Balancing care capacity and care demand: ensuring sufficient human and other resources are available to meet demand for health care is the goal. Achieving it can be difficult.As I dressed Jay's laceration, I asked him if he had ever harmed himself before As I gained his trust, he opened up and told me he wanted help I gained his agreement to talk to the Crisis Assessment Team Over the next few hours I tried to keep an eye on him while he waited, but I got tied up with a more acutely needy patient and when the team arrived, Jay had left ... I hope Jay got the care he needed I don't know Jay got a bandage on his arm But he missed out on the chance to really heal Another little sense of failure for me, as I failed to meet Jay's need Another opportunity lost."
Scenarios like this--where a patient does not receive a desirable aspect of care--represent care rationing It results from a mismatch between care capacity and care demand, and is distressing for both patients and staff Achieving quality care is not only the result of the efforts of health care professionals. The entire organisational system must be geared towards this outcome The accuracy of forecasting the services required, matching resources, putting the resources and systems in place and the quality of the monitoring system all affect the ability of those on the frontline to deliver safe, quality patient care It is a core responsibility of district health boards (DHBs) to ensure the system and resources match the actual capacity of the organisation to deliver planned health services
DHBs, like any organisation, operate within the boundaries of economic failure, unacceptable workload and unacceptable performance: ie, not spending more than they have, ensuring the demands on employees are not unreasonable and achieving an acceptable level of quality and safety (see illustration). (1) But, of course, health care cannot operate constantly close to the boundary of unacceptable performance, so a margin is required that provides the buffering and resilience needed to cope with fluctuations in demand and resources.
For a number of reasons, it is likely many health care organisations have experienced a "drift" of this buffering margin towards the boundary where quality and safety are regularly under threat With a narrow margin and insufficient buffering, it only takes a small variation in the demand on services to create an unsafe and unstable situation, where the organisation is grid locked, eg frequent "code-red" occupancy The ability of the organisation to mount a credible response when demand fluctuates, becomes more and more difficult For example, Mr Jones cannot come out of theatre because Mr Smith can't leave recovery, because Mrs Cook can't leave the intensive care unit, because Mrs Baker can't go home, because she hasn't had her serf-administered medication card completed by the pharmacist. Pressure then goes on the system to free up or create capacity and care rationing occurs, as front line professionals attempt to maintain safety and service.
That care rationing is a reality reflects that our hearth care system has acted for some time as a huge sponge, absorbing and adapting to the changes and increased demands in health care This has been achieved principally through better matching resources to need, working more efficiently and increased work effort However, once the limits of those gains are exhausted, the only option left (without injections of new resource) is to reduce the quality of the service offered Chronic workload pressure and compromises to quality are frequently cited reasons why nurses and midwives leave their professions. (2,3)
The goal is to find the place where the demand for health care is balanced with reasonable expectations of the work effort required to meet it and acceptable quality of outcomes. Getting there requires cooperation across the whole system and decision-making based on good quality information Currently we tack the sensitive data required Apart from major incidents or failures, quality and safety remain Largely invisible to those who are not directly giving or receiving care.
So what should we do--more forms and targets? Health professionals would probably argue (reasonably) that the level of monitoring and bureaucratic oversight is already onerous. The current system is over-monitored but, paradoxically, under-informed. However, if we accept the system requires good quality information to be able to manage and respond, perhaps we should be questioning what information we collect, when we should correct it and, most importantly, how we should respond to it. Much of the information is contained within service delivery, where nurses, midwives and other hearth professionals operate.
What does normal operating look like? What is our maximum capacity? How will we know when we have reached it? How do we measure true productivity, which includes quality as weft as quantity? What early warning systems of a drift towards unacceptable performance should we be monitoring for? What actually happens when occupancy exceeds 85 percent? What are the rear consequences of care rationing?
Only when we have the answers to such questions can we hope to manage the total system in a way that accurately relates the forecasted work programme to the organisation's ability to deliver it to an acceptable standard.
The third article will took at what actions we can take as a nation, as a sector and as health professionals committed to the provision of a safe, quality public hearth service.
(1) Cook, R. & Rasmussen, J (2005) Going solid: a model of system dynamics and consequences for patient safety. Quality and Safety in Healthcare; 14, 130134.
(2) Peter, E. H, Macfarlane, A.V & O'Brien-Pallas, L. (2004) Analysis of the moral habitability of the nursing work environment Journal of Advanced Nursing; 47: 4, 356364
(3) Verplanken, B. (2004) Value congruence and job satisfaction among nurses: A human relations perspective International Journal of Nursing Studies; 41, 599605
Jane Lawless, RN, MA Appld (Nsng), is the director of the Safe Staffing Healthy Workplaces Unit. This article is the second of three on the concept of care rationing.