TWS ACA ReportingBoth human resource professionals and healthcare providers are grappling with the immediate compliance issues associated with the Affordable Care Act, even as the rules continue to evolve.  Practitioners on both sides of this equation are also contemplating the longer term cost and management implications of the Act.   Despite, or perhaps because of all the press that the ACA receives, there is still plenty of confusion about what the Act really means for employers and healthcare providers.

In order to shed some light on how practitioners are gearing up for the ACA, I spoke with our  board member, Dr. Tim Porter O'Grady and Kronos Senior Director Jim Rowe. Tim has been involved in health care for 40 years and has held roles from staff nurse to senior executive in a variety of health care settings.  Jim Rowe is the Senior Director of Total Rewards at Kronos.  Both are deeply embroiled in the practical implications of implementing the ACA, on both the employer side as well as the healthcare delivery side of the equation.  And both agree that while there should be long term benefits for Americans in the form of more comprehensive, economical and effective healthcare, there are also plenty of short term challenges to enacting the law.

You can listen to a podcast of our discussion of the following questions at:  Tim Porter OGrady and Jim Rowe Discuss the ACA 1.20.14.

 What about you?  How is your organization preparing for the ACA?

Other Relevant Posts:

The Affordable Care Act Isn't a Benefits Change - It's a Culture Change

Engaging Health Reform

Part Time Workers Confused by the Affordable Care Act



patient gurneyToday's guest blog post is courtesy of our board member, Tim Porter-O'Grady, DM, EdD, ScD, FAAN, FACCWS.  Tim brings a deep and informed perspective to the implications of the Affordable Care Act for workers, their employers and healthcare providers.  What's your organization doing to get ready to comply with the Act?

The Patient Protection and Affordable Care Act (PPACA) is well on its way into the fourth year of implementation. Looking past the strident political machinations, human resource leaders need to now deepen their understanding of its components and characteristics and what it actually does to improve the lives of workers and how it addresses long-standing health concerns of management. For the first time in the history of American healthcare, there is a drive to achieve real health value and ultimately to change the health status of the American population.

This focus on value economics now means that there must be increasing evidence of impact in health services.  The longstanding dependence on a tertiary care model where we wait until employees get sick and then undertake a flurry of activity to address the problem leads us to higher levels of cost and a lower capacity for a sustainable positive health outcome.  Our primary care foundations or infrastructure is not yet so well developed to a level that we can focus on preventing the conditions and circumstances that lead to our highest priced illnesses and conditions. One need only look at the overwhelming problems we are now confronting with the challenges and cost of treating an uncontrolled level of diabetes directly related to obesity and the high sugar, high fat diet in the U.S. The costs associated with treating diabetes and its co-morbidities over a lifetime far outstrip the costs associated with early addressing the practices and behaviors that lead to them.

The PPACA now emphasizes efforts that directly address health concerns and issues that can prevent the later onset of illnesses. Regular screening for high risk health issues can now be incorporated into health plans in a way that addresses both illness prevention and related costs. In addition, free preventive services are provided for potentially high risk, high cost services such as abdominal aortic aneurysm, alcohol misuse, blood pressure, cholesterol, colorectal, depression, type II diabetes, HIV screenings, diet counseling and immunizations (hepatitis, herpes, papilloma virus flu, measles, mumps, rubella, pneumonia, tetanus, diphtheria, pertussis, and varicella). In addition, free counseling is available regarding obesity, sexually-transmitted diseases, and tobacco use. Since many if not most employee related sick days are the result of these identified health problems, there is a potential for significant cost benefit for employers to assure their employees participate in these free preventive services.

Provider performance now emphasizes those activities which prevent accelerating utilization of high intensity health services and repeated admission to health services because earlier services were inadequate or ineffective. Recidivistic health care will simply not be supported or funded if it represents poor provider practices or ineffective standards of care. The PPACA now requires that providers “get it right” by assuring the application of evidence-based protocols and best practices for defined episodes of care. Besides accelerating the potential for quality care, the impact on the cost of that care of more effective provider practices will be significant.

