records Department p r o v i d e s a n a l y s i s and t e c h n i c a l e v a l u a t i o n o f c l i n i c a l r e c o r d s . A l s o , '93 i t I s a s s i g n e d the f u n c t i o n o f p r e p a r i n g a d a i l y c ensus, as w e l l as monthly and a n n u a l s t a t i s t i c a l r e p o r t s o f s e r v i c e s t o p a t i e n t s , i n o r d e r t o a s s i s t the s t a f f i n e v a l u a t i o n and i m p r o v i n g p r o f e s s i o n a l work of the h o s p i t a l . The department may make group s t u d i e s o f d i s e a s e s and c o l l e c t s c i e n t i f i c d a t a from l i t e r a t u r e f o r use by the m e d i c a l s t a f f . I n a d d i -t i o n , s i n c e the m e d i c a l r e c o r d has g r e a t v a l u e i n l e g a l defense t o b o t h p h y s i c i a n and h o s p i t a l , the l i b r a r i a n i s o c c a s i o n a l l y c a l l e d t o p r e s e n t m e d i c a l r e c o r d s i n c o u r t . 94 FUNCTIONS, ACTIVITIES OR PROCEDURES MEDICAL RECORDS DEPARTMENT Number o f p a t i e n t s a d m i t t e d Number o f p a t i e n t s d i s c h a r g e d Number o f r e c o r d s r e q u e s t e d Number o f r e s e a r c h r e q u e s t s System o f r e c o r d k e e p i n g System o f c o d i n g r e c o r d s System o f m a i n t a i n i n g s t a t i s t i c s L e n g t h o f s t a y on each p a t i e n t Number o f exams, t e s t s , e t c . performed on each p a t i e n t Number o f r e q u e s t s f o r r e c o r d s by: I n d i v i d u a l s Law f i r m s I n s u r a n c e companies P h y s i c i a n s Other 95 POSITION OR STAFF TITLES  MEDICAL RECORDS DEPARTMENT M e d i c a l Record L i b r a r i a n M e d i c a l Record T e c h n i c i a n M e d i c a l Record C l e r k T r a n s c r i p t i o n S u p e r v i s o r M e d i c a l T r a n s c r i p t i o n i s t F i l e Room S u p e r v i s o r F i l e Room C l e r k Correspondence C l e r k A b s t r a c t C l e r k Coding C l e r k I n s u r a n c e C l e r k M i c r o f i l m S u p e r v i s o r M i c r o f i l m C l e r k 96 NURSING SERVICE DEPARTMENT The purpose o f N u r s i n g S e r v i c e i s t o p r o v i d e s a f e , e f f i c i e n t and t h e r a p e u t i c a l l y e f f e c t i v e n u r s -i n g care . The b a s i c r e s p o n s i b i l i t y o f the department i s t o care f o r the p a t i e n t . The N u r s i n g S e r v i c e De-partment c a r r i e s out i t s f u n c t i o n s a c c o r d i n g t o the p h i l o s o p h y , o b j e c t i v e s and p o l i c i e s o f the h o s p i t a l e s t a b l i s h e d by the g o v e r n i n g a u t h o r i t y . W i t h i n t h i s framework the department's f u n c t i o n s i n c l u d e : 1. To p r o v i d e and e v a l u a t e n u r s i n g s e r v i c e f o r p a t i e n t s and t h e i r f a m i l i e s i n support o f m e d i c a l c a r e , as d i r e c t e d by the m e d i c a l s t a f f . 2. To d e f i n e and c a r r y out the p h i l o -sophy, o b j e c t i v e s , p o l i c i e s and s t a n d -a r ds f o r n u r s i n g care o f p a t i e n t s and r e l a t e d n u r s i n g s e r v i c e s . 3. To p r o v i d e and implement a department-a l p l a n o f a d m i n i s t r a t i v e a u t h o r i t y which c l e a r l y d e l i n e a t e s r e s p o n s i b i l i t i e s and d u t i e s of each c a t e g o r y of n u r s i n g p e r s o n -n e l . 4. To c o o r d i n a t e the department's f u n c t i o n s 97 w i t h the f u n c t i o n s o f a l l o t h e r h o s p i -t a l departments and s e r v i c e s . 5. To e s t i m a t e the department's r e q u i r e -ments and t o recommend p o l i c i e s and p r o -cedures t o m a i n t a i n an adequate and comp-e t e n t n u r s i n g s t a f f . 6. To p r o v i d e the means and methods by which the n u r s i n g p e r s o n n e l can work w i t h o t h e r groups i n i n t e r p r e t i n g the o b j e c t i v e s o f the h o s p i t a l and n u r s i n g s e r v i c e t o the p a t i e n t and community. 7. To p a r t i c i p a t e i n the f o r m u l a t i o n o f p e r s o n n e l p o l i c i e s , i n t e r p r e t e s t a b -l i s h e d p o l i c i e s , and e v a l u a t e t h e i r e f f e c t -i v e n e s s . 8. To develop and m a i n t a i n an e f f e c t i v e system o f c l i n i c a l and a d m i n i s t r a t i v e n u r s i n g r e c o r d s and r e p o r t s . 9. To e s t i m a t e needs f o r f a c i l i t i e s , s u p p l i e s and equipment, and t o e s t a b -l i s h an e v a l u a t i o n and c o n t r o l system. 10. To p a r t i c i p a t e i n and adhere t o the f i n a n c i a l p l a n o f o p e r a t i o n o f the h o s p i -t a l . 1 1 . To i n i t a t e , u t i l i z e and/or p a r t i c i p a t e i n s t u d i e s o r r e s e a r c h p r o j e c t s f o r improv-i n g p a t i e n t care and o t h e r a d m i n i s t r a t i v e and h o s p i t a l s e r v i c e s . •9;8 12. To p r o v i d e and execute a program o f con-t i n u i n g e d u c a t i o n f o r a l l n u r s i n g p e r s o n n e l . 13. To p a r t i c i p a t e i n and/or f a c i l i t a t e a l l e d u c a t i o n a l programs which i n c l u d e s t u d e n t e x p e r i e n c e s i n the N u r s i n g S e r v i c e D e p a r t -ment . The s p e c i a l n u r s i n g u n i t s i n the N u r s i n g S e r v i c e Department u s u a l l y i n c l u d e m e d i c a l , s u r g i c a l , p e d i -a t r i c , o b s t e t r i c , and p s y c h i a t r i c . I n a d d i t i o n t o the o v e r a l l r e s p o n s i b i l i t i e s and f u n c t i o n s o f n u r s -i n g s e r v i c e , the u n i t s a l s o c a r r y more s p e c i f i c r e -s p o n s i b i l i t i e s and f u n c t i o n s o f p a t i e n t c a r e , v a r y -i n g w i t h each n u r s i n g u n i t . The e s t a b l i s h m e n t and e x e c u t i o n o f e d u c a t i o n a l programs f o r s t a f f and s t u -dent n u r s e s are f u n c t i o n s o f the s e s p e c i a l n u r s i n g u n i t s . M e d i c a l and S u r g i c a l : N u r s i n g care i s p r o v i d e d i n m e d i c a l and s u r g i c a l u n i t s i n accordance w i t h p h y s i c i a n ' s i n s t r u c t i o n s and r e c o g n i z e d t e c h n i q u e s and p r o c e d u r e s . While m e d i c a l c o n d i t i o n s are not e a s i l y d i v i d e d i n t o d i s t i n c t c a t e g o r i e s , m e d i c a l n u r s i n g i s c o n s i d e r e d a s p e c i a l t y i n t h a t normal and abnormal r e a c t i o n s o r symptoms o f d i a g n o s e d d i s e a s e s must be r e c o g n i z e d and r e p o r t e d . The p a t i e n t w i t h a s t r o k e o r a c a r d i a c c o n d i t i o n r e q u i r e s a much d i f f e r e n t type o f n u r s i n g from t h a t g i v e n the p a t i e n t w i t h an u l c e r o r d i a b e t e s . S u r g i c a l p a t i e n t s a l s o r e q u i r e s p e c i a l p r e - o p e r a t i v e and p o s t - o p e r a t i v e 9S care . • P e d i a t r i c s : T h i s s e r v i c e embraces the care o f c h i l d r e n . Care of the newborn i s u s u a l l y i n a sep-a r a t e u n i t l o c a t e d i n the o b s t e t r i c u n i t . The a c t -i v i t i e s o f the p e d i a t r i c u n i t r e q u i r e u n d e r s t a n d i n g o f the unique needs, f e a r s and b e h a v i o r o f c h i l d r e n , which i s r e f l e c t e d i n the type and degree of n u r s i n g care g i v e n . Where i l l n e s s e s r e q u i r e p r o t r a c t e d con-v a l e s c e n c e , e d u c a t i o n a l and o c c u p a t i o n a l t h e r a p y be-come concerns of the n u r s i n g s e r v i c e . R e l a t i o n s h i p s w i t h p a r e n t s pose f u r t h e r i m p o r t a n t r e s p o n s i b i l i t i e s . O b s t e t r i c s : P r e n a t a l c a r e , o b s e r v a t i o n and com-f o r t o f p a t i e n t s i n l a b o r ; d e l i v e r y room a s s i s t a n c e ; and care o f mother a f t e r d e l i v e r y , as w e l l as n u r s i n g care o f the newborn, are i m p o r t a n t r e s p o n s i b i l i t i e s of t h i s u n i t . O b s t e t r i c n u r s e s a s s i s t i n i n s t r u c t -i n g new mothers i n p o s t - . n a t a l care and care of 1 t h e newborn. Care o f t t h e newborn, p a r t i c u l a r l y the p r e -mature, r e q u i r e s s p e c i a l n u r s i n g s k i l l s d i c t a t e d by t h e i r unique r e q u i r e m e n t s . P s y c h i a t r i c : While most e m o t i o n a l l y d i s t u r b e d p a t i e n t s are t r e a t e d i n s p e c i a l i z e d h o s p i t a l s , the g e n e r a l h o s p i t a l a l s o r e c o g n i z e s a r e s p o n s i b i l i t y and p r o v i d e s f a c i l i t i e s f o r the m e n t a l l y i l l . N urs-i n g care o f t t h e m e n t a l l y i l l r e q u i r e s a knowledge of t h e i r v a r i o u s b e h a v i o r p a t t e r n s and how t o cope w i t h them. Techniques must be l e a r n e d f o r d e a l i n g w i t h a l l t y p e s o f problem b e h a v i o r , so t h a t s k i l l e d , t h e r -100 a p e u t i c care i s g i v e n t o such p a t i e n t s . F a m i l y and community e d u c a t i o n i s a l s o an i m p o r t a n t f u n c t i o n o f the p s y c h i a t r i c u n i t . Other s p e c i a l u n i t s w i t h i n the N u r s i n g S e r v i c e Department are O p e r a t i n g Room, Recovery Room, Emer-gency Room, and the I n t e n s i v e Care U n i t . O p e r a t i n g Room: T h i s u n i t has p r i m a r y r e s p o n s -i b i l i t y f o r c o m f o r t i n g p a t i e n t s i n the O p e r a t i n g Room; m a i n t a i n i n g a s e p t i c t e c h n i q u e s ; s c h e d u l i n g a l l o p e r a t i o n s i n c o o p e r a t i o n w i t h surgeons; and de-t e r m i n i n g t h a t adequate p e r s o n n e l , s pace, and e q u i p -ment are a v a i l a b l e . N u r s i n g p e r s o n n e l a s s i s t the surgeon d u r i n g o p e r a t i o n s and are p a r t o f the s u r g -i c a l team. P r e p a r a t i o n f o r o p e r a t i o n s i n c l u d e s s t e r -i l i z a t i o n o f In s t r u m e n t s and equipment; c l e a n i n g up a f t e r o p e r a t i o n s i s a l s o p a r t o f the u n i t ' s r e s p o n s -i b i l i t y . Recovery Room: I n many h o s p i t a l s , the Recovery Room u n i t i s an a d j u n c t r e s p o n s i b i l i t y of the Operat-i n g Room u n i t . S p e c i a l n u r s i n g a t t e n t i o n must be g i v e n p a t i e n t s a f t e r an o p e r a t i o n u n t i l t h ey have c o m p l e t e l y r e c o v e r e d from the e f f e c t s o f the anes-t h e s i a . 