Thomas C. Ricketts, III, PhD Learning Objectives




Learning Objectives

After completing this chapter, the reader should be able to

• trace the history of human resources for health and workforce planning; • learn why and when workforce planning is undertaken; • briefly describe the five major methods used in workforce planning; • understand the key concepts of benchmarking, adjusted needs, and

demand as they apply to workforce planning; • develop a simple estimate of the future supply of a profession for a

population; and • interpret the results of workforce planning reports as they relate to

individual healthcare organizations and delivery systems.


Most of this book views human resources management (HRM) from the per- spective of the healthcare organization. Chapters focus on such topics as job design, recruitment and retention, and evaluation of individual performance. However, organizations are also affected by the larger external environment in which they are situated. In HRM, broad workforce policy and labor mar- ket factors, which are external aspects, affect an organization’s ability to attract and retain employees. An organization may have a theoretically sound recruit- ment program for nurses, but if sufficient numbers of nurses are not being trained in the national healthcare system, the program will likely prove unsuccessful.

This chapter’s focus is unique among the chapters in this book in that it addresses workforce planning for communities, regions, states, countries, and other jurisdictions. It devotes attention to the healthcare workforce needs throughout society rather than the needs of a particular organization.

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C o p y r i g h t 2 0 0 8 . H e a l t h A d m i n i s t r a t i o n P r e s s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

EBSCO Publishing : eBook Academic Collection (EBSCOhost) - printed on 2/1/2022 4:14 PM via WESTERN KENTUCKY UNIVERSITY AN: 237620 ; Fottler, Myron D., Fried, Bruce.; Human Resources in Healthcare : Managing for Success Account: s8993066.main.ehost

Human resources for health (HRH) workforce planning deals with questions, including the following:

• How do we determine the number of surgeons needed in a particular geographic area?

• What factors help us to best anticipate future supply and need for various types of healthcare workers?

• What methods are used to project future workforce needs? What are the strengths and weaknesses of different approaches, and how may they be most effectively applied?

This chapter, therefore, takes a macro-level perspective on the healthcare workforce and examines concepts and methodologies that are useful in pro- jecting workforce requirements for communities and larger regions. Much of the remainder of this book focuses on internal strategies for managing human resources, which we can view as micro-level approaches, and addresses work- force concerns from the perspective of a single organization.

Workforce planning is the assessment of needs for human resources. This process can be very formal and complex or depend on “back-of-the-envelope” estimates and can be applied to small organizations or practices as well as to national and international healthcare delivery systems. Workforce planning fits in with overall health systems planning and human resources development and management. One conceptualization sees workforce planning as one of three steps in workforce development (De Geyndt 2000):

1. Planning is the quantity concern. 2. Training is the quality concern. 3. Managing is the performance and output concern.

The Australian Medical Workforce Advisory Committee (2003) de- scribes workforce planning succinctly: “ensuring that the right practitioners are in the right place at the right time with the right skills.” However, the consen- sus remains that workforce planning is “not an exact science” (Fried 1997).

Workforce planning is used to support decision making and policy de- velopment for a wide range of concerns. For healthcare organizations to meet their clinical and operating goals and objectives, they must effectively deploy and support workers of all kinds. Doing so requires that the numbers and types of workers match the needs of the patients, regulators, and payers who make up the functional environment of the healthcare organization. For state, provincial, and regional or national systems, policymakers also require infor- mation from planning processes that include workforce projections and assess- ments. Functionally, workforce planning does several things:

• Interprets tasks and roles • Establishes education and training needs

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• Explains the dynamics of the workforce • Describes and disseminates information about workforce and workplace

change • Defines and identifies shortages and surpluses

The History of Healthcare Workforce Planning

HRH planning dates back to the origins of organized medicine and health- care. Military planners recognized the need to provide adequate numbers of caregivers for wounded and ill soldiers, and very rough assessments of the requirements for qualified medical workers were part of the preparation for military campaigns. The healthcare system in the Soviet Union, and later in socialized nations, made use of systemwide planning (which includes an es- timate of the numbers and types of workers) in structuring healthcare. As European democracies moved toward national healthcare insurance sys- tems, they recognized the need to balance their policies for training and preparing healthcare workers with the anticipated needs of the covered pop- ulations. Given the importance of human resources to healthcare systems and the examples of planning that were in existence, it was still possible for an expert group to observe that “only very recently has there been more of a substantive debate about this issue internationally” (Dubois, McKee, and Nolte 2006). While HRH planning has a fairly rich history within individ- ual nations and among international bodies like the United Nations, it has received little reflection in most other countries. The United States offers an exception.