Providers will now be incented not only by price but also by quality.  Competition between plans and providers now include measures of impact especially as it relates to comparable measures of quality of service.  Quality measures will now include clinical comparative effectiveness and user evaluation of service satisfaction. Imbedded in health reform is the intent that the system must ultimately produce a healthy population, not simply treat its ails and illnesses. In fact, the notion that admission to a hospital bed is evidence of the failure of the system to better address the health needs of the person plays out as a theme throughout the PPACA.  Beginning January 1st, 2015, physicians and other providers will begin to be paid for value not for volume. The question in this climate for the provider is not how much did I do for persons but rather did I make any difference for individuals in what together we chose to do in their best interests.  Those providers than can advance the quality of service and care at the same time as carefully managing its costs will be positioned to reap value-based rewards.

For employers and their health plans, the net aggregate value of this shift in design, delivery and outcome in the PPACA provides one of the strongest efforts to date to get at real issues of health-driven care and service. It is now time for employers who have a large stake in a healthy workforce to reinvigorate their own efforts to partner with their health plans in the pursuit of early engagement health services, primary care health interventions, and the pursuit of healthier life choices. The impact of such an effort will accrue to both healthy workers and a healthier bottom line.

 Related Posts:




Our board member Dr. Tim Porter O'Grady submitted the following guest blog interpreting the radical transformation of the US healthcare system required by the Patient Protection and Affordable Care Act.  Technology can help, but the biggest changes will begin with linking process to outcomes via intelligent process design and meaningful analytics.

Now that the Supreme Court has ruled on aspects of the Patient Protection and Affordable Care Act, the healthcare system is in overdrive as it attempts to reconfigure itself within the context of the Act (PPACA). The central driver for both the formation of the act and the response of the healthcare system has been the accelerating, some would say spiraling, costs of healthcare. In 2009, the gross domestic product percentage devoted to health care was just over 17%. In 2008 it was just over 16%; in 2001 it was under 15%. Clearly, the accelerating costs of providing contemporary healthcare and its growing portion of the gross domestic product have made continuing the existing tertiary care late stage engagement model impossible to sustain. As a result of the passage of the PPACA, major recalibration of the way health services will be provided over the next two decades is underway with shifts in policy, regulation, and program design. Growing emphasis on terms such as "value" and "accountability" are shifting the focus of healthcare away from emphasis on "process and volume" toward "product and value".

The rising public and private costs of healthcare are insupportable by governments, employers, small businesses, and individuals. At the same time, costs of health service are rising and despite high levels of spending in healthcare, measures of impact, outcome, quality as tested by quality-of-life indicators such as health status, life expectancy, and infant mortality compares dramatically unfavorably with other developed nations. While advances in clinical technology have progressed significantly in the United States, providers lag notably behind the European Community, Australia, and New Zealand in the use of electronic health information systems. On top of these realities, the average annual health insurance premium for a family hovers around $14,000, nearly 55% greater than the family costs for healthcare in 2000.

There is simply no longer any doubt that major change toward higher levels of accountability from providers and a more clearly delineated health outcome needs to be more firmly embedded in a transformed health system. As all services generally become more "user-driven", emerging models of health service must also reflect "user" or "patient-centered" approaches to delivering service. At the same time, services must result in a net aggregate positive impact on sustainable health status of both individuals and populations. With this reality as a centerpiece for healthcare design, providers must now focus their efforts within a different context in a way that demonstrates the convergence between discernible and intentional processes and their goodness-of-fit with clearly delineated and measurable health impact and outcome.

The challenge with this shift away from process emphasis is reflected in the esteem that providers have for their own good process. Indeed, indicators and measures of productivity have historically been driven by workflow, time and motion, and physical efficiency measures. This overarching emphasis on process and productivity has done much to focus on efficiency but has had little discernible impact on effectiveness. Emerging understanding of the character of professional work and judgment-based decision-making points to the inestimable value of assessment-reflection-evaluation as a foundation for delineations of value-defined productivity. The factors that now emerge as important in professional work more emphatically advance the value of creating a goodness-of-fit between effective process and relevant outcome. Indeed, the structure of service payment in the provision of healthcare will reflect how the convergence between effort and effect demonstrates best practice. Comparative effectiveness data will now compare and contrast the variety of service settings devoted to addressing particular health concerns or the health of specific populations. It is here where the shift in the minds and efforts of providers from volume to value will be most challenging.