101 FUNCTIONS, A C T I V I T I E S OR PROCEDURES  NURSING DEPARTMENT The d e v e l o p m e n t o f manpower and. s t a f f i n g g u i d e -l i n e s i n n u r s i n g t a k e s i n s e v e r a l v a r i a b l e s . The t y p e o f h o s p i t a l ( P e d i a t r i c , P s y c h i a t r i c , Extended. C a r e , G e n e r a l M e d i c a l and S u r g e r y ) , number o f b e d s and t y p e s o f s e r v i c e s o f f e r e d a r e p r i m a r y c o n s i d e r a -t i o n s when e s t a b l i s h i n g t h e s e g u i d e l i n e s . Once, t h e t y p e o f h o s p i t a l and number o f b e d s h a v e b e e n i d e n t i -f i e d , t h e f o l l o w i n g c omponents must be c o m p l e t e d t o e n s u r e more a c c u r a t e s t a f f i n g g u i d e l i n e s : 1. D e v e l o p i n g a. p a t i e n t c l a s s i f i c a t i o n o r m i x : The n e e d f o r : . . n u r s i n g c a r e s e r v i c e s d e pends on t h e t y p e o f p a t i e n t . A g e , s e x , d i a g n o s i s and c u r r e n t i n p a t i e n t c o n d i t i o n a r e a l l v a r i -a b l e s t h a t r e l a t e t o p a t i e n t n e e d s and t h e manpower r e q u i r e m e n t s t o f u l f i l l t h e s e n e e d s . 2. D e v e l o p t i m e s t a n d a r d s : Time s t a n d a r d s s h o u l d be done i n ' ' t h e f o r m o f how many m i n -u t e s a p a r t i c u l a r n u r s e (RN, LPN, e t c . ) w i l l s p e n d on a p a t i e n t o r p a t i e n t s i n e a c h c l a s -s i f i c a t i o n d u r i n g one d a y , e v e n i n g , o r n i g h t s h i f t . 3. C o n v e r t i n g t i m e s t a n d a r d s t o manpower: Time 1Q2 st a n d a r d s are c o n v e r t e d t o the t o t a l number o f s t a f f needed by t a k i n g the t o t a l number o f minutes each nurse w i l l spend on d i f f e r e n t p a t i e n t s w i t h d i f f e r e n t c l a s s i f i c a t i o n s i n t o the a p p r o p r i a t e s t a f f l e v e l s and s k i l l s needed f o r each u n i t o r ward and on each s h i f t . The f o l l o w i n g are f u n c t i o n s , a c t i v i t i e s or p r o c e d u r e s performed by the n u r s i n g s t a f f : Ambulate, Dangle, E x e r c i s e A.M. Care A s s i s t P a t i e n t i n t o Bed, C h a i r , Commode Back Rub Bathroom A t t e n d e d Bed Change Bed Pan: Give & Empty B l o o d P r e s s u r e Check C a l l System Calming Measures Clean-up P a t i e n t Room D i a p e r : change Force F l u i d s H.S. Care I n t a k e & Output L i n e n : D i s p o s a l M e d i c a t i o n s : O r a l M e d i c a t i o n s : Subcutaneous 10 3 M e d i c a t i o n s : I n t r a m u s c u l a r M e d i c a t i o n s : I n t r a v e n o u s Nourishments: Prepare & Pass P o s i t i o n Bed Pre-Meal Care Rounds: Charge Nurse Rounds: w i t h D o c t o r R o u t i n e P a t i e n t Check Temperature, P u l s e , R e s p i r a t i o n T r a y s : Pack and P i c k - u p Turn, Cough, Deep B r e a t h U r i n a l : Give and Empty V i t a l S i g n s Check Water: D e l i v e r & R e f i l l Ace Bandage: A p p l y , Remove Wrap A d m i s s i o n o f P a t i e n t t o U n i t B a t h : Bed/Complete B a t h : B e d / P a r t i a l B a t h : Tub or S i t z / A t t e n d e d B a t h : Tub or S i t z / U n a t t e n d e d B a t h : Shower/Attended B a t h : Shower/Unattended B a t h : I n f a n t Bed Making/Occupied B i l i r u b i n L i g h t B i n d e r s B l o o d Sugar Test Blow B o t t l e s 1 0 4 B r e a s t F e e d i n g I n s t r u c t i o n s C a s t : B i V a l e C a t h e t e r : I r r i g a t i o n C a t h e t e r : Remove C a t h e t e r i z a t i o n : Female C a t h e t e r i z a t i o n : Male Check C i r c u l a t i o n of P a t i e n t Check V a l u a b l e s C i r c u m c i s i o n C i r c u m c i s i o n Care C l i n i t e s t C r i b : Change L i n e n C r i b (warmer): C l e a n i n g C o l o s t o m y - I l e o s t o m y Care Colostomy: I r r i g a t i o n C r o u p e t t e Care D e l i v e r S u p p l i e s D e r m a t i t i s Treatment D i s c h a r g e P a t i e n t ' Drainage Systems Dress P a t i e n t / I n f a n t D r e s s i n g Change: Dry D r e s s i n g Change: M o i s t Douche E l a s t i c S t o c k i n g s Emesis B a s i n Empty T r a s h Enema: D i s p o s a b l e ( F l e e t s ) 105 E x p i r a t i o n Feed: Cut and A s s i s t Feed: I n f a n t Feed: Spoon G a s t r i c A n a l y s i s Handwashing Heart M o n i t o r : setup Hemovac Hypothermia I n c o n t i n e n t Care IPPB I r r i g a t e Wound I s o l a t i o n Technique: gown, g l o v e I s o l e t t e Care I.V. : A d d i t i v e I.V. : D i s c o n t i n u e I.V. : M a i n t a i n I.V. : S t a r t L e v i n e Tube: D i s c o n t i n u e L e v i n e Tube: I r r i g a t i o n L e v i n e Tube: M a i n t a i n L e v i n e Tube: P a s s i n g & S u c t i o n Menu A s s i s t a n c e NPO: b e g i n O.B. P a c k e t : D i s t r i b u t e O r a l Hygiene Oxygen: S t a r t Oxygen: M a i n t a i n .106 Packs: C o l d I ce Packs: Hot P e l v i c Exam P e r i and Abdomen Check P e r i Care P i c t u r e s : Baby PKU T e s t i n g Post Mortem Care P o s t r i a l Drainage Prep: Surgery o r o t h e r P r o c t . Exam R e s t r a i n t : Posey B e l t s , w r i s t Shampoo Shave, F a c i a l S k i n Care Specimen C o l l e c t i o n : C l ean Catch Specimen C o l l e c t i o n : S k i n C u l t u r e Specimen C o l l e c t i o n : Sputum Specimen C o l l e c t i o n : S t o o l Specimen C o l l e c t i o n : U r i n e Specimen C o l l e c t i o n : 2k Hour U r i n e S p i n a l Tap S t o o l Specimen f o r Guaiac S u c t i o n P.R.N. Teac h i n g P a t i e n t T e l e m e t r y Temperature M o n i t o r : Setup Tracheotomy Care •10-7 T r a c t i o n : Disassemble T r a c t i o n : M a i n t a i n T r a c t i o n : Set up T r a n s f e r : Another U n i t T r a n s f e r : W i t h i n U n i t T r a n s f u s i o n T r a n s f u s i o n : Exchange T r a n s p o r t : Another Department T r a n s p o r t : Baby t o Mother T r a n s p o r t : Baby t o N u r s e r y Weigh: Baby S c a l e Weigh: Bed S c a l e Weigh: F l o o r S c a l e 1 0 8 POSITION OR STAFF TITLES  NURSING SERVICE DEPARTMENT D i r e c t o r , N u r s i n g S e r v i c e • A s s i s t a n t D i r e c t o r , N u r s i n g S e r v i c e N u r s i n g S u p e r v i s o r - Day N u r s i n g S u p e r v i s o r - E v e n i n g N u r s i n g S u p e r v i s o r - N i g h t Head Nurse S t a f f Nurse L i c e n s e d P r a c t i c a l Nurse R e g i s t e r e d Nurse N u r s i n g Aide Ward C l e r k Ward O r d e r l y D i r e c t o r , I n - S e r v i c e E d u c a t i o n I n s t r u c t o r - Nurses I n - S e r v i c e s I n s t r u c t o r - A n c i l l a r y N u r s i n g P e r s o n n e l 1 0 9 RADIOLOGY DEPARTMENT The purpose of the R a d i o l o g y Department I s t o p r o -v i d e an a d j u n c t d i a g n o s t i c and t h e r a p e u t i c r a d i o l o g y s e r v i c e as r e q u i r e d i n e x a m i n a t i o n , c a r e and t r e a t -ment o f h o s p i t a l p a t i e n t s . B a s i c r e s p o n s i b i l i t i e s i n c l u d e t a k i n g , p r o c e s s i n g , e x a m i n i n g , and i n t e r p r e t i n g r a d i o g r a p h s and f l u o c o -g r a p h s , Radiographs may be t a k e n f o r d i a g n o s t i c p u r -p o s e s , o r t o study p h y s i o l o g i c a l p r o c e s s e s . P l u o r o -s c o p i n g may be done t o study a c t i o n o f i n t e r n a l phys-i o l o g i c a l p r o c e s s e s , l o c a l i z e f o r e i g n b o d i e s , o r f o r r e l a t e d m e d i c a l p u r p o s e s . R a d i o i s o t o p e s are used t o i n d i c a t e the course o f compounds i n t r o d u c e d i n t o the human body. Radiographs and f l u o r o g r a p h s must be examined, and the e x t e n t and s i g n i f i c a n c e o f t h e i r p a t h o l o g y o r d e v i a t i o n from the normal i n t e r p r e t e d . Roentgenotherapy and t h e r a p y by radium and r a d i o -a c t i v e s u b s t a n c e s are a l s o a r e s p o n s i b i l i t y of t h i s department. I n l a r g e r e s e a r c h or t e a c h i n g h o s p i t a l s t h e r e may be a s e p a r a t e Department o f N u c l e a r Medi-c i n e concerned w i t h m e d i c a l d i a g n o s i s and t h e r a p y t h r o u g h the use o f r a d i o i s o t o p e s , as w e l l as r e -s e a r c h i n r a d i o c h e m i c a l a n a l y s i s , r a d i a t i o n b i o l o g y r e s e a r c h , i n s t r u m e n t a t i o n and m o n i t o r i n g t e c h n i q u e s , r a d i o a c t i v e waste d i s p o s a l , c o n t r o l and r e d u c t i o n o f 110 o c c u p a t i o n a l and e n v i r o n m e n t a l e x p o s u r e s , and spe-c i a l h e a l t h problems o f n n u c l e a r p r o p u l s i o n . I n a d d i t i o n t o t h e s e f u n c t i o n s , the department i s r e s p o n s i b l e f o r p l a n n i n g and c a r r y i n g out p o l i -c i e s and p r o c e d u r e s t o i n s u r e p r o t e c t i o n t o a l l h o s p i t a l p e r s o n n e l i n c o n t a c t w i t h r a d i a t i o n mo-d a l i t i e s ; p r o v i d i n g c o n s u l t a t i o n and a d v i c e t o c l i n -i c i a n s i n i n t e r p r e t i n g d i a g n o s t i c r o e n t g e n o l o g i c a l f i n d i n g s ; p l a n n i n g d i a g n o s t i c X-ray p r o c e d u r e s and o t h e r p e r t i n e n t m a t t e r s ; a d m i n i s t e r i n g t h e r a p e u t i c t r e a t m e n t ; p a r t i c i p a t i n g i n r e s e a r c h programs; p r e -s e n t i n g f i l m s at a u t o p s i e s and making a d d i t i o n a l post-mortem e x a m i n a t i o n s as r e q u i r e d t o complete r e c o r d s ; p a r t i c i p a t i n g i n h o s p i t a l ' s e d u c a t i o n p r o -gram; and maintaining a c c u r a t e and complete r e c o r d s . I l l FUNCTIONS, A C T I V I T I E S OR PROCEDURES  RADIOLOGY DEPARTMENT The R a d i o l o g y D e p a r t m e n t c o n s i s t s o f a r a d i o -l o g i s t , t e c h n o l o g i s t s , c l e r i c a l s t a f f a n d f i l e room s t a f f . L i s t e d b e l o w a r e a r e a s o f c o n c e r n one must c o n s i d e r when e s t a b l i s h i n g s t a f f i n g g u i d e l i n e s . A l i s t o f p r o c e d u r e s w i l l be g i v e n f r o m w h i c h t h e t i m e s t a n d a r d s w i l l be made t o d e v e l o p t h e a c t u a l g u i d e l i n e s . T e c h n o l o g i s t s : 1. Number o f x - r a y e x a m i n a t i o n s a c c o m p l i s h e d . 