Daniel Fox (1996) describes healthcare workforce policy in the United States as “contentious and uncertain” and characterizes its history as a process that moved from “piety, to platitudes, to pork.” His observations apply mostly to the ongoing debate over whether the government should di- rectly support the education and preparation of physicians, or indirectly through some levy on social insurance, or not at all. Fox tracked the history of policies that were discussed and applied over time to support medical ed- ucation. His analysis pertains to the development of policy that depends on workforce planning, but he did not speak specifically of that development process.

Fox’s observations provide a useful context for understanding why we would or would not plan for a healthcare workforce in the United States. These reasons have implications for whether planning should be supported. By calling the initial stage of workforce policymaking the result of “pious” thinking, Fox implies that policymakers knew exactly the “right thing to do” and needed no or little specific guidance or planning to assist them. The sub- sequent dependence on “platitudes” about the reality of need and supply of

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physicians and nurses was made by using “accepted wisdom,” which again meant that there was little need for either planning or research. The culmi- nation of the policy stream with “pork” meant that resources were distrib- uted according to political power with little regard for the “facts”—again, a situation that does not require the development of information and specific planning.

Healthcare workforce policy has traditionally been driven by a percep- tion of a shortage of one or more of the healthcare professions. The history of concern over shortages may have started with physicians, but nurses were also considered a special part of the healthcare workforce and were subject to policy attention. The Nurse Training Act of 1941 attempted to expand nurs- ing schools during wartime to provide nurses for the military. An apparent shortage of nurses in the late 1950s generated the first federal legislation to support training of healthcare professionals for the “market,” not for some specific federal role. Subsidies for nursing education and public health trainee- ships were included in the Health Amendments Act of 1956, beginning an in- cremental expansion of federal government support for healthcare workforce training.

What followed were a series of healthcare professions laws that en- couraged the creation of training programs, supported faculty, expanded schools, or provided special aid for programs to redistribute the workforce. The Health Professions Educational Assistance Act of 1963 (P.L. 88-129) provided construction money for healthcare professions schools—funds tied to increased enrollment requirements to assist with the school’s operating expenses as well as loans and scholarship programs. The Act authorized sup- port to medical schools for the first time and firmly established the presence of the federal government in health-related educational institutions. This was followed by an almost annual succession of laws that added support for nurses, created loan-repayment plans, and paid for construction. In 1970, the National Health Service Corps was created, which put the federal gov- ernment in a role as a direct provider of healthcare professional service for the general population.

The precedent had been set for federal involvement in workforce pol- icy in 1956, but early in the twentieth century many states took on health- care professions education and regulation as an extension of their responsi- bility for public education and their implied “police powers” to protect the health, safety, and welfare of their citizens. Assuming a combination of power over both education and entry into the healthcare professions seems to sug- gest that the conditions were ripe for some form of planning on the part of the states that were investing substantial resources in medical and other health professions schools and that had ready policy levers to control the sup- ply of practitioners. However, the politics of the healthcare professions were

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clearly dominated by the professions themselves, and the dominant culture was to support the market for a highly paid elite physician workforce assisted by less-well-paid nurses and other caregivers (Starr 1982). According to Weissert and Silberman (1998), not until the 1990s did the states begin to “send a message that the medical schools have a responsibility to the state and its citizens.” For some reason, the states were not overly concerned with healthcare workforce supply and needs until the beginning of the twenty-first century.

Workforce planning can be considered a subtopic in the general area of HRH planning, but the two do not necessarily share a common history, and important differences exist in the way they are approached. Planning is usu- ally initiated when a perception exists that limited resources are available to meet all possible needs and that the market will not adequately distribute the available benefits.

The Rationale for Healthcare Workforce Planning

History tells us that policy and political pressures are generated when either the market or the public signals a shortage of some type of basic good or serv- ice. In the case of healthcare workforce, the shortage is of healing practition- ers and their supporting trades and professions. The case for formal planning, however, is often made in a more abstract and value-free context. Advocates for workforce planning sometimes appeal to a need for “rational policymak- ing,” but often the stimulus for formal action is when people claim that they cannot get what they want, need, or deserve.