The historic vertically constructed and compartmentalized service infrastructure in healthcare that insulated providers within the walls of their own clinical categorization and role boundaries now must become more porous. Individual disciplines must now configure in a more intentional and enumerated interface with a community of other disciplines who play a determined and articulated role in a complex mosaic of population specific health-generating activities. Financial and service success in a value-driven equation now depends on the intensity of interface and relational effectiveness between each member of the service team and the aggregated convergence of effort they all exhibit in the achievement or advancement of particular health outcomes for given populations or services. In order to both achieve and sustain this quality and value paradigm several key dramatic systems and role changes must occur:

  1. Providers in each discipline will need to create a common understandable language which clearly elucidates their specific roles and contribution to the team's collective effort in the individual patient experience.
  2. Organization of healthcare services now must configure around a “health script” in a way that relates to advancing the health of specific persons or populations.
  3. Provider communities must be constructed and effectively configured to work conjointly both in defining unique discipline-specific contributions and collective impact and values achieved by the convergence of mutual effort.
  4. Patient “users” must now be incorporated as members of the clinical team demonstrating their commitment and accountability for their own health and for their role in contributing to the health of the community.
  5. Measures of quality and value (including financial) will now be deeply embedded in indicators of aggregated community health and wellness sustainability.

There has not been as dramatic and broad a systems shift in health services perhaps since the introduction of Medicare. Both broad and deep changes in the configuration and payment of healthcare services will call for different delineation of clinical work, relationships, productivity, effectiveness, integration, and impact. This cycle of change is early in its dynamic and it is far too soon to determine the extent of viable change and the degree of its impact. For the cynics, it may imply nothing more than rearranging the deck chairs, and for the optimists, the achievement of meaningful and sustainable community health.

As always, reality lies somewhere in the midline between these two extremes. However, what is not sustainable is an increasing acceleration of costs for health service and a concomitant decline in health status. What results in this dramatic health system transformation will, as usual, not look anything like what is imagined at its initiation. Innovation, creativity, availability to change, and adaptation will be the usual attributes that characterize successful transformation. Re-languaging health service, recalibrating service design, and evaluating provider and programmatic impact and value will be necessary for all participants and will require evaluating effectiveness within a just-in-time frame. Never having reconfigured in process and innovated on the go, healthcare leaders will have to demonstrate new competence and capacity for network management, emergent dynamics, collective enterprise, and new financial/payment arrangements. For everyone in America we are at the “Nike moment” in health transformation and it is now time to “just do it”.

The following guest blog post is provided by our board member Dr. Tim Porter-O'Grady.  In it, he argues for the benefits of employee self-scheduling in the healthcare environment.  In addition to the citations he includes below, readers can also learn more about self-scheduling best practices in our recent publication "Elements of Successful Organizations".

As viable as staffing self-scheduling can be, it is surprising that it is still a minority choice for scheduling professional workers. Perhaps much of the problem relates to the need for a positive understanding of the characteristics of professional workers and the unique need they have to control their time and their practice. This delineation of the knowledge worker's need for control over life and professional practice is the relatively recent product of professional staffing research (1). As a result, it may not have reached full exposure in the management techniques and methodologies of contemporary clinical managers. Even though virtually no one should be able to claim they've not heard of self-scheduling, it still has not caught on as the majority work scheduling vehicle for most clinical settings. We might do well to advance the argument representing some of the basic elements and characteristics of effective professional worker self-scheduling as the foundation for advancing interest in its utility.

Variations in self-scheduling have been around since the 1960s and hospitals and health systems have used it since that time with varying degrees of consistency and success. Benefit claims include ownership, engagement, consistent compliance, cost savings, high levels of staff satisfaction, and potential reduction in staff turnover. Self-scheduling is especially useful for round-the-clock workers who must address the needs for schedules 24 hours a day seven days a week. The inclusion of weekend scheduling implications makes self-scheduling especially useful in so far as it balances and regulates the use of weekend work time more equitably across the service or departmental workforce. In addition, compressed workweek schedules (three to four 12 hour shifts per week or seven day/12 hour work weeks one week on/one week off schedules) and Baylor Plan schedules (two 12 hour weekend work shifts counted as a full week schedule), all serve to add creativity and flexibility to round-the-clock professional worker scheduling (2).