2. T y p e s o f e x a m i n a t i o n s a c c o m p l i s h e d . 3. C o n d i t i o n s o f t h e p a t i e n t b e i n g e x a m i n e d . 4. S t a g e o f t h e t r a i n i n g o f r e s i d e n t p h y s i -c i a n d o i n g t h e e x a m i n a t i o n . 5. A v a i l a b i l i t y ' ' o f a r a d i o l o g i s t f o r a s p e c i -f i c s p e c i a l t y . 6. The a v a i l a b i l i t y o f t r a n s p o r t a t i o n . 7. Number o f b e d s i d e e x a m i n a t i o n s and o p e r a t -i n g room p r o c e d u r e s . 8. Amount o f a c c r u e d l e a v e w h i c h must be c o v e r e d . C l e r i c a l S t a f f : 1. Number o f e x a m i n a t i o n r e p o r t s t o be t y p e d . 2. Number o f i n t e r r u p t i o n s ; i . e . , t e l e p h o n e c a l l s , v i s i t o r s , e t c . 1.12 3- The l e n g t h o f the r e p o r t s . 4. Number o f l i n e s t y p e d . 5. Number o f t r a n s c r i p t s r e q u e s t e d . 6. Amount o f correspondence g e n e r a t e d by p h y s i c i a n s t a f f t o i n c l u d e t e a c h -i n g , p r o f e s s i o n a l s o c i e t i e s and o t h e r U n i v e r s i t y r e l a t e d b u s i n e s s . 7. Amount o f a c c r u e d l e a v e which must be co v e r e d . F i l e Room: 1. Number o f p a t i e n t s examined. 2. Number o f c l i n i c s r e q u e s t i n g f i l m s . 3. Number o f f i l m s r e q u e s t e d by each c l i n i c . 4. Number o f f i l m s b e i n g t r a n s f e r r e d i n and out. 5. Number o f p h y s i c i a n s r e q u e s t i n g i n d i v i -d u a l f o l d e r s . 6. Number of r e q u e s t s f o r e x a m i n a t i o n r e -s u l t s . 7. A v a i l a b l e space, p a r t i c u l a r l y concerned w i t h how t i g h t l y x - r a y j a c k e t s are jammed i n t o s h e l v i n g . 8. D i s t a n c e o f v a r i o u s f i l e rooms from R a d i o l o g y S e r v i c e . 1 1 3 The f o l l o w i n g p r o c e d u r e s are pe o l o g y Department: Abdomen Abdomen S e r i e s GB, GI Esophagus GI GI w i t h Esophagus GI w i t h S m a l l Bowel S m a l l Bowel S e r i e s Barium Enema Barium Enema w i t h A i r G a l l b l a d d e r O p e r a t i v e Cholangiogram T-Tube Cholangiogram I n t r a v e n o u s Cholangiogram C l a v i c l e S h o u l d e r S c a p u l a A c r o m i o c l a v i c u l a r J o i n t s Humerus Elbow Forearm W r i s t Hand Both Hands F i n g e r s Hip formed by the R a d i -Both H i p s Hip N a i l i n O p e r a t i n g Room Femur Knee Both Knees T i b i a Ankle Both A n k l e s Foot Os C a l c i s Toes . Post R e d u c t i o n 1. E.R. 2. O.R. P.E.G. V e n t r i c u l o g r a m Eye f o r F o r e i g n Body Eye, F o r e i g n Body L o c a l i z a t i o n M a n dible M a s t o i d s F a c i a l Bones or O r b i t s N a s a l Bones O p t i c Foramen or S e l l a T u r c i c a S i n u s e s .11.4 Procedures performed by R a d i o l o g y Department (c o n t ' d ) S k u l l TMJ's Neck f o r S o f t T i s s u e S i a l o g r a m P a l a t e Study Chest C a r d i a c S e r i e s (.4 views o f c h e s t ) Chest or C a r d i a c P l u o r o Bronchogram, U n i l a t e r a l Bronchogram, B i l a t e r a l R i b s , U n i l a t e r a l R i b s , B i l a t e r a l Sternum or S t e r n o c l a v i c u l a r J o i n t s 1 1 5 POSITION OR STAFF TITLES  RADIOLOGY DEPARTMENT D i r e c t o r o f R a d i o l o g y R a d i o l o g i s t C h i e f , N u c l e a r M e d i c i n e C h i e f , R a d i o l o g i c T e c h n i c i a n R a d i o l o g i c T e c h n i c i a n Darkroom A t t e n d a n t N u c l e a r L a b o r a t o r y T e c h n i c i a n S u p e r v i s o r N u c l e a r M e d i c a l T e c h n o l o g i s t S c h e d u l i n g C l e r k 116 SOCIAL SERVICE DEPARTMENT The purpose of the S o c i a l S e r v i c e Department i s t o a s s i s t i n meeting the problems of p a t i e n t s whose p h y s i c a l needs may be a g g r a v a t e d by s o c i a l f a c t o r s and who, t h e r e f o r e , may r e q u i r e s o c i a l t r e a t m e n t based on t h e i r m e d i c a l c o n d i t i o n s and c o u r s e s of t r e a t m e n t . The r e s p o n s i b i l i t y o f t h i s department i n c l u d e s c o n t r i b u t i o n t o d i a g n o s i s and t r e a t m e n t t h r o u g h an u n d e r s t a n d i n g of the s o c i a l elements of p a t i e n t s ' l i v e s i n r e l a t i o n to.' d i s a b i l i t y , i l l n e s s , or o t h e r problems. By o b t a i n i n g i n f o r m a t i o n about the pa-t i e n t s as t o t a l i n d i v i d u a l s i n the s o c i a l and eco-nomic environment i n which they l i v e and work; t h e i r c a p a c i t y t o u n d e r s t a n d and p a r t i c i p a t e i n a p l a n o f m e d i c a l or p s y c h i a t r i c t r e a t m e n t ; t h e i r o b l i g a t i o n s ; and t h e i r m a t e r i a l and p e r s o n a l r e s o u r c e s , the de-partment a i d s the h o s p i t a l s t a f f i n u n d e r s t a n d i n g and t r e a t i n g i l l n e s s e s more e f f e c t i v e l y . S i m i l a r l y , by i n t e r p r e t i n g the p l a n of t r e a t m e n t t o the p a t i e n t s and a s s i s t i n g i n t h e i r p e r s o n a l a f f a i r s so as t o b r i n g r e l i e f from w o r r y , the S o c i a l S e r v i c e D e p a r t -ment c o n t r i b u t e s t o t r e a t m e n t and r e h a b i l i t a t i o n o f the whole p e r s o n . The department may be r e s p o n s i b l e f o r f o l l o w u p v i s i t s t o homes of d i s c h a r g e d p a t i e n t s 117 and o u t p a t i e n t s , i n o r d e r t o i n s u r e c o n t i n u a t i o n o f t r e a t m e n t i n an atmosphere conducive t o p r e s e r v a t i o n o f h e a l t h . I n a c c o m p l i s h i n g i t s r e s p o n s i b i l i t i e s , such f u n c t i o n s are performed as the p r a c t i c e o f case work and group work; development o f s o c i a l s e r v i c e program w i t h i n the h o s p i t a l ; and p a r t i c i p a t i o n I n development of s o c i a l and h e a l t h programs i n the community, i n e d u c a t i o n a l programs f o r p r o f e s s i o n a l p e r s o n n e l , and i n m e d i c a l s o c i a l r e s e a r c h . Records t o be i n c o r p o r a t e d w i t h p a t i e n t s ' c h a r t s must be kept on the s o c i a l work w i t h p a t i e n t s , and f o r ed-u c a t i o n a l and r e s e a r c h purposes. S o c i a l workers are a s s i g n e d t o duty i n v a r i o u s c l i n i c s and i n pa-t i e n t s e r v i c e s o f the h o s p i t a l , w h e r e t hey a s s i s t p a t i e n t s r e f e r r e d t o them by the m e d i c a l s t a f f o r o t h e r persons and a g e n c i e s . 118 FUNCTIONS, ACTIVITIES OR PROCEDURES  SOCIAL WORK DEPARTMENT Number o f h o s p i t a l a d m i s s i o n s Number o f o u t p a t i e n t v i s i t s Number of s o c i a l work cases Type o f case: C h i l d abuse Drug abuse A l c o h o l abuse Other C o m p l e x i t y o f case - does i t r e q u i r e one s o c i a l w o r k e r , two s o c i a l w o r k e r s , one s o c i a l worker and one s o c i a l work a i d e , e t c . ? 1 1 9 POSITION OR STAFF TITLES  SOCIAL SERVICE DEPARTMENT D i r e c t o r , S o c i a l S e r v i c e S o c i a l Worker - M e d i c a l S o c i a l Worker - P s y c h i a t r i c S o c i a l Worker Aide 120 CHAPTER IV Review, S t a t e - o f - t h e - A r t , C o n c l u s i o n s , Recommendations 121 The o b j e c t i v e o f t h i s t h e s i s as o u t l i n e d i n the f o r e g o i n g c h a p t e r s was t o i p r e s e n t v a r i o u s concepts and the n e c e s s a r y knowledge i n v o l v e d i n manpower p l a n n i n g , h e a l t h manpower p l a n n i n g , and the development o f man-power and s t a f f i n g g u i d e l i n e s i n h o s p i t a l s . To e s t a b -l i s h a c c u r a t e s t a f f i n g g u i d e l i n e s , one must have a thorough knowledge o f b o t h manpower p l a n n i n g and h e a l t h manpower p l a n n i n g . Once t h i s knowledge i s o b t a i n e d , d i f f e r e n t f o r m u l a s and c r i t e r i a may be deve l o p e d t o e s t a b l i s h t h e s e g u i d e l i n e s . The purpose o f t h i s chap-t e r i s t o r e v i e w those i n g r e d i e n t s i n v o l v e d i n man-power p l a n n i n g , h e a l t h manpower p l a n n i n g , and d e v e l o p -i n g s t a f f i n g g u i d e l i n e s i n major h o s p i t a l departments. The f o l l o w i n g pages w i l l p r e s e n t a r e v i e w o f t h i s t h e s i s , the S t a t e - o f - t h e - A r t , c o n c l u s i o n s , and s u g g e s t i o n s f o r f u t u r e r e s e a r c h . MANPOWER PLANNING There are many concepts and d e f i n i t i o n s a t t a c h e d t o manpower p l a n n i n g . Chapter One i n d i c a t e d i t i s d i f -f i c u l t t o draw up a p r e c i s e d e f i n i t i o n o f t h i s type o f p l a n n i n g . Manpower p l a n n i n g i s a p r e c i s e a r t o f wh i c h no p a r t i c u l a r d i s c i p l i n e can c l a i m a monopoly on i t s i n t e r e s t . T h i s i n v o l v e s h a v i n g the r i g h t k i n d o f l a b o r and a d j u s t i n g manpower r e q u i r e m e n t s t o meet a v a i l -a b l e s u p p l i e s and demands. Manpower p l a n n i n g denotes many dimensions o f human r e s o u r c e development b o t h as a term o f a r t and as an a r e a o f p u b l i c p o l i c y . As s t a t e d e a r l i e r , t h e r e i s no s i n g l e u n i v e r s a l l y a c c e p t e d 122 method f o r p r o j e c t i n g manpower s u p p l i e s and r e q u i r e -ments. The b e s t approach i s o f t e n d e r i v e d from a b o r -r o w i n g o f s e v e r a l t e c h n i