In the United States today, the perception of a nursing shortage and the concern over a potential physician shortage are stimulating the de- mand for workforce planning. In Canada and the United Kingdom, both of which provide national healthcare coverage, queues for certain types of care are long, drawing attention to the need for workforce planning. The World Health Organization (2000, 2006) recognizes that HRH planning has to be able to respond to changes in technology and global patterns of migration in both population and profession. The drivers of HRH plan- ning have expanded to include the workforce’s adaptation to technology as well as the match of needs to supply. Figure 2.1 describes an analytical framework for HRH planning that considers the emerging concerns over global markets; migration; and changes in technology, institutions, and populations. The figure emphasizes that the healthcare system is embed- ded in a complex web of very strong external forces that shape the inputs to the system, including the human resources necessary for the system to function.

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Overview of Workforce Planning Methodologies

Five basic strategies are used in workforce planning: (1) population-based estimating, (2) benchmarking, (3) needs-based assessment, (4) demand-based assessment, and (5) training-output estimating. Each approach has its strengths and weaknesses, depending on the goal of the planning exercise and the con- text in which it will be applied. These methods may be used separately or in combination, depending on the system at which the planning is targeted as well as the specific policy questions posed during planning.

For national health systems, population-based estimating combined with training-output estimating may be more applicable than the other methods. The goal of planning in such systems may be to balance investments in training with the healthcare needs of the overall population. For individual organizations, benchmarking with peer institutions may provide useful information on how to staff a hospital or clinic to achieve productivity. Demand-based assessment can al- low managers to anticipate the effects of changes in requirements for staff after in- creased marketing efforts or proactive modifications to product mix (Schnelle et al. 2004). Needs-based assessment may be appropriate as systems and agencies try to cope with changes in disease prevalence or the availability of new technologies.

32 H u m a n R e s o u r c e s i n H e a l t h c a r e

Demographic Transition

Technological Innovation

Organizational Reform

Institutional Change

Global Trade

Human Resources

Work Outcomes

Health System

Work Content Workplace

FIGURE 2.1 The Contexts

for Planning in HRH

Workforce Planning

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Population-Based Estimating

This method rests on presumed appropriate or normative ratios of personnel and professionals to population. These ratios are not always generated from epidemiological analysis or careful study of productivity and utilization, but they often come from rules of thumb or from the current state of balance of practitioners to population. In the United States, several proposals for the most appropriate ratio of physicians to population have been based on obser- vations of current and past ratios. For example, in the United States, the Health Professional Shortage Area criterion views a ratio of 1 full-time equiv- alent primary care physician for every 3,500 people as an indicator of a severe level of need. A ratio of 1 physician to 3,000 people accompanied by elevated population-risk indicators, such as high infant mortality and a high proportion of people older than 65 years in a “rational service” area, also signals high need, making the area or population eligible for shortage designation.

In a description of the origins of the Health Professional Shortage Area (formerly Health Manpower Shortage Area) criterion, a federal report sug- gested that the 1:3,500 ratio was selected because it was 1.5 times the mean population-to-primary-care-physician ratio by county in 1974 and because it qualifies a quarter of all counties with the worst ratios (Bureau of Health Man- power 1977). That report indicated that the ratio of 1:2,500 was selected as a measure of relative adequacy, being close to the median ratio for all U.S. counties in 1974.

Many ratios have been suggested as indicative of adequate supply. Fig- ure 2.2 summarizes 16 such “ideal” or “adequate” ratios. The ratios are drawn from work by David Kindig (1994) and the Council on Graduate Medical Ed- ucation (1996, 1999). The wide variation in ratios points to the weaknesses inherent in population-based approaches. Variability can be the result of dif- ferences in assumptions concerning the productivity of practitioners, the needs for services in the population, and even miscalculations caused by poor data in surveys and practice lists. Nevertheless, analysts and planners persist in using ratios as standard indicators of desired staffing or as guides to their stud- ies of professional supply.