Self-scheduling processes involves engaging the staff and assuming primary responsibility for the planning and constructing of their own staffing schedules. Usually large worksheets or computer programs cover all available staff over a period of 4 to 6 weeks. Schedules are made available two weeks to a month in advance via specific protocols and guidelines agreed to by management and staff establishing the essential staffing rules and processes that must be applied to scheduling all persons. Often, rotations are suggested by software programs designed to fit the particular staffing modality of an individual unit or service, thus allowing the schedule to present as complete so that staff can see the objective array of scheduled shifts and rotations before adjustments and modifications can be addressed to apply the unique and particular needs of staff in a way that adjusts the originating schedule. In many healthcare organizations, shift patterns have been long well established and individuals have frequently been slotted into those patterns for long periods of time factors reflecting tenure, role, patient characteristics, intensity, acuity, individual professional skill set, and a range of other factors can often influence the routine foundations for self-scheduling. Having a fully developed and visual staffing schedule helps individual staff see the complexity, vagaries, and impact of shifts or changes each might seek to apply to the existing potential schedule. It helps the individual identified complexities and impact of changes across the scheduling array, deepening individual understanding of the vagaries and challenges associated with making changes in one place and its significant impact on other components of the schedule. This increased awareness accelerates the sense of engagement and impact, challenging individuals to caution regarding choices, carefully justifying their choices and the adjustments they make and their impact on the schedule and lives of colleagues and peers.

While accountability for appropriateness and balance in the schedule now emerges between peers and the affected staff in self-scheduling, the role of the manager also changes. From the more directive, parental, and controlling agency, the manager now must become proctor of the terms of engagement, the consistent requisites of the protocols and processes regarding fairness and equity agreed to by all stakeholders, and assure that the final schedule product represents balance, fairness and equity, sufficiency and adequacy, and meets the general staffing requirements of the service or department. In the role of "agent of accountability", the increasing obligation on the role of the manager emphasizes the need for the manager to develop the more adult to adult capacity in the staff for quid pro quo, negotiating particulars, trade-offs, time bartering, and value exchange. These techniques require a higher skill set than simply evidenced in the manager's traditional ability to unilaterally manage the mathematics flow of shifting numbers and persons on a paper grid. Secondarily, the development of these "agency" management skills yields parallel results in resolving personal conflicts, mediating issues, negotiating outcomes, and interest-based problem resolution on a broad range of nonrelated but important human dynamics issues (3).

There are a range of positive results that arise is the product of self-scheduling in most professional organizations. For the manager, less time is spent in the parental role of directing and managing others requests for time shifts, days off, schedule adjustments, and shift changes. Two outcomes result from this shifting accountability: more time is provided for the manager to develop in others the skills necessary to negotiate relationships and choices and, secondly, peer ownership and investment in the work schedule accelerates, moving the locus of control for related issues to staff at the point-of-service. Predictably, personal ownership and life self-management of individual staff accelerates simply because engagement and predictability joined to allow the professional more personal control over choices that affect his or her life and the use of time. In addition, the acceleration in the degree of interaction between members of the professional staff around the balance and distribution of time and schedule increases the intensity of communication, interaction, interpersonal capacity, and agreement with secondary benefits of increased ownership, increasing interaction, staff satisfaction, and a more professional context for the work (4).

In self-scheduling, when problems do occur they become more readily apparent and more visible to all stakeholders. Issues related to absenteeism, chronic violations of time and schedule, and the pattern of sick time use generally decreases because the schedule more clearly represents the needs and wants of staff and the personally negotiated parameters which more clearly define agreements around the use and distribution of work time. Suggestions also indicate that greater shift in scheduling satisfaction leads to reduction in turnover and accelerates the potential for positive recruitment (5). Academic programs now suggest that as staff seek employment one of the questions they raise relates to the presence of staff-driven self-scheduling approaches.

As a concluding point, questions abound as to the sustainability and viability of self-scheduling over the long term. Major concerns exist whether staff is continuously able to negotiate and construct viable and satisfactory schedules over the long term. Increasingly, current data suggests that staff increasingly demonstrated expectations for models of self-scheduling as a foundational expectation and the positive influence for making potential employment choices (3). The initial flurry of reactive "noise" and struggled in transferring the locus-of-control for scheduling to staff is more than compensated for increasing effectiveness engagement, ownership, and process efficiency for both organization and staff. As the self-scheduling process becomes an increasing normative way of doing business in more clinical services, the negative challenges apparent in the transition to such systems can be significantly diminished. In the final analysis, the evidence increasingly suggests that self-scheduling is not only an effective method of managing workload and professional worker time but is the most efficient and engaging method of time management for the contemporary workforce and for sustaining positive staff investment and ownership and reducing problems in a critical area of effective workload management.