q u e s and i n c o r p o r a t i n g t h e s e i n t o ones own method o f manpower f o r e c a s t i n g o r p l a n -n i n g . Manpower p l a n n i n g i s based on s y s t e m a t i c a t t e m p t s t o a n t i c i p a t e r e q u i r e m e n t s f o r p e r s o n n e l w i t h p a r t i c u -l a r s k i l l s , q u a l i f i c a t i o n s and a p t i t u d e s . The f o r e -c a s t o f b t h e s e r e q u i r e m e n t s i s g e n e r a l l y the f i r s t s t e p i n the manpower p l a n n i n g p r o c e s s . I t i s .a major c o n c l u s i o n t h a t the s h o r t e r the f o r e c a s t i n g p e r i o d , the more a c c u r a t e the f o r e c a s t w i l l be. T h i s a c c u r -acy d i m i n i s h e s as the l e n g t h ( y e a r s ) o f t h i s f o r e c a s t -i n g p e r i o d i n c r e a s e s . To some e x t e n t manpower p l a n -n i n g i s . a j u d g m e n t a l p r o c e s s . F o r e c a s t i n g d e c i s i o n s must be based on b o t h p r e s e n t c o n d i t i o n s , as w e l l as c o n d i t i o n s i n the f u t u r e . I n t h e p r i v a t e s e c t o r the demand f o r l a b o r i s a d e r i v e d demand. That i s , t h i s demand i s the r e s u l t o f the demand f o r goods and s e r v i c e s produced by l a b o r . U n l i k e the p r i v a t e s e c t o r , manpower p l a n n e r s i n the p u b l i c s e c t o r are not concerned e n t i r e l y w i t h the d e r i v e d demand f o r l a b o r . They have the added r e s p o n s -i b i l i t y o f i d e n t i f y i n g groups which are unable t o ob-t a i n s t a b l e employment and p r o v i d i n g manpower programs f o r them. Some of the s p e c i f i c areas of concern f o r government manpower p l a n n e r s are i d e n t i f y i n g the need f o r manpower s e r v i c e s , f o r e c a s t i n g f u t u r e l a b o r market 123 c o n d i t i o n s , l o c a t i o n s o f e x i s t i n g l a b o r m a r k e t s , and p r o v i d i n g v a r i o u s forms of s k i l l development o p p o r t u n -i t i e s t o f a c i l i t a t e placement f u n c t i o n s i n the f u t u r e . P r e s e n t e d e a r l i e r i n t h i s t h e s i s were v a r i o u s t e c h -n i q u e s or methods of f o r e c a s t i n g used i n manpower p l a n -n i n g . T h i s i n c l u d e d e c o n o m e t r i c methods, p r o d u c t i v i t y methods, survey methods and t r e n d p r o j e c t i o n methods. The f o l l o w i n g i s a r e v i e w of t h e s e methods or t e c h -n i q u e s used i n manpower p l a n n i n g . The s t r e n g t h and weakness o f - e a c h method w i l l a l s o be r e v i e w e d . E c o n o m e t r i c method: T h i s method of manpower f o r e -c a s t i n g i s a t e c h n i q u e f o r d e r i v i n g o c c u p a t i o n a l l a b o r r e q u i r e m e n t s from e s t i m a t e d l e v e l s f o r f i n a l demand f o r goods and s e r v i c e s i n the economy i n some f u t u r e y e a r . E c o n o m e t r i c methods have the advantage of p r o -d u c i n g r e f i n e d f o r e c a s t s o f manpower r e q u i r e m e n t s by i n d i v i d u a l o c c u p a t i o n s . I t does t h i s w i t h i n the frame-work and r e l a t i o n s h i p s o f the e n t i r e economy. A maj-or weakness of the e c o n o m e t r i c method i s an i n s u f f i -c i e n c y of t r u t h f u l data:>.and i n f o r m a t i o n . Because t h i s method r e q u i r e s s e v e r a l e x p e r t s and a n a l y s t s , I t i s b o t h c o s t l y and time consuming. P r o d u c t i v i t y method: T h i s method f o r e c a s t s em-ployment f o r v a r i o u s t a r g e t y e a r s by s e c t o r and occup-a t i o n . P r o d u c t i v i t y methods have the advantage of c o o r d i n a t i n g manpower f o r e c a s t s w i t h the o v e r a l l eco-nomic development p l a n . The weaknesses a s s o c i a t e d w i t h t h i s method are the d i f f i c u l t i e s i n d e t e r m i n i n g 124 t a r g e t y e a r output and. d e r i v i n g o c c u p a t i o n a l r e q u i r e -ments from aggregate s e c t o r a l r e q u i r e m e n t s . Survey method: T h i s method makes p r a c t i c a l use of manpower r e q u i r e m e n t s f o r employers f o r f o r e c a s t -i n g manpower demand at a g i v e n t a r g e t y e a r . The main advantage t o t h i s method i s t h a t s u r v e y s and i n -t e r v i e w s can be made at e s t a b l i s h e d o r f r e q u e n t i n t e r -v a l s . T h i s means manpower r e q u i r e m e n t s and demands can be ke p t m o d e r a t e l y up t o d a t e . The main problem a s s o c i a t e d w i t h t h i s method i s t h a t f i r m s i n c l u d e d i n the sample may not respond t o the s u r v e y . T r e n d - p r o j e c t i o n method: T h i s method i s used t o p r o j e c t p a s t t r e n d s o f aggregate and o c c u p a t i o n a l l a b o r f o r c e s t h r o u g h t o the t a r g e t y e a r s . The major s t r e n g h o f t h i s method i s t h a t the r e s u l t s r e q u i r e a c o n s i d e r a b l e amount of ..data g o i n g back a f a i r number of y e a r s . HEALTH MANPOWER PLANNING The concept o f ' i h e a l t h manpower i n c l u d e s those a l r e a d y w o r k i n g i n the f i e l d o f h e a l t h s e r v i c e s . P o t e n -t i a l h e a l t h workers are those who have the a b i l i t y t o engage i n a h e a l t h o c c u p a t i o n but at p r e s e n t are not do i n g s o , and p r o s p e c t i v e manpower which i n c l u d e s those who are p r e s e n t l y u n d e r g o i n g e d u c a t i o n and t r a i n -i n g t h a t w i l l p e r m i t them t o j o i n the h e a l t h s e r v i c e s s e c t o r . As i n d i c a t e d i n Chapter Two, h e a l t h manpower p l a n n i n g i s the p r o c e s s o f ' e s t i m a t i n g t h e q u a n t i t y and t ype o f knowledge, s k i l l s , and a b i l i t y needed t o 125 i n t r o d u c e p r e d e t e r m i n e d a l t e r a t i o n s i n the f u n c t i o n -i n g o f a h e a l t h system so as t o make i t more p r o b a b l e t h a t the d e s i r e d changes i n the h e a l t h o f a p o p u l a -t i o n w i l l be a c h i e v e d . H e a l t h manpower p l a n n i n g s h o u l d be i n t e g r a t e d i n t o b r oad s o c i a l - e c o n o m i c p l a n -n i n g f o r a n a t i o n as a whole. The same h o l d s t r u e i n h e a l t h manpower p l a n n i n g as was found i n manpower p l a n -n i n g ; t h a t i s , t h e r e i s no s i n g l e u n i v e r s a l l y a c c e p t e d method f o r p r o j e c t i n g h e a l t h manpower s u p p l i e s and r e -qu i r e m e n t s . There are no' p r e c i s e c r i t e r i a f o r d e t e r -m i n i n g what h e a l t h manpower p l a n n i n g s h o u l d encompass and what problems i t s h o u l d t r y t o s o l v e . One o f the d i f f i c u l t i e s i n h e a l t h manpower p l a n -n i n g i s the l o n g l e a d time r e q u i r e d t o b r i n g about changes t h r o u g h some e d u c a t i o n and t r a i n i n g p r o -grams. I t was i n d i c a t e d e a r l i e r t h a t f o r a p r o f e s -s i o n such as m e d i c i n e , a t e n - y e a r p l a n n i n g p e r i o d i s i n s u f f i c i e n t . D e c i s i o n s made i n y e a r one w i l l a f f e c t the s u p p l y t hroughout the r e m a i n i n g y e a r s o f one's e d u c a t i o n . Through optimum u t i l i z a t i o n o f c u r r e n t and f u t u r e s u p p l i e s o f h e a l t h manpower, we can p r o v i d e the most e c o n o m i c a l mix o f p r o f e s s i o n a l and a u x i l i a r y h e a l t h w o r k e r s . Thus, t h i s d i f f i c u l t y may be overcome. Chapter Two o f t h i s t h e s i s p r e s e n t e d c h a r a c t e r -i s t i c s of the demand f o r h e a l t h manpower. Two t y p e s of t h e s e damands a r e : (1) demands p l a c e d d i r e c t l y on p r i v a t e p r a c t i t i o n e r s , and (2) t h o s e demands p l a c e d on h e a l t h care i n s t i t u t i o n s . The demand f o r h e a l t h 126 manpower s e r v i c e s r e q u i r e s an u n d e r s t a n d i n g o f the f a c t o r s which i n f l u e n c e the consumer's h e a l t h , h i s be-h a v i o r , and h i s consumption o f h e a l t h manpower s e r v i c e s . B a s i c a l l y , t h i s i n v o l v e s c u l t u r a l demographic f a c t o r s , economic f a c t o r s , and h e a l t h care d e l i v e r y c o n s t r a i n t s . C u l t u r a l and demographic f a c t o r s : T h i s i n c l u d e s one's age, sex, m a r i t a l s t a t u s , f a m i l y s i z e , e d u c a t i o n , and r e s i d e n c e . I n f o r m a t i o n o b t a i n e d t h r o u g h c u l t u r a l and demographic f a c t o r s are used as a b a s i s f o r d e t e r -m i n i n g h e a l t h s e r v i c e s u t i l i z a t i o n p a t t e r n s . Economic f a c t o r s : The p r i c e o f h e a l t h s e r v i c e s and the a b i l i t y o f the consumer t o pay f o r s e r v i c e s are f a c t o r s which a f f e c t the demand f o r h e a l t h manpower. Another f a c t o r which must be c o n s i d e r e d when a n a l y z i n g the economics o f h e a l t h care u t i l i z a t i o n i s h e a l t h , i n s u r a n c e . T h i s i n s u r a n c e i n f l u e n c e s b o t h the quant-i t y and type o f m e d i c a l care demanded. H e a l t h care d e l i v e r y c o n s t r a i n t s : Long t r a v e l , w a i t i n g t i m e s , a c c e s s i b i l i t y , e t c . are a l l f a c t o r s which i n f l u e n c e an i n d i v i d u a l ' s d e c i s i o n t o seek h e a l t h c a r e . A l t e r n a t i v e modes o f h e a l t h care d e l i v e r y , such as p r e p a i d v e r s u s f e e - f o r - s e r v i c e o r group p r a c t i c e v e r s u s s o l o p r a c t i c e , f u r t h e r a f f e c t the manner i n which t h e s e s e r v i c e s are u t i l i z e d . T h i s i n t u r n has a tremendous i n f l u e n c e on h e a l t h manpower r e q u i r e m e n t s . H e a l t h manpower p l a n n e r s must i n s u r e the p r o p e r manning o f the h e a l t h care d e l i v e r y system. They must see t h a t the r i g h t number and t y p e s o f h e a l t h manpower 1 2 7 are a v a i l a b l e when