The benchmarking method takes into consideration existing ratios but adds a test of efficiency to the analysis. The most prominent example focuses on the physician workforce in the United States, where regional, population-based ra- tios have been estimated and compared to organizational ratios (Schroeder 1996; Goodman et al. 1996). In this case, regional ratios for hospital-referral areas generated for the Dartmouth Atlas of Health Care were compared to the ratio in a large managed care system and selected market-area ratios where there was intense or little managed care penetration. This approach to setting national standards is much more controversial than its use for organizations

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(Malone 1997; Wholey, Burns, and Lavizzo-Mourey 1998). The ratios used in the Goodman analysis included an adjusted HMO (health maintenance organ- ization) staffing ratio (1:1,908) and the actual generalist ratio for the Wichita (1:1,527) and Minneapolis (1:1,316) hospital-referral regions (see Figure 2.2). Across the United States, using the hospital-referral regions to calculate denominators, 96 percent of the population lived in areas with more general- ist physicians than the HMO benchmark, 60 percent lived in areas that ex- ceeded the Wichita standard, and 27 percent lived in areas that exceeded the Minneapolis standard.

Advocates of benchmarking view these ratios as achievable, optimal ra- tios and accept the implication that these ratios describe the most efficient supply of practitioners. Benchmarking has become a part of the workforce- analysis process, and the influence of the Dartmouth Atlas of Health Care in guiding policy debate may make this approach more important. However, there has been little acceptance of specific standards for setting policy targets or for setting standards for underservice. The development of a revised stan- dard for underservice for primary medical care has been under discussion by the federal government since 1998 when a formal proposal was published but withdrawn (Ricketts et al. 2007).

Needs-Based Assessment

Perhaps the most obvious method of determining how many healthcare pro- fessionals should be supported in a system or an organization is to match the consensus healthcare needs of a population or client base with their biologi- cal need for care. Unfortunately, healthcare need is difficult to determine and is subject to much variation. The substantial differences in physician opinions over the indicators and conditions that signal need for various procedures— such as carotid endarterectomy and coronary bypass graft operations, among other costly and specialized interventions—have been well documented (Birk- meyer et al. 1998; Wennberg et al. 1998). That variation has been persistent, and even concerted efforts to develop consensus on the need for specialist care have not been altogether successful (Fink et al. 1984). Those consensus meth- ods, however, can be applied to more localized situations, and useful guidance can be developed to determine how many individuals in a population are likely to require selected services.

The consensus process for needs-based assessment is iterative, where lists of indicators, signs, and conditions are presented in various combina- tions and where “expert” clinicians are asked to determine if these combi- nations are high-, medium-, or low-level reasons for hospitalization, for conducting a specific procedure, for course of therapy, or for prescribing a specific medication. The expert panel members rate these combinations, dis- cuss the results, and re-rate them. These steps usually result in a mix of

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combinations—strong agreement on a particular care pathway is achieved, but agreement on other situations is not as high. However, the area of agree- ment is usually sufficiently large to allow for estimation of the total burden of care that certain groups of people are likely to require.

For national or other large populations, analysts can combine sepa- rate classes of diseases and their associated estimates of care to develop pro- jections of staffing requirements. This was the approach taken by the Grad- uate Medical Education National Advisory Committee (1980) when it developed national projections of need and supply of physicians and primary care practitioners. That process was called “adjusted needs-based approach” to workforce planning, and it has been used since its development for spe- cialty-specific estimates of requirements (Elisha, Levinson, and Grinshpoon 2004). For very specific specialties, the task of determining even supply is very difficult: “The actual number of FTE [full-time equivalent] neurosur- geons in practice is more difficult to determine, because the number is con- stantly changing as a result of death, retirement, modification of practice habits and mix of clinical practice versus other professional activities” (Popp and Toselli 1996).

The use of needs-based assessment to plan for staffing is supported in some sectors of the healthcare system by more carefully structured studies. An example includes the development of appropriate ratios of dental care practi- tioners (DeFriese and Barker 1982). Practical applications in healthcare or- ganizations and bounded delivery systems require a focus on a particular type of need related to a specific type of organizational form—for example, the need in relation to staffing for outpatient mental health clinics that are man- aged centrally and that are located in areas where few alternative sources of this type of care exist (Elisha, Levinson, and Grinshpoon 2004).