  1. Kerzner, H. (2009). Project management: A systems approach to planning scheduling and controlling. New York; Wiley.
  2. Talier, P. (2008). Nursing staffing ratios and patient outcomes. New York; VDM Verlag.
  3. Amoldussen, B. (2009). First-year nurse: Wisdom, warnings, and what I wish I'd known my first hundred days on the job. Chicago; Kaplan Publishing.
  4. Meisel, M. (2010). For ideas to improve staff management. Health Management Technology 31:4, pp 10-11.
  5. Robb, E.; Determan, A.; Lampat, L.; Scherbring, M. (2003). Self-scheduling: Satisfaction guaranteed. Nursing Management. 34:7, pp16-18.

Our board member, Dr. Tim Porter-O'Grady, contributed today's guest blog post regarding the importance of evidence (data)-driven decision making and service delivery to achieving the effective transformation of our healthcare organizations.

Recently, Michael Porter and colleagues have refocused our attention on the central attributes of a successful health system (1). Within the context of a value driven script, recalibrating the foundations of healthcare services ultimately means re-validating the central value of a healthcare system. The point they make is simple; patients and their families are looking for health, not treatment. While the message is simple, it implies a relative complex array of actions and intersections necessary to create those conditions in a meaningful way. From decisions at the social level about how we live, what we do, what we eat and what is sold to us, to personal choices we make with regard to individual lifestyle, relationships, stressors, and actions, all converge to create conditions affecting sustainable health.

All health professionals now realize that the script we've lived in the American healthcare system is neither viable nor sustainable. Yet, the challenges to change it and make it more relevant are, for most of us, overwhelming. Yet, at every level of the socio-political enterprise in America and within each component of healthcare service, dialogue regarding the need to transform health care is now moving quickly into increasingly substantive action. The question is no longer: will the health system change? It is, instead how will the changes look and what will work to create a value-driven and sustainable American model of healthcare.

This essentially means that every stakeholder at every level of society has a role to play in transforming the health equation and experience within the American culture. Political, business, social, and health leaders must now all converge around the construct and design of healthcare to reflect a truly value-based, cost-effective, and sustainable model for healthcare. This means that members of the healthcare workforce must consolidate their own efforts and begin to collaborate within the system and with the larger social community (patients, politicians, regulators, government, policy makers, etc.), to write an effective script upon which efficient, effective, and value-based health service might grow. This means, essentially, changing the relationship in most organizations between members of the provider community as well as altering the mechanisms for the work they do in a way that more clearly values collaboration, integration, collective wisdom, and team-based approaches to healthcare delivery.

The growing focus and construction based on principles of accountable care establish a different foundation upon which health practices emerge. Bundling service and payment around particular patient populations in a way that represents the construction of the appropriate architecture, information, integration, and clinical relationship necessary to advance quality healthcare is the driving centerpiece for the future delivery of health service. Healthcare leaders and managers must now recognize the centrality of point-of-service ownership and engagement in the creation of relevant clinical models that emphasize a local locus-of-control for practice while demonstrating the linkage between local practice across the continuum of care in a way that advances the health of the community.

Healthcare leaders and managers now must recognize and develop in their roles essential skills related to facilitating point-of-service, team based engagement and ownership models which center decision-making, problem-solving, and model building closest to the places where they will be exercised. Intersecting technology with human dynamics in the practice setting means that evidence-based practice becomes evidentiary dynamics reflecting an operating system that makes just-in-time clinical data available to the practitioner suggesting to her or him immediate adjustments in practice and care that require action now. Dense policy and procedure systems, management-driven control systems, ritualistic organizational standardization now quickly fall away immediately replaced with point-of-service decision support systems, immediate action feedback tools, and technology which continually supports the practitioner with portable up-to-date data reflecting the goodness of fit between action and outcome.

It is not a matter any longer as to whether these processes will unfold, it is simply a question of when and of readiness. Practitioners from registered nurses, pharmacists, physicians, therapists, technologists, and/or healthcare associates must certainly all realize that they have a stake and a role to play in reconfiguring health service delivery built on a health value equation and reflecting personal and professional ownership of impact evidenced by measures of sustainable health. Health systems managers and leaders now must realize their fundamental task is creating a context of engagement between the social environment and the health system, patients and providers, providers as the caring community, and the technical and operating infrastructure which supports us all in moving collectively and collaboratively toward effective and sustainable health. The leader's ability to develop skills in complexity and network management, interdisciplinary integration, point-of-service shared decision-making, and human - technology clinical interface will be critical in creating a supporting context sufficient to advance effective health service.