and where they are needed. To a c c o m p l i s h t h i s , h e a l t h manpower planners: must g a t h -e r two k i n d s o f i n f o r m a t i o n . The f i r s t concerns i t -s e l f w i t h the e x i s t i n g s t o c k of manpower i n terms o f bo t h t h e i r number and t y p e . The second type o f i n -f o r m a t i o n r e l a t e s t o b o t h p r e s e n t and p r o j e c t e d r e -quirements f o r h e a l t h manpower. A l t e r n a t i v e methods f o r e s t i m a t i n g r e q u i r e m e n t s are used by h e a l t h man-power p l a n n e r s . M e t h o d o l o g i c a l approaches p r e v i o u s l y d i s c u s s e d i n . ' t h i s t h e s i s i n c l u d e the manpower p o p u l a -t i o n r a t i o a p proach, the s e r v i c e t a r g e t s a pproach, the h e a l t h need approach, the economic demand'approach, the f u n c t i o n a l a n a l y s i s a pproach, and the use o f models approach. F o l l o w i n g i s a b r i e f r e v i e w o f the s e methods and t h e i r v a r i o u s s t r e n g t h and weaknesses: Manpower p o p u l a t i o n r a t i o approach: T h i s i s the most w i d e l y used approach f o r d e t e r m i n i n g h e a l t h man-power r e q u i r e m e n t s . T h i s method i n v o l v e s the i d e n t i -f i c a t i o n of a s u i t a b l e h e a l t h manpower p o p u l a t i o n r a t i o f o r a f u t u r e p o i n t i n t i m e , and th e n the a p p l i -c a t i o n o f t h i s r a t i o t o the p r o j e c t e d p o p u l a t i o n t o d e r i v e manpower r e q u i r e m e n t s . The s i m p l i c i t y o f t h i s method i s i t s g r e a t e s t advantage. Data r e q u i r e m e n t s are u s u a l l y modest and not v e r y s e n s i t i v e t o e r r o r s . D i s a d v a n t a g e s o f t h i s approach r e l a t e t o the s e l e c t i o n o f u n r e a l i s t i c r a t i o s r e s u l t i n g i n major e r r o r s i n economic and manpower p o l i c i e s . Another d i s a d v a n t a g e of t h i s approach i s t h a t w i t h p r i m a r y emphasis on man-128 power, l i t t l e a t t e n t i o n may be g i v e n t o the k i n d , q u a l -i t y , volume and f r e q u e n c y of s e r v i c e s . S e r v i c e t a r g e t s approach: T h i s approach addresses the q u e s t i o n as t o how many s e r v i c e s o f each k i n d s h o u l d be produced t o meet e x p e c t e d r e q u i r e m e n t s f o r h e a l t h c a r e , and what manpower w i l l be r e q u i r e d t o p r o -v i d e t h e s e s e r v i c e s or t a r g e t s . The major advantage of t h i s approach i s i t s p r i m a r y impetus on s e r v i c e s r a t h e r than manpower. A t t e n t i o n i s d i r e c t e d towards p r o d u c t i v i t y , i n t e r p e r s o n a l r a t i o s , and e f f i c i e n t r e -source u t i l i z a t i o n . The major drawback t o t h i s method i s t h a t i t i s prone t o h a v i n g s t a n d a r d s based more on d e s i r e s than on r e a l i t y , l e a d i n g t o major p l a n n i n g e r r o r s . H e a l t h needs approach: T h i s approach seeks t o determine what k i n d s , amounts, and q u a l i t y l e v e l s o f s e r v i c e s are r e q u i r e d t o m a i n t a i n a h e a l t h y p o p u l a t i o n . These s e r v i c e s are t h e n c o n v e r t e d i n t o manpower r e q u i r e -ments. The g r e a t e s t s t r e n g t h o f t h i s approach i s t h a t i t p e r m i t s a l l o c a t i o n o f r e s o u r c e s where they w i l l have the g r e a t e s t a f f e c t on h e a l t h . Another advant-age of t h i s approach i s t h a t i t p r o v i d e s s e r v i c e s a c -c o r d i n g t o need and not t o s o c i a l o r economic con-d i t i o n s o f consumers. The main drawback o f t h i s ap-p r oach i s t h a t i t can be c o m p l i c a t e d , c o s t l y , and r e -q u i r e s s o p h i s t i c a t e d d a t a . T h i s approach may a l s o r e s u l t i n c o s t l y p r o j e c t i o n s o f s e r v i c e r e q u i r e m e n t s f a r i n excess of a b i l i t y t o p r o v i d e them. 129 E c o n o m e t r i c demand approach: T h i s approach con-s i d e r s what h e a l t h s e r v i c e s are i n d i v i d u a l s and/or the government w i l l i n g and a b l e t o pay f o r . Advantages a s s o c i a t e d w i t h t h i s approach are t h a t i t h e l p s de-s c r i b e the dynamics and d e t e r m i n a n t s o f h e a l t h s e r v -i c e s u t i l i z a t i o n . Another advantage i s t h a t i t tends t o produce e c o n o m i c a l l y r e a l i s t i c p r o j e c t i o n s . Major d i s a d v a n t a g e s r e l a t e d t o t h i s approach are t h a t i t does not n e c e s s a r i l y t a k e i n t o account the q u a l i t y o f s e r v i c e s o r t h e i r r e l e v a n c e t o the h e a l t h problems o f the c o u n t r y . T h i s approach may f u r t h e r n e g l e c t con-s i d e r a t i o n ofrways t o improve manpower p r o d u c t i v i t y . F u n c t i o n a l a n a l y s i s approach: T h i s type o f ap-proach i s concerned w i t h ways i n which the w u a l i f i c a -t i o n s of p e r s o n n e l can be s y s t e m a t i c a l l y matched t o the r e q u i r e m e n t s o f job performance. The main advant-age o f t h i s approach i s t h a t i t produces w r i t t e n r e -quirements f o r job performance. Weaknesses a s s o c i a t e d w i t h t h i s approach i s i t s i n d e c i s i v e n e s s on what norms t o use i n e v a l u a t i n g and e s t a b l i s h i n g q u a l i f i c a t i o n s and r e q u i r e m e n t s of job performance. Use o f models approach: The purpose o f t h i s ap-proach i s t o a l l o w use o f a model as a low c o s t and r e a d i l y m o d i f i a b l e s u b s t i t u t e f o r a c t u a l h e a l t h man-power p l a n n i n g s i t u a t i o n s . Advantages t o t h i s ap-proach are i t s ease in:.'.manipulating models t o meeting r e a l or a c t u a l s i t u a t i o n s . The major weakness of t h i s approach i s t h a t the model w i l l be no more a c c u r a t e 130 than the d a t a used i n f o r m i n g the model. HOSPITAL MANPOWER PLANNING As i n d i c a t e d e a r l i e r , s o p h i s t i c a t e d equipment, h o s p i t a l a c c r e d i t a t i o n , and p a t i e n t s themselves have a l l a f f e c t e d manpower p l a n n i n g and the development o f manpower and s t a f f i n g g u i d e l i n e s i n h o s p i t a l s . W ith the r a p i d changes i n v o l v e d i n b o t h new h o s p i t a l s and expanding h o s p i t a l s , manpower p l a n n i n g i n h o s p i t a l s i s now more th a n e v e r a v i t a l i s s u e . H o s p i t a l d e p a r t -ments are becoming more complex, more p r o d u c t i v e , and p r o v i d e more s e r v i c e s . T h i s alone demonstrates the need f o r a c c u r a t e development o f manpower and s t a f f i n g g u i d e l i n e s i n h e a l t h i n s t i t u t i o n s . Over the p a s t number o f y e a r s t h e r e has been a c o n s i d e r a b l e i n c r e a s e i n the u t i l i z a t i o n o f h o s p i t a l s e r v i c e s . One o f the most d i f f i c u l t q u e s t i o n s the manpower p l a n n e r must c o n s i d e r i s the r a t e of t h i s i n -c r e a s i n g u t i l i z a t i o n . The p l a n n e r must c o n s i d e r how f a s t w i l l the number o f p a t i e n t s i n c r e a s e t o f i l l h o s p i t a l beds? W i l l the i n c r e a s e s l o w , o r w i l l i t s e t ' a r a p i d pace? The purpose o f Chapter Three was to t a k e a c l o s e l o o k a t these concerns and v a r i o u s o t h e r areas which one must be aware o f i n the d e v e l o p -ment o f manpower and s t a f f i n g g u i d e l i n e s i n h o s p i t a l s . The main c r i t e r i a i n d e v e l o p i n g t h e s e g u i d e l i n e s i s t o develop l a b o r performance s t a n d a r d s . As p r e v i o u s l y o u t l i n e d , t h i s i s a c c o m p l i s h e d by l i s t i n g a l l p r o c e -d u r e s , e x a m i n a t i o n s , f u n c t i o n s , e t c . performed i n each 131 department. T h i s l i s t s h o u l d i n c l u d e not o n l y c u r -r e n t a c t i v i t i e s , but any f u t u r e p l a n s t h a t may i n c r e a s e or d ecrease f u n c t i o n s o f each department. A s t a n d a r d c o m p l e t i o n time f o r each f u n c t i o n i s d e t e r m i n e d . Ad-j u s t m e n t s t o c o m p l e t i o n t i m e s may be s e t by d e v e l o p -i n g an aggragate s t a n d a r d . T h i s aggragate t h e n be-comes the s t a n d a r d time a l l o w e d t o complete t h e f u n c -t i o n or a c t i v i t y . Time s t a n d a r d s f o r the m a j o r i t y o f a c t i v i t i e s , f u n c t i o n s or p r o c e d u r e s can be developed t h r o u g h d i r e c t o b s e r v a t i o n . A p p r o p r i a t e a l l o w a n c e s w i l l p r o b a b l y n e c e s s a r y i n c e r t a i n c i r c u m s t a n c e s . Once the a c t i v i t y f r e q u e n c i e s have been d e t e r m i n e d , they are m u l t i p l i e d by the c o r r e s p o n d i n g time s t a n d -ards t o determine the w o r k l o a d by day and s h i f t . T h i s i s th e n c o n v e r t e d i n t o the a c t u a l manpower and s t a f f i n g g u i d e l i n e s . . Chapter Three a l s o p r e s e n t e d a d i s c u s s i o n on each of t he f o l l o w i n g departments which i n c l u d e d a l i s t o f f u n c t i o n s , p r o c e d u r e s , e t c . t h a t one must pay a t t e n -t i o n t o when e s t a b l i s h i n g manpower and s t a f f i n g g u i d e -l i n e s . A l i s t o f p o s s i b l e s t a f f o r p o s i t i o n t i t l e s was a l s o g i v e n i n r e l a t i o n t o the s e departments. A d m i t t i n g M e d i c a l Records B u s i n e s s O f f i c e N u r s i n g D i e t a r y R a d i o l o g y Housekeeping S o c i a l Work 132 STATE-OF-THE-ART, CONCLUSIONS, RECOMMENDATIONS D e v e l o p i n g s t a n d a r d s f o r use i n d e t e r m i n g and a s s e s s i n g h e a l t h manpower needs i n a l o c a l a r e a f o r the n a t i o n as a whole i s an i m p o r t a n t but v e r y d i f f i -c u l t u n d e r t a k i n g . One of the major problems i s s e -l e c t i o n of an a c c e p t a b l e and a p p r o p r i a t e methodology f o r j u d g i n g the n u m e r i c a l adequacy o f the e x i s t i n g s u p p l y o f manpower. No s i n g l e method o f d e t e r m i n i n g s t a n d a r d s has proven e n t i r e l y s a t i s f a c t o r y or u n i v e r s -a l l y a p p l i c a b l e , and t h e r e i s l i t t l e concensus on what s t a n d a r d s s h o u l d attempt t o measure, nor how the meas-urement s h o u l d be made. 1 There are many d i f f e r e n t approaches t o and methods f o r e s t i m a t i n g and f o r e c a s t -i n g h e a l t h manpower r e q u i r e m e n t s , r a n g i n g from the v e r y s i m p l e p h y s i c i a n - p o p u l a t i o n approach t o the ex-t r e m e l y complex and t e c h n i c a l e q u i l i b r a t i n g and o p t i m -i z i n g model approaches. Each o f th e s e approaches has r e a l advantages; each o f them a l s o has p o t e n t i a l p r o b -lems and d i s a d v a n t a g e s . 