Demand-Based Assessment

This workforce planning method is explicitly economic in nature and is based largely on past patterns of service utilization. Demand is considered to be somewhat independent of need for care in that some individuals may seek care when they are not ill, because they either misread their symptoms or desire to be treated regardless of medical need. In practice, need and demand are con- sidered very closely tied. In an economic sense, demand is equal to utiliza- tion—what is consumed is what is demanded; that is, there is a balance in sup- ply and demand in the market that is regulated by the price of the goods and services that are consumed. However, often the case is that demand and sup- ply are not in balance in a sector such as healthcare because prices are not eas- ily determined by either the purchaser or the supplier. Still, utilization can be a strong indicator of demand in a system in which the few barriers to care are caused by access restrictions. An open argument in the United States is whether or not the government restricts access by market rationing—a system

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that is opposite the explicit budget-rationing system in countries such as the United Kingdom and Canada.

A good example of the use of demand-based assessment is provided in studies commissioned by the American Medical Association (Marder et al. 1988). Any mathematical model that projects the supply or demand for healthcare professionals must include certain assumptions about the future. For example, knowing that a substantial growth is likely in the outdated num- ber and population proportion allows the planner to anticipate much higher levels of utilization. These elevated levels of demand will be reflected in in- creased supplies of practitioners who are trained to care for the elderly, pro- vided the training system is able to respond. In an application of this principle at a very macro level, a study by Cooper and colleagues (2002) demonstrates that overall economic activity is what determines the future supply of physi- cians in the United States. The authors’ assumption is that the supply of med- ical practitioners is determined by the degree to which demand can be ex- pressed in a relatively open market for care.

Training-Output Estimating

Training-output estimating is perhaps the most common method for antici- pating supply of practitioners. Essentially, it draws on data from training pro- grams, such as the number of enrollees, the number of anticipated graduates, and the trends in applications. This approach has been used to anticipate trends in the general supply of physicians (Cooper, Stoflet, and Wartman 2003), general surgeons (Jonasson, Kwakwa, and Sheldon 1995), internists (Andersen et al. 1990), pediatricians (Bazell and Salsberg 1998), and allied health professionals (DePoy, Wood, and Miller 1997).

Estimations of the supply of nurse practitioners and physician assistants rely heavily on trends in enrollment in training programs (Hooker and Caw- ley 2002; Buerhaus, Staiger, and Auerbach 2000). Anticipating the character- istics of the future workforce in relation to current training patterns is impor- tant to understand how well today’s practitioners will meet clinical and social needs in the future. This issue has become critical in the United States, as the focus of national policy has shifted toward having a workforce that matches the racial and ethnic structure of the population (Fiscella et al. 2000).

Challenges and Difficulties of Workforce Planning

The fundamental challenge to HRH planning is that any credible analysis that points to an impending shortage or surplus of practitioners is likely to result in a policy or an organizational response that precludes that scenario from occurring. Retrospective analyses of “how well we did” often empha- size how poorly the projections performed rather than how much reaction

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these projections generated (Cooper et al. 2002). Disappointingly, such ret- rospective analyses are applied only to national estimates of the state of the workforce at some unspecified future time. In planning for physician supply, rarely are organizational or delivery system analyses discussed and critiqued, except when making them the basis of national estimates (Weiner 2004, 1994, 1987; Hart et al. 1997).

Planning for nursing staffing includes much more organizational em- phasis because such planning is considered a “staffing” problem subject to management, rather than a need to anticipate a market response (Seago et al. 2001). Nursing staffing, however, is also subject to broad-scale analyses to an- ticipate local conditions (Cooper and Aiken 2001).

International Perspectives

National-level HRH workforce planning is practiced more often in other coun- tries. This is a function of the political economy of these countries’ healthcare systems, in which central direction and planning is the norm. In other coun- tries, most ministries or departments of health include a human resources divi- sion or section that is responsible for the planning function. The planning that goes on is applicable to the overall system, where decisions are made concern- ing the number of practitioners and support staff to be trained or allowed into the country. Planning for specific staffing needs of institutions often takes place within the same part of the bureaucracy, but sometimes delineation is made be- tween strategic planning for national needs and strategic planning for policy and institutional planning for staffing and management decision making.