One thing that remains historically constant, even in our contemporary time, is the centrality of effective leadership. While the content and character of leadership has grown and transformed over the centuries of human experience and its expression continuously matured, its centrality to the success of organized human effort has never diminished. This holds true today. The content and expression of leadership has certainly transformed in the post-digital age but instead of eliminating the need for good leadership, our current challenges reaffirm its centrality to sustainability and success. However, in order to assure that leadership is valid and vital, the commitment to transforming expressive and applied leadership capacity must be continuous and dynamic. That, in fact, is both the price of entry into the role of leader and the demonstration of its continuing effectiveness even in this fast-paced post-digital age.

Porter, M. (2009).  A strategy for healthcare reform: Toward a value-based system. New England Journal of Medicine 361; 109-112, July 9, 2009.

Earlier this month,  I had a discussion with Workforce Institute board members David Creelman, Mark Lange and Dr. Tim Porter O'Grady about their perspectives on how changes in the age demographics of the workplace are likely to impact organizations.  There have been multiple stories about this in the news lately including this recent NPR broadcast about delayed retirement, this Towers Perrin report on attitudes toward retirement, and this article by Peter Cappelli in HRE on the need for changing perceptions of older workers as more delay retirement.  All of these sources point to a trend toward later retirements, driven not only by economic factors like the recession and needed health benefits, but also by the desire of older workers to stay engaged in the world of work.  On the other end of the demographic spectrum, younger workers are entering the workplace with an equally keen desire to work, although arguably under a different employment contract than their elders were willing to accept.

I asked our panelists to talk about both boomer and millenial workers and what the future holds.  We recorded the discussion of these questions.  You can access their responses by clicking on the links below.

Question 1: For the better part of the last decade, there has been a lot of discussion and much written about how the retirement of the baby boomers would create significant deficits in the supply of labor.  To what extent do you think those predictions have or will come true?

Panel Discussion of Baby Boom Retirement Implications for the Workplace

Question 2: There are mixed reviews of the Millennial generation - generally thought of as those born after 1980.  What are your thoughts about the newest generation of workers and what contributions they're likely to make to the organizations that employ them?

Panel Discussion of Millenials' impact in the workplace

Bonus Feature! Readings and video suggested by our board members during this podcast:

Millenials Rising - Howe & Strauss

Drive - Daniel Pink

Dan Pink video about surprising aspects of what motivates us. (Hint - for knowledge work, it's not money...)

Today's post is written by Dr. Tim Porter-O'Grady, a member of the board of advisors for the Workforce Institute at Kronos.  A long time nursing champion and educator, he writes here about the importance of collaboration between health care providers and  vendors in the drive to optimize the design and application of workforce management solutions in healthcare settings.

Regulators are now writing the legal language and policy for implementation of the Patient Protection and Affordable Care Act. It is now critical for hospitals and health professionals to begin seriously thinking about the implications for staff, staffing, and quality patient care. Make no mistake; the act requires serious and unrelenting focus on issues of cost, quality, and patient safety. Indeed, increasingly the availability of payment for health services is tied to matters of care standards, practices, quality, and safety.

Nurses, at the forefront of patient care services, will have a critical role to play in setting, advancing, and reinforcing clinical standards that evidence a high-level of patient care quality and safety. The time has come for practicing nurses to realize that they are quickly becoming the centerpiece of the coordination, integration, and facilitation of processes and activities that translate mandates for quality and safety into clinical practice is. Because the nurse provides for coordinating and integrating role in patient care delivery settings, it is logical that the nurse become the linchpin in linking resources, persons, and processes to the demand for high-level patient care.

They need to advance a clear shift between the skills of the provider, the demands of clinical practice, and the requisites of quality outcomes now becomes a requisite in the appropriate distribution and use of nurses and other providers. Managers must now look more carefully at their clinical quality control mechanisms including those related to clinical preparation for practice, specific skill sets, the fit between provider and patient, and the expectations for particular patient outcomes. More detailed attention must be paid to the kind of systems and information resources which best support the alignment of practitioners, practice, and patient needs in the most efficient and effective manner.