2 One o f the major r o a d b l o c k s i n e s t i m a t i o n o f manpower r e q u i r e m e n t s i s the problem of d a t a . Needed d a t a are o f t e n s i m p l y not a v a i l a b l e . 1 A p p l i e d Management S c i e n c e s , I n c . , S i l v e r S p r i n g s , M a r y -l a n d . Review o f H e a l t h Manpower P o p u l a t i o n Requirements  S t a n d a r d s . U.S. Dept. o f H.E.W., Pub.No. (HRAJ 77-22, October 1976. 2U.S. Dept. o f H.E.W., E s t i m a t i n g Manpower R e q u i r e - ments, A Background Paper. U.S. Dept. of H.E.W., Report No. 76-114, March 1977-133 Data t h a t are a v a i l a b l e may have i n c o n s i s t e n c i e s i n d e f i n i t i o n , d i f f e r e n c e s i n coverage, or i n c o n s i s t e n t t i m i n g i n c o l l e c t i o n . The s t a t e - o f - t h e - a r t o f t e n does not p e r m i t p r o p e r u t i l i z a t i o n o f e e . x i s t i n g d a t a , so d a t a may have t o be t a i l o r e d t o the e x i s t i n g methodology by which the e s t i m a t e s are t o be made. I n a d d i t i o n , i t may not be c l e a r as t o how e x i s t i n g d a t a can be u t i l i z e d , and how v a r i o u s paramaters are t o be accounted f o r by ina d e q u a t e data.3 C u r r e n t l y , b o t h manpower and h e a l t h manpower p l a n -n i n g are r e c e i v i n g w i d e s p r e a d r e c o g n i t i o n . B oth p r i v a t e and government i n t e r e s t s are i n c r e a s i n g t o a l a r g e de-gree i n b o t h t h e s e a r e a s . Because of t h i s , t he f u n d i n g mechanism i s much more e a s i e r f o r the s e two areas t h a n i n h o s p i t a l manpower p l a n n i n g . Both manpower p l a n n i n g and h e a l t h manpower p l a n n i n g a r e w e l l beyond the i n f a n c y stage and are e s t a b l i s h i n g an e x c e l l e n t t r a c k r e c o r d f o r p r o g r e s s . H o s p i t a l manpower p l a n n i n g and the d e v e l -opment o f s t a f f i n g g u i d e l i n e s i n t h i s type o f h e a l t h care f a c i l i t y has not been so f o r t u n a t e . T h i s t y p e o f p l a n n i n g i n h o s p i t a l s i s s t i l l i n the embryo stage and i s j u s t b e g i n n i n g t o make i t s mark i n the p l a n n i n g i n d u s t -r y . Numerous r e p o r t s on b o t h manpower and h e a l t h man-power r e p r e s e n t an I n c r e a s i n g E f f o r t i n s e v e r a l c o u n t r i e s 3u...S.. .Dept.. o f H.E.W. ,' E s t i m a t i n g Manpower Requirements, A Background Paper. U.S. Dept. o f H.E.W., Report No. 76-114, March 199-134 t o determine t h e i r h e a l t h manpower needs. Major changes have o c c u r r e d i n the s t r u c t u r e o f m e d i c a l e d u c a t i o n . Many o f the e a r l i e r manpower s t u d i e s c o n s i d e r e d o n l y one type o f h e a l t h w o r k e r , t h i s b e i n g the p h y s i c i a n . More r e c e n t s t u d i e s have c o n s i d e r e d s o c i a l , p s y c h o l o g i c a l , and economic a t t r i b u t e s o f the p o p u l a t i o n . These more r e c e n t s t u d i e s have c a r r i e d i n t o c o n s i d e r a t i o n s f o r b o t h s t u d e n t s e n r o l l e d i n h e a l t h manpower f i e l d s , t e a c h e r s i n v o l v e d i n the e d u c a t i n g p r o c e s s o f the s e v a r i o u s h e a l t h p r o f e s s i o n s , and those p r a c t i t i o n e r s who are c u r r e n t l y employed i n a h e a l t h manpower p o s i t i o n . Once a g a i n , the f o c u s here has been on e i t h e r manpower or h e a l t h manpower p l a n n i n g . One o f the major c o n c l u s i o n s o f t h i s t h e s i s i s t h a t a l t h o u g h the development o f manpower and s t a f f i n g g u i d e -l i n e s i n h o s p i t a l s i s s t i l l r e l a t i v e l y young, i t h o l d s an i m p o r t a n t f u t u r e . F o r t h i s a r e a t o r e c e i v e the amount o f a t t e n t i o n t h a t i s r e q u i r e d , we w i l l need r e -sources from many d i s c i p l i n e s . A l t h o u g h t h e r e are i n -d i v i d u a l s a c r o s s b o t h Canada and the U n i t e d S t a t e s who can be c o n s i d e r e d an e x p e r t i n the a r e a o f d e v e l o p i n g s t a f f i n g g u i d e l i n e s , we w i l l need more q u a l i f i e d p e o p l e . V a r i o u s h e a l t h and h o s p i t a l a s s o c i a t i o n s i n t h e s e two c o u n t r i e s are h e a d i n g i n t h i s d i r e c t i o n . They are c o l -l e c t i n g d a t a r e l a t e d t o those h o s p i t a l departments d i s -cussed e a r l i e r i n t h i s t h e s i s . From t h i s d a t a t h e s e a s s o c i a t i o n s are b e g i n n i n g t o de v e l o p s t a f f i n g g u i d e -l i n e s . 135 The p l a n n i n g , r e s e a r c h , w r i t i n g and r e v i e w of t h i s t h e s i s has brought about the f o l l o w i n g recommend-a t i o n s : 1. A c o l l e c t i o n o f s t a f f i n g g u i d e l i n e s on those departments o u t l i n e d i n t h i s t h e s i s be made. T h i s can be a c c o m p l i s h e d t h r o u g h i n q u i r i n g t o each h o s p i t a l or h e a l t h a s s o c i a t i o n a c r o s s Canada and the U n i t e d S t a t e s . The key t o t h i s recommendation i s f i n a n c i a l s u p p o r t f o r t h i s type of p r o j e c t . Since- t h e development of manpower and s t a f f i n g g u i d e l i n e s i n h o s p i t a l s i s s t i l l v e r y young, the work t h a t i s I n v o l v e d i n t h e s e r e p o r t s i s e x t r e m e l y l a r g e , and t h u s , the p r i c e o f t h e s e r e -p o r t s i s e x t r e m e l y h i g h . The a u t h o r of t h i s t h e s i s d eveloped a l e t t e r and sent I t t o over s i x t y h e a l t h and h o s p i t a l a s s o c i a t i o n s i n b o t h Canada and the U n i t e d S t a t e s . The response from t h i s l e t t e r was not t h a t which was e x p e c t e d . Two.-.major problems were encount-e r e d . One, a m a j o r i t y of those a s s o c i a t i o n s responded i n s a y i n g t h a t the r e p o r t s t h a t were w r i t t e n by members of t h e i r s t a f f were not a v a i l a b l e t o non-members o f t h e i r a s s o c i a t i o n . The second problem e n c o u n t e r e d was t h a t t h o s e a s s o c i a t i o n s who were w i l l i n g t o r e -l e a s e such r e p o r t s were a s k i n g a h i g h d o l l a r amount f o r i n d i v i d u a l r e p o r t s . I t was c a l c u l a t e d I f a l l the r e p o r t s t h a t were asked f o r c o u l d be r e c e i v e d , t h e d o l l a r amount would range between $2,000. and $2,500. 2. A l t h o u g h the c o s t i s e x t r e m e l y h i g h f o r t h i s 1 3 6 type o f r e s e a r c h , i t i s recommended t h a t the know-ledge and work produced i n w r i t i n g t h i s t h e s i s be used as a s t e p p i n g stone t o ones advantage i n r e c e i v i n g a r e s e a r c h g r a n t or s t i p e n d t o be used towards the d e v e l -opment of manpower and s t a f f i n g g u i d e l i n e s i n h o s p i t a l s . The a u t h o r g i v e s f u l l p e r m i s s i o n f o r the knowledge g i v e n i n t h i s t h e s i s t o be used f o r such a purpose. 3 . P r o v i d i n g the above i s a c c o m p l i s h e d , i t i s recommended t h a t i f manpower and s t a f f i n g g u i d e l i n e s are d e v e l o p e d f o r those departments o u t l i n e d i n t h i s t h e s i s , t h a t t h i s volume of work be c o m p i l e d and a model or r e p r e s e n t a t i v e s t a f f i n g g u i d e l i n e be e s t a b l i s h e d f o r a l l h o s p i t a l s . The work may then c a r r y f u r t h e r i n t o a l l o t h e r h o s p i t a l departments. 137 BIBLIOGRAPHY Ahmad, B. & B l a u g , M., The P r a c t i c e o f Manpower F o r e -c a s t i n g . A C o l l e c t i o n o f Case S t u d i e s . E l s e v i e n , N.Y., 1 9 7 3 . A l k e r , Robert T., A d m i n i s t r a t i v e S e r v i c e s and Fac-i l i t i e s f o r H o s p i t a l s , A P l a n n i n g Guide.. U.S. Dept. o f H.E.W., Pub. No. (HSM) 7 2 - 4 0 3 5 -Anderson, D.O., The C r e a t i o n o f a C o o p e r a t i v e Data  Base f o r H e a l t h Manpower P l a n n i n g , Address t o the Annual M e e t i n g o f the Assn. o f Canadian  M e d i c a l C o l l e g e s and A f f i l i a t e d O r g a n i z a t i o n s . Vancouver, B.C., Canada, October 1 9 7 6 -A p p l i e d Management S c i e n c e s , I n c . , S i l v e r S p r i n g s , M a r y l a n d . The Area Resource F i l e . U.S. Dept. o f H.E.W., Pub. No. (HRA) 7 7 - 2 3 , October 1 9 7 6 . A p p l i e d Management S c i e n c e s , I n c . , S i l v e r S p r i n g s , M a r y l a n d . Assessment of H e a l t h Manpower Model-l i n g E f f o r t s and Development o f A l t e r n a t i v e  M o d e l l i n g S t r a t e g i e s . U.S. Dept. o f H.E.W., Pub. No. (HRA) 7 7 - 1 7 , October 1 9 7 6 . A p p l i e d Management S c i e n c e s , I n c . , S i l v e r S p r i n g s , M a r y l a n d . 