Canada, for example, developed the Pan-Canadian Health Human Resources (HHR) Planning Initiative intended to bring more evidence- based methods to the work of Health Canada. This consortium effort relies on external research and analysis groups as well as on internal staff. The task of the Canadian HHR planning group is focused on assessing the future staffing and contracting needs of Health Canada and the provincial ministries and departments, as that nation attempts to reform the Canadian healthcare system in response to the 2003 First Ministers’ Accord on Health Care Re- newal. The 2003 Canadian federal budget allocated $90 million over five years to strengthen healthcare human resources planning and coordination. The national work and interprovincial planning activities are coordinated through the Advisory Committee on Health Delivery and Human Re- sources, which has assigned a planning subcommittee to develop evidence- based recommendations on education strategies, especially interprofessional education, and on establishing a workforce that can respond to a patient-centered healthcare system.

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In 1995, Australia developed formal structures in its Department of Health to oversee planning activities for its healthcare workforce. For politi- cal and practical reasons, the oversight of planning functions was divided be- tween two committees—one for medical positions (Australian Medical Workforce Advisory Committee) and one for all other professions and occu- pations (Australian Health Workforce Advisory Committee). The central technical task of these committees is to estimate the “required health work- force to meet future health service requirements and the development of strategies to meet that need” (Australian Medical Workforce Advisory Com- mittee 2003).

The World Health Organization supports the Human Resources for Health program, which has invested heavily in developing skills of personnel who can do workforce planning for national and regional healthcare systems (see www.wpro.who.int/sites/whd for an example of work done in the west- ern Pacific). Australia, for example, has committed substantial resources and energy in the development of plans for its rural and remote workforce, and it has developed a national public health workforce program (see www.nphp.gov.au/workprog/workforce).

Barriers to healthcare workforce development in all countries in- clude a failure to specify health goals, limited liaison between the health and education sectors, and resource constraints. Other factors that have complicated a strategic approach to healthcare workforce development in- clude the diversity and rapid evolution of health services, the long train- ing period for most healthcare professions, and the increasing mobility of the healthcare workforce. Political ideology can also be a major player. In New Zealand, the market-oriented health reforms of the 1990s created a competitive rather than a collaborative environment in which workforce development was not a priority (Hornblow 2002). That has changed to some extent in recent years, but the Health Workforce Advisory Commit- tee that was established to direct policy was disbanded in 2006 (see www.hwac.govt.nz).

One international development that is beginning to have widespread effects on workforce planning and planning in a management context is the European Union’s Working Time Directive (WTD) (Roche-Nagle 2004; Paice and Reid 2004). This rule applies to a wide range of healthcare profes- sionals and sets limits on the amount of time an individual is allowed to work in a day and over a work week. The initial implementation of the WTD began in August 2007. In August 2009, the directive will restrict the hours that trainees can work from 58 hours to 48 hours per week. The response to the restrictions has been to increase the intake of trainees in some systems, such as the National Health Service in the United Kingdom, and to restructure some training program schedules.

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Workforce Supply Metrics

Measuring the supply of healthcare professionals is not as straightforward as it seems. A doctor is what a doctor does, but when considering the overall professional supply needed for a specific area or organization, the distinction between what a doctor is and what a doctor does is harder to make. For ex- ample, in counting primary care physicians, most experts and many explicit policies consider a family physician as dedicated to providing primary care, which is defined as healthcare that most people need most of the time. Un- der that description, a primary care practitioner, then, takes care of the most common complaints and coordinates the care needs of a patient—be it specialty or inpatient. However, is a psychiatrist or an OB-GYN a primary care physi- cian? Each may be the patient’s first contact with the medical system, and each may coordinate the care for many individuals, but the practice of a psychiatrist and an OB-GYN is limited to certain aspects of human health and illness.

To add more confusion, in many states and under certain federal regula- tions, these practitioners are considered primary care physicians. In other sys- tems, the primary care physician’s work is proscribed by certain rules to include only ambulatory care. These physicians are most often termed “GPs” or general practitioners. They may, however, have greater autonomy in the system and be able to control entry into hospitals. This kind of gatekeeping power may, in turn, influence the resulting demand or expressed need for surgery and, subsequently, for surgeons. The dynamics of the system, thus, become important to the esti- mation of the need for specialists and the staff who support them.