Practicing nurses and other providers must now become more intimately involved in selecting and configuring information and workload systems tools that best reflect clinical realities and the decisions which respond to them. This emerging information infrastructure now must be intricately interwoven into practice assessment, judgment, decision-making, and clinical evaluation. These tools must increasingly be seamless and portable, embedded into the practice capacity in a way which assures they are seamless and relevant to the day-to-day practice experiences and activities of nurses. Integration and interaction with other data sources will also be essential to aggregate the varieties of information necessary to assure evidence-driven, best practice-based approaches to meeting patient's needs. Furthermore, since the evidentiary dynamic requires a continuous production of real-time information related to appropriateness of clinical activities, these information tools must display just-in-time data that has utility in the moment and produces information relevant to the nurse in the midst and moment of her or his practice.

Clearly, these issues now call for a much stronger partnership between vendors and nurses in the design stage of information tools and products. This partnership is critical to providing the language and configuration of technology tools necessary to support this growing evidence-based, just-in-time practice relationship between information tools and practitioner. Moreover, time is of the essence. As federal standards and protocols begin to provide a stronger frame for resource distribution based on quality outcomes, providers must have relevant tools necessary to respond to an accelerating demand for quality. Let the partnership begin!!

Following is a guest blog from our board member Tim Porter-O'Grady. I particularly like his discussion regarding the importance of evaluating the supply chain of nurses in one's local geography, and deploying strategies to develop and augment the supply by investing in available employees. Effective workforce planning requires both micro- and macroeconomic approaches as Tim aptly discusses below. We'd love to hear your comments!

Workforce planning and management requires more than simply responding to current issues and levels of concern related to how many resources and what kind are necessary for rendering good patient care. In fact, workforce planning activities should be a major construct of ongoing nursing leadership responsibilities in both the short and long term. While this is not a revolutionary notion, many of the mechanisms used to plan workforce strategy are often missing from the conceptual and content foundations of the role and practices of nurse leaders.

Of course, workforce planning should be systematic. Included in its activities should be the following discrete yet integrated activities related to effective workforce utility:
• patient population and care characteristics
• population demands and clinical needs
• clinical demands and intensity measures
• skill level demands and staff competency needs
• nursing age distribution and clinical competency levels
• nursing education and developmental opportunities for and responding to care demands and related competency
• performance expectations, quality measures, and evidence of clinical value
• support service availability, clinical technology and tools, resource allocation, and financial factors affecting budgeting

These major arenas of workforce planning require that nurse leaders have a systematic approach to fully managing the resource capacity of the organization in relationship to matching patient needs with appropriate levels of clinical service response. Of course, response to these various arenas of workload and service planning should reflect understanding of the state-of-the-art, available research, and full comprehension and management of the resource configurations available to support workload planning within a particular organizational milieu. Effectiveness in any one of these areas does not assure well managed resource planning activities unless the integration with all of the elements associated with effective use of knowledge workers is equitably addressed.

Often, recognized standards and data which reflect them are not consistently used as a basis for establishing a rationale for good workforce planning activities. Contemporary understanding with regard to educational levels and clinical experience suggest that there is a direct relationship between the two that influences competence, capacity, and clinical outcomes. However, the continuing production of the most limited prepared practitioner in huge numbers has done nothing to improve or accelerate value, clinical outcome, quality measures, or patient safety. One might even suggest that low levels or challenges in each of these areas can be directly related to the percentage of nurses prepared at the most foundational levels of nursing education. This is not to suggest that such nursing education is not appropriate for access or entrée into the profession. It does suggest however that if that remains the foundational level of education of the practitioner, there is a direct limitation of impact on advancing clinical outcomes, service quality, value, and patient safety.

A good workforce planning model should include the recognition of these realities and incorporation of them in the selection of strategies related to particular workforce planning activities. For example, if a hospital or health service is in an area where limited access to baccalaureate and above nursing preparation is unavailable, much more attention needs to be paid to continuing education and development as well as competency and outcome assessments driven from the employing institution to compensate for what isn't available in the educational arena. This differentiates from the academic medical center which may have ready access to higher levels of BSN education and continuing education than does the more isolated or rural counterpart not having access to such resources. Both are influenced by their prevailing reality and their workforce planning priorities should reflect this differentiation.

Every nurse manager and executive should have a specific model that addresses each of the above workforce planning elements in her or his own institution. Seeing workforce planning as a system rather than a response ensures that each of the elements affecting nurse utilization, competence, and clinical impact are carefully considered, linked and integrated in a way which presents a whole-systems picture of continuing workforce force needs as they influence and inform management priorities and clinical values and measures. In fact, the ability to demonstrate both challenge and value with regard to workforce resources and positive patient outcomes can't be sustained without this more systematic and effective approach.

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