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U.S. Dept. o f H.E.W., H e a l t h Resources S t u d i e s , An  A n a l y s i s o f S t a t e and R e g i o n a l H e a l t h R e g u l a - t i o n s . U.S. Dept. o f H.E.W., Pub. No. (HRA) 75-611. U.S. Dept. o f H.E.W., H e a l t h R e s o u r c e s r - S t u d i e s , S e l e c t e d I n n o v a t i v e H o s p i t a l Programs i n Amb- u l a t o r y Care. U.S. Dept. o f H.E.W. Pub. No. (HRA) 75-610. U.S. Dept. o f H.E.W., H o s p i t a l O u t p a t i e n t and Emer- gency A c t i v i t i e s , G u i d e l i n e s t o F u n c t i o n a l Programming, E q u i p p i n g and D e s i g n i n g . U.S. Dept. 6'f H.E.W., Pub. No. (HRA) 77-4002, 1977. U.S. Dept. o f H.E.W., P u b l i c H e a l t h S e r v i c e . P u b l i c  H e a l t h R e p o r t s , V o l . 91, No. 1, Jan.-Feb,~1976,  H e a l t h P l a n n i n g , 1976. U.S. Dept. of H.E.W., S o c i a l S e c u r i t y B u l l e t i n , V o l . 40, No. 1, 1977. V e c t o r R e s e a r c h , I n c . , Ann A r b o r , M i c h i g a n . An A n a l - y s i s o f H e a l t h Manpower Models, V o l . 1. U.S. Dept. o f H.E.W. Pub. No. (HRA) 75-19, May 1974. V e c t o r R e s e a r c h , Inc.,'Ann A r b o r , M i c h i g a n . An A n a l - y s i s o f H e a l t h Manpower Models. V o l . 2. U.S. Dept. o f H.E.W., Pub. No. (HRA) 75-19, May 1974. V e c t o r R e s e a r c h , I n c . , Ann A r b o r , M i c h i g a n . An I n - v e n t o r y o f H e a l t h Manpower Models, V o l . 2. U.S. Dept. o f H.E.W., Pub. No. (HRA) 75-19, May 1974. V e t e r a n s A d m i n i s t r a t i o n , I n s t r u c t i o n s f o r C l a s s i f y - i n g P a t i e n t s and R e p o r t i n g . DM&S C i r c u l a r 10-63-255, VA H o s p i t a l , S a l t Lake C i t y , Utah. Warner, D.M., Nurse S t a f f i n g , S c h e d u l i n g & R e a l l o - c a t i o n i n the H o s p i t a l . H o s p i t a l & H e a l t h S e r v -i c e s A d m i n i s t r a t i o n , V o l . 21, No. 3. 1976. W i l s o n , F.A. & Neuhauser, Duncan, H e a l t h S e r v i c e s i n the U n i t e d S t a t e s . B a l l i n g e r P u b l i s h i n g Co., 19W. 145 World H e a l t h O r g a n i z a t i o n . The Development of S t u d - i e s i n H e a l t h Manpower, Report of a WHO S c i e n t - i f i c Group. World H e a l t h O r g a n i z a t i o n Tech. R e p o r t . S e r i e s No. 4 8 l . Geneva, S w i t z e r l a n d , 1 9 7 1 . 146 A p p e n d i x A LIST OF HEALTH OCCUPATIONS The occupations designated as "health occupations" and included in this list are restricted to those for which special education or training, designed to prepare the worker to function in a health setting, is usually required. There are some exceptions to this rule, notably in the areas of natural and social sciences, in order to include within disciplines that are not closely related ro health the particular sub-specialties which are intimately concerned with health subject-matter. As a result of including these sub-specialties (such as esruarine oceanographer, limnologist, physical anthropologist), the list repre-sents occupations that the health administrator must be concerned with when assembling staff to attack health problems. It is more inclusive than a list of occupations for which health authorities must assume responsibility for education. About 125 occupations are identified by primary title. Also shown are approximately 250 alternate titles; these are synonyms, or designations related to form of practice, place of practice, or specialty. An attempt has been made to standardize terminology in relation to level of training. Unless there is strong contrary convention, our usage is: "Technologist" J educational preparation at the baccalaureate level "Therapist" j or above „ _ . . . . . , educational preparation at the associate degree level Technician l . r „ r , , ° , "Assistant" ! Y^3ii of college education or other formal prepa-' ration beyond high school) "Aide" specialized training of less than 2 years duration beyond high school, or on-the-job training. It is hoped that the primary occupational titles used here will have some influence on nomenclature in educational and training programs and also help the reader understand the relationship of occupations within the various health fields. Of course, job titles used in the health services industry do not conform to this or any other scheme or system. Titles indicating distinct levels of training or responsibility within a field are shown whenever it is known that planning or actual development of such a hierarchy is underway. Although approximately 375 titles are listed, the inventory omits some workers within the health services industry. There are many business, clerical, and maintenance occupations that are essential but not unique to the industry, so that no special education or formal training for the health field is required. 147 Among such occupations are accountants, admitting officers, business man-agers, cashiers, controllers, credit managers, directors of office services, employ-ment interviewers, employment managers, housekeepers and housekeeping workers, job analysts, laundry managers and workers, maintenance workers, personnel directors and office workers, public relations directors, purchasing agents, stationary engineers, and stockroom managers. The titles were compiled by the Division of Allied Health Manpower, Bureau of Health Professions Education and Manpower Training. An earlier version of this list appears as an appendix to H E A L T H RESOURCES STA-TISTICS, 1968 (PHS Pub. No. 1509, 1968 edition). The estimated number of persons employed in each health occupation in 1967 is shown in appendix table A - l . Where there are no data, the symbol - - -appears. The total of 3,515,000 workers, while obviously an understatement, is the best figure available for tabular presentation in this publication. LIST O F H E A L T H O C C U P A T I O N S Primary title 1 Alternate title A D M I N I S T R A T I O N Health administrator Health officer or commissioner Environmental control administrator Health agency executive director Health care administrator Hospital administrator Medical care administrator Nursing home administrator Public health administrator Health program analyst Public health analyst Public health specialist Health program representative Public health advisor Public health representative Health systems analyst B I O M E D I C A L E N G I N E E R I N G Biomedical engineer Bioengineer Medical engineer Biomedical engineering technician Medical engineering technician Biomedical engineering aide C H I R O P R A C T I C A N D N A T U R O P A T H Y Chiropractor Doctor of Chiropractic Naturopath Naturopathic physician 148 A p p e n d i x A The occupations designated as "health occupations" and included in this list are restricted to those for which special education or training, designed to prepare the worker to function in a health setting, is usually required. There are some exceptions to this rule, notably in the areas of natural and social sciences, in order to include within disciplines that are not closely related ro health the particular sub-specialties which are intimately concerned with health subject-matter. As a result of including these sub-specialties (such as estuarine oceanographer, limnologist, physical anthropologist), the list repre-sents occupations that the health administrator must be concerned with when assembling staff to attack health problems. It is more inclusive than a list of occupations for which health authorities must assume responsibility for education. About 125 occupations are identified by primary title. Also shown are approximately 250 alternate titles; these are synonyms, or designations related to form of practice, place of practice, or specialty. An attempt has been made to standardize terminology in relation to level of training. Unless there is strong contrary convention, our usage is: "Technologist" ) educational preparation at the baccalaureate level "Therapist" j or above „ _ , . . „ . educational preparation at the associate degree level "Assistant" I ^ years of college education or other formal prepa-' ration beyond high school) "Aide" specialized training of less than 2 years duration beyond high school, or on-the-job training. It is hoped that the primary occupational titles used here will have some influence on nomenclature in educational and training programs and also help the reader understand the relationship of occupations within the various health fields. Of course, job titles used in the health services industry do not conform to this or any other scheme or system. Titles indicating distinct levels of training or responsibility within a field are shown whenever it is known that planning or actual development of such a hierarchy is underway. Although approximately 375 titles are listed, the inventory omits some workers within the health services industry. There are many business, clerical, and maintenance occupations that are essential but not unique to the industry, so that no special education or formal training for the health field is required. 