The extent of details involved in creating an inventory of primary care physicians is indicative of the complexity of any process that tries to ascertain how well the supply of healthcare professionals meets the needs of a popula- tion or an organization. This challenge often deters managers as well as plan- ners from attempting to balance their anticipated needs for healthcare profes- sionals with likely scenarios for supply. Sufficient models are available on how to approach HRH workforce planning that can make the effort well worth- while in reducing overall costs of staffing or training and the costs associated with mismatches of needs and resources.


HRH workforce planning is the anticipation of how many practitioners and support workers an organization or a system will require to achieve its mis- sion. The development of effective workforce plans depends on the use of ac- curate and reliable data that describe current supply, pattern of entry and exit from professions and positions, and the number of incoming workers from training programs and schools. At the national level, HRH planning requires

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Discussion Questions

41C h a p t e r 2 : H e a l t h c a r e W o r k f o r c e P l a n n i n g

1. What are the major types of healthcare workforce planning? Provide examples of situations where each strategy would be more appropriate than the others.

2. Healthcare workforce planning is often done after a shortage in a particular profession is recognized. How could planning help avert those shortages?

3. Counting healthcare professionals as part of healthcare workforce planning is not always straightforward. For a specific profession—nursing, dentistry, or medicine—describe how the prac- tice patterns of the professionals may change the effective supply of that profession.

Experiential Exercise

In 1999, California became the first state to pass a law

that requires minimum staffing ratios for nurses in general acute care hospitals (Coffman, Seago, and Spetz 2002). California Assembly Bill 394 (AB 394) mandated the Department of Health Services to create “minimum, spe- cific, and numerical nurse-to-patient ratios by licensed nurse classification and by hospital unit for the inpatient parts of general hospitals in the state.” In January 2004, those regulations came into effect, translating into the following: In the emergency department, one nurse cannot care

for more than four patients, while in postoper- ative surgical units, nurses cannot care for more than six patients.

Using the national nursing supply- and-demand model, the following table on page 42 shows the projected supply of regis- tered nurses (RNs) and a trend for inpatient days in general acute care hospitals in North Carolina, from 2007 through 2023.

The North Carolina General Assem- bly is considering implementing a mandatory staffing ratio that matches the California rules for emergency departments and post-op


an understanding of major economic and social trends as well as a keen sense of the politics involved in labor and professions.

Five basic methods are used in workforce planning: (1) population- based estimating, (2) benchmarking, (3) needs-based assessment, (4) de- mand-based assessment, and (5) training-output estimating. Each ap- proach offers strengths and presents weaknesses, depending on the context in which it is applied. The institutional planner can use all or a combina- tion of these approaches in developing staffing plans, preparing for turnover and transitions, and positioning the organization to compete ef- fectively for resources.

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If North Carolina imple- ments a staffing law ex-

actly like the one in California, and that law is put into effect on January 1, 2009, how would the numbers in the above table change? Estimate the change in the number

42 H u m a n R e s o u r c e s i n H e a l t h c a r e

surgical units in general acute care hospitals. The North Carolina Hospital Association found that in all of the hospitals in the state with emergency departments and post-op surgical units, emergency departments ac- counted for 8 percent of total inpatient days in 2007, and the post-op units accounted for 11 percent of inpatient days. Overall, hospi-

tal RNs accounted for 38 percent of all RNs practicing in North Carolina. Three percent of these hospital RNs worked in emergency departments, while 2.2 percent worked in post-op units. The available supply of RNs in 2007 allowed all hospitals in the state to fully staff their emergency departments and post- op units.

of RNs required to staff the emergency de- partments and post-op units of acute care hospitals in North Carolina. The use of both units is expected to rise in direct proportion to the overall use of hospitals as measured by inpatient days.


Year Number of RNs Trend of Inpatient Days

2007 67,712 4,024,336

2008 68,382 4,090,608

2009 69,049 4,156,880

2010 69,718 4,223,151

2011 74,387 4,289,423

2012 75,050 4,355,695

2013 75,536 4,421,967

2014 75,730 4,488,239

2015 75,890 4,554,511

2016 76,020 4,620,782

2017 76,160 4,687,054

2018 76,210 4,753,326

2019 76,208 4,819,598

2020 76,199 4,885,870

2021 76,165 4,952,141

2022 76,065 5,018,413

2023 75,800 5,084,685

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