149 Among such occupations are accountants, admitting officers, business man-agers, cashiers, controllers, credit managers, directors of office services, employ-ment interviewers, employment managers, housekeepers and housekeeping workers, job analysts, laundry managers and workers, maintenance workers, personnel directors and office workers, public relations directors, purchasing agents, stationary engineers, and stockroom managers. The titles were compiled by the Division of Allied Health Manpower, Bureau of Health Professions Education and Manpower Training. An earlier version of this list appears as an appendix to H E A L T H RESOURCES STA-TISTICS, 1968 (PHS Pub. No. 1509,1968 edition). The estimated number of persons employed in each health occupation in 1967 is shown in appendix table A - l . Where there are no data, the symbol - - -appears. The total of 3,515,000 workers, while obviously an understatement, is the best figure available for tabular presentation in this publication. LIST O F H E A L T H O C C U P A T I O N S Primary title 1 1. A D M I N I S T R A T I O N Health administrator. Health program analyst Health program representative. Health systems analyst 2. B I O M E D I C A L E N G I N E E R I N G Biomedical engineer Biomedical engineering technician. Biomedical engineering aide 3. CHIROPRACTIC A N D N A T U R O P A T H Y Chiropractor. Naturopath. . Alternate title Health officer or commissioner Environmental control administrator Health agency executive director Health care administrator Hospital administrator Medical care administrator Nursing home administrator Public health administrator Public health analyst Public health specialist Public health advisor Public health representative Bioengineer Medical engineer Medical engineering technician Doctor of Chiropractic Naturopathic physician 150 Primary title 1 4. CLINICAL LABORATORY SERVICES 2 Clinical laboratory scientist 3 Clinical laboratory technologist Clinical laboratory technician. Clinical laboratory aide. Alternate title Clinical chemist 3 Microbiologist 3 Medical laboratory technologist Medical technologist Blood banking technologist Chemistry technologist Hematology technologist Microbiology technologist Medical laboratory technician Medical technician Cytotechnician Cytotechnologist Laboratory assistant Certified laboratory assistant Histologic aide Histologic technician Pathology laboratory aide 5. DENTISTRY AND ALLIED SERVICES Dentist Endodontist Oral pathologist Oral surgeon Orthodontist Pedodontist Periodontist Prosthodontist Public health dentist Dental hygienist Dental assistant Dental laboratory technician Dental laboratory assistant 6. DIETETIC AND NUTRITIONAL SERVICES Dietitian Administrative dietitian Consultant (public health) dietitian Research dietitian Teaching dietitian Therapeutic dietitian Nutritionist 3 Public health nutritionist Dietary technician Dietary (food service) assistant Food service manager Food service technician Dietary aide j Dietary (food service )worker Food service supervisor j •' v ' 7. ENVIRONMENTAL HEALTH SERVICES 4 Environmental scientist 3 Sanitary sciences specialist 3 Air pollution meteorologist 3 Environmental control chemist3 Estuarine oceanographer 3 Ground water hydrologist 3 Health physicist 3 Limnologist8 151 Alternate title Primary title 1 7. ENVIRONMENTAL HEALTH SERVICES-Cont. Environmental engineer Sanitary engineer Air pollution engineer Hospital engineer Industrial hygiene engineer Public health engineer Radiological health engineer Environmental technologist Sanitarian Air pollution specialist Industrial hygienist Radiological health specialist Environmental technician Sanitarian technician Environmental engineering technician Radiological health technician (monitor) Environmental aide Sanitarian aide Environmental engineering aide Sewage plant assistant Waterworks assistant 8. FOOD AND DRUG PROTECTIVE SERVICES Food technologist Food and drug inspector Food and drug analyst 9. HEALTH EDUCATION Health educator Health education aide Community health educator Public health educator School health coordinator School health educator 10. INFORMATION AND COMMUNICATION Health information specialist Biomedical communication specialist Health science writer Medical writer Health technical writer Medical technical writer Medical editor Medical illustrator Medical photographer 11. LIBRARY SERVICES Medical librarian Medical library assistant Hospital librarian Patients' librarian 12. MATHEMATICAL SCIENCES 4 Mathematician Biomathematician Demographer Statistician Biostatistician Health statistician Vital tecord registrar 152 Primary title 1 13. M E D I C A L R E C O R D SERVICES Alternate title Medical record librarian Medical record specialist Medical record technologist Medical record assistant Medical record aide Medical record technician Medical record clerk 14. M E D I C I N E A N D O S T E O P A T H Y Physician Osteopathic physician Doctor of Medicine—M.D. Doctor of Osteopathy—D.O. Allergist Anesthesiologist Aviation medicine specialist Cardiovascular disease specialist Colon and rectal surgeon (proctologist) Dermatologist Forensic pathologist Gastroenterologist General practitioner Manipulative therapy specialist Neurological surgeon Neurologist Occupational medicine specialist M . D . Obstetrician or I Ophthalmologist D . O . Orthopedic surgeon Otolaryngologist (otorhinolaryngologist) Pathologist Pediatrician 6 Physiatrist (physical medicine and rehabilitation specialist) Plastic surgeon Preventive medicine specialist Psychiatrist 6 Public health physician Pulmonary disease specialist Radiologist 7 Surgeon Thoracic surgeon Urologist Intern Resident Fellow it 15. M I D W I F E R Y Midwife Lay midwife Nurse midwife 8 153 Primary title 1 Alternate title 16. NATURAL SCIENCES 4 Anatomist Cytologist Embryologist Histologist Botanist Chemist Bioanalyst Biochemist Clinical chemist 9 Environmental control chemist 1 0 Ecologist Entomologist Epidemiologist Geneticist Hydrologist Ground water hydrologist 1 0 Immunologist Meteorologist Air pollution meteorologist 1 0 Microbiologist 9 Bacteriologist Mycologist Parasitologist Virologist Nutritionist 1 1 Oceanographer Estuarine oceanographer 1 0 Pathologist Pharmacologist Toxicologist Physicist Biophysicist Health physicist 1 0 Physiologist Sanitary sciences specialist 1 0 Zoologist Limnologist 1 0 17. NURSING AND RELATED SERVICES Nurse Registered nurse—R.N. Graduate nurse Professional nurse Hospital nurse Occupational health (industrial) nurse Office nurse Private duty nurse Public health nurse School nurse Nurse anesthetist Nurse midwife 1 2 Obstetrical nurse Pediatric nurse Psychiatric nurse Surgical (operating room) nurse Practical nurse Licensed practical nurse Vocational nurse Licensed vocational nurse Nursing aide 1 X T Orderlv 1 Nursing assistant A t t e n d a n t I P sy chi a t r' c (mental health) aide Home health aide Home aide—homemaker Visiting health aide Ward clerk Floor clerk 154 Primary title 1 Alternate title 18. OCCUPATIONAL THERAPY Occupational therapist Occupational therapy assistant Occupational therapy technician Occupational therapy aide 19. ORTHOTIC AND PROSTHETIC TECHNOLOGY Orthotist Orthopedic brace maker Orthotic aide Prosthetist Artifical limb maker Prosthetic aide Restoration technician 20. PHARMACY Pharmacist Community pharmacist Hospital pharmacist Industrial pharmacist Pharmacy aide Pharmacy helper 21. PHYSICAL THERAPY Physical therapist Physical therapy assistant Physical therapy technician Physical therapy aide 22. PODIATRY Podiatrist Chiropodist Foot orthopedist Foot roentgenologist Podiatric surgeon Pododermatologist 23. RADIOLOGIC TECHNOLOGY Radiologic technologist Radiologic technician X-ray technician Radiation therapy technician 24. SECRETARIAL AND OFFICE SERVICES 4 Secretary Dental secretary Medical secretary Office assistant Dentist's office assistant Medical assistant Optometrist's office assistant Physician's office assistant 25. SOCIAL SCIENCES 4 Anthropologist Cultural (social) anthropologist Physical anthropologist Economist Health economist Psychologist Clinical psychologist Counseling psychologist Measurement psychologist (psychometrist) Social psychologist Sociologist Medical sociologist 155 Primary title 1 Alternate title 26. SOCIAL W O R K Clinical social worker Medical social worker Psychiatric social worker Clinical social work assistant Clinical social work aide Clinical casework aide 27. SPECIALIZED R E H A B I L I T A T I O N SERVICES Corrective therapist Corrective therapy aide Educational therapist Manual arts therapist Music therapist Recreation therapist Therapeutic recreation specialist Recreation therapy aide Homemaking rehabilitation consultant 28. SPEECH P A T H O L O G Y A N D A U D I O L O G Y Audiologist Hearing therapist Speech pathologist Speech therapist 29. V E T E R I N A R Y M E D I C I N E Veterinarian Laboratory (animal medicine) veterinarian Public health veterinarian Veterinary laboratory diagnostician Veterinary microbiologist Veterinary pathologist Veterinary radiologist Veterinary surgeon Veterinary toxicologist Veterinary technician Animal technician 30. VISION CARE Ophthalmologist 1 3 Optometrist Vision care technologist Ocular care technologist Ophthalmic technologist Optometric technologist Technician— Vision care technician Ocular care technician Ophthalmic technician (assistant) Optometric technician (assistant) Orthoptic technician Orthoptist Optician Dispensing optician Ophthalmic dispenser (optical fitter) Contact lens technician Lens grinder-polisher 1 4 Optical (laboratory) mechanic Visual care aide Ocular care aide Ophthalmic aide Optometric aide Visual training aide 156 Primary title 1 Alternate title 31. V O C A T I O N A L R E H A B I L I T A T I O N C O U N S E L I N G Vocational rehabilitation counsel ot Rehabilitation counselor 32. MISCELLANEOUS H E A L T H SERVICES Assistance for physicians— Physician's associate 1 5 Child health associate Pediatric associate Physician's assistant Anesthetic assistant Orthopedic assistant Physician's aide Obstetrical aide Pediatric aide Surgical aide Emergency health service— Medical emergency technician Ambulance attendant (aide) Inhalation therapy— Inhalation therapist Inhalation therapy technician Inhalation therapy aide Medical machine technology— Cardiopulmonary technician Electrocardiograph technician Electroencephalograph technician Other Biomedical instrument technician Nuclear medicine— Nuclear medical technologist Nuclear medical technician Other health services— Community health aide Dental health aide Mental health aide (worker) School health aide Extracorporeal circulation specialist Other Footnotes 1 The occupations listed are those which make a significant contribution to the health field and for which individuals have developed specialized competence. 2 Includes pathology laboratory. s See Natural Sciences. * For some of the occupations listed, only a minority of the workers may be engaged in health related work. ' Includes specialists in pediatric allergy and cardiology. • Includes specialists in child psychiatry. 7 Includes specialists in diagnostic and therapeutic radiology. 8 See Nursing and Related Services. 9 See Clinical Laboratory Services. 1 0 See Environmental Health Activities. 1 1 See Dietetic and Nutritional Services. 1 2 See Midwifery. " See Medicine and Osteopathy. 1 4 Also known as assembler, benchman, edger, or sur-faces optical technician or shopman. 1 4 Baccalaureate or higher educational background. 

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