A Framework for Collaborative Pan-Canadian Health Human Resources Planning

Appendix: Example of a Conceptual Model for HHR Planning

by Gail Tomblin Murphy

Figure 1 illustrates a conceptual model for population needs-based, system design driven HHR planning. It was developed by O'Brien-Pallas, Tomblin Murphy, Birch, and Baumann (2005). [Fig. 1]. The model has been adapted from earlier work by O'Brien-Pallas, Tomblin Murphy, Birch, Baumann (2001) and O'Brien-Pallas and Baumann (1997), and has been constructed from Anderson's (1995) service utilization model, Donabedian's (1966) quality of care framework, Leatt and Schneck's conceptualization of technology in human services organizations (1981), and work of a Canadian think tank summarized by Kazanjian, Pulcins and Kerluke (1992). It is designed to include the essential elements of health human resource planning in a way that captures the dynamic interplay among a number of factors that have previously been conceptualized in isolation of one another (O'Brien-Pallas, 2002). It provides policy makers and planners with a guide to decision-making which takes account of current circumstances (e.g., supply of workers) as well as those factors which need to be accounted for in HHR planning (e.g., fiscal resources, changes in worker education and training). This conceptual model considers factors that, though important in the HHR planning process, may not have been considered in planning to date. These factors include social, political, geographic, economic, and technological factors. At the core is the recognition that health human resources must be matched as closely as possible to the health care needs of the population (O'Brien-Pallas 2002).

Figure 1: Health System and Health Human Resources Conceptual Model*

*O'Brien-Pallas, Tomblin Murphy, Birch, and Baumann (2001) adapted from O'Brien-Pallas and Baumann (1997)

When used to guide planning, a conceptual model like the one above can help policy makers and planners take into account the impact a range of dynamic variables on:

  • current circumstances (e.g., supply of workers)
  • the number and skills required which need to be accounted for in HHR planning (e.g., fiscal resources, changes in worker education and training)
  • other factors important in the HHR planning process that may not have been considered in the past, such as social, political, geographic, economic, and technological factors.

Planners can use this type of model as the basis for simulations which, in turn, can provide needs-based estimates of the health human resources required to achieve health, provider and system outcomes.

Elements of the Conceptual Model

The description of the elements of the conceptual model is based on the work of O'Brien-Pallas (2002).

Population health care needs (Needs-Based Factors) reflect the multivariate characteristics of individuals in the population that create the demand for curative as well as preventative health services. Population health needs are influenced by several factors (Eyles, Birch, & Newbold, 1993) such as actual and perceived population health status, socio-economic status, demographics, and health behaviours. Health need is influenced by social, culture, political, contextual, geographical, environmental and financial factors. Population health needs are also influenced by the determinants of health including such things as: people's biological endowment and individual responses, the social and physical environment in which they live, the economic conditions (i.e., productivity and wealth) of their society, and the accessibility and quality of the health care system.

It is important for researchers and planners to have an accurate picture of the current and predicted health status of the population. As Figure 1 illustrates, population health needs are influenced by, and in turn influence, a number of other elements of the conceptual model (O'Brien-Pallas, 2002). The failure of utilization and supply driven approaches to HHR planning can be traced to the failure to adequately link planning to the health care needs of the population.

System Design. The design of health care services impact human resources requirements. The health system is designed to address the given level of need of the population. Governments (policy makers and funders) in partnerships with stakeholders determine the delivery models (e.g. primary health care and acute care facilities) to deliver services, and the associated level of services required. These planning activities are also shaped by inter-governmental agreements such as First Ministers commitments to improve patient safety, reduce wait times for medically necessary procedures, provide home care programs, and increase disease prevention initiatives.

Planning and Forecasting reflects the varieties of available HHR planning practices and models, their assumptions, methods, data requirements, and limitations. It relates to the actual methods used to predict human and other resource requirements. Predictions of health care provider requirements will vary according to the methods used to make those predictions. The choice of method will be determined by a number of factors including: traditional practices, data availability, political pressure and, most importantly, the question that is being asked. It is important that forecasting and planning activities be conducted continuously with regular data analysis and outcomes assessment.

Supply reflects the actual number, type, and geographic distribution of regulated and unregulated providers; it also recognizes that supply is fluid and is related to production as well as to factors such as recruitment and retention, licensing, regulation, and scope of practice. Supply is subject to alteration according to a number of labor market indicators such as: participation rates, provider-to-population ratios, demographic and educational characteristics of providers, employment status, and employment sector (International Labour Organization). Death, retirement, and emigration or immigration also affect the supply of providers. The geographic distribution of providers may vary according to general economic trends, work incentives, and life-style choices. Distribution of providers within health labor market segments may depend on production related factors, such as number of medical residency spaces available and the level of competition, availability of post-graduate nursing specialty training, and the technological sophistication and working conditions of competing market segments.

Supply also includes the type of service each provider is competent to provide. This is related both to production as well as to issues of standards and scope of practice, and governance (i.e., certification, licensure, regulation and local employer control) (O'Brien-Pallas, 2002).

Financial Resources provide an ëeconomic context' for HHR decisions and involve estimating the future size of the economy from which the particular health human resource and competing services will be funded. This allows planners to estimate the proportion of total resources that might be allocated to health care, and the share to be devoted to health human resources. Decisions about the allocation of resources to health care and other public programmes are likely based on, among other things, the level and distribution of needs in the population, and the role health human resources play in meeting those needs. It refers to the total portion of the Gross Domestic Product (public and private) that is allocated to health care (preventative and curative), health provider education, and health related research. Balance must be sought between human and physical capital. This involves determining the appropriate quantity, mix, and distribution of health services. Careful choices need to be made on the basis of the best available research and in the context of broader social choices as reflected in current fiscal realities. Financial resources must be directed to those initiatives and capital expenditures that are most likely to meet the health care needs of the population. The mix of financial resources for health must strike a balance between non-human resources (e.g., technology, drugs, hospital beds, etc.) and human resources (WHO, 2000; O'Brien-Pallas, 2002).

Production (education and training) involves the education and training of future health providers. Educational programs differ in the level of qualifications required and approaches to learning. The number of formal positions offered in any educational institution is influenced by financial resources and designated number of funded seats. The link between population health care needs and future capacity to meet those needs ought to be considered in setting production targets for seats in any health discipline (O'Brien-Pallas, 2002). This relationship has not been well explored to date.

Management, Organization and Delivery of Health Services contribute indirectly to outcomes (O'Brien-Pallas, 2002). They are key variables that influence how care is delivered (i.e. changing health care delivery models) across all sectors. Management and organizational characteristics (such as structural arrangements, the degree of formalization and centralization, environmental complexity, and culture) each influence the way work gets done, the amount and quality of care provided, provider health and satisfaction, costs associated with delivery of services, and outcomes (O'Brien-Pallas, 2002).

Resource Deployment and Utilization reflects the amount and nature of the resources deployed to provide health services to the population at large. Utilization reflects the nature and type of resources utilized by the population to meet health care needs. The efficiency and effectiveness of service delivery depends to a great extent on the efficient and effective deployment and use of personnel. Decisions made about the deployment and use of personnel across all sectors of the system influences access to services and utilization by the population and outcomes (O'Brien-Pallas, 2002).

Health Outcomes are classified into those focusing on individual health and the health of populations or communities. Many indicators of health status have been developed from both primary and secondary sources including population health surveys, vital statistics mortality data, cancer registry data, hospital discharge diagnoses, and the diagnoses submitted on claims from physicians visits. Examples of some of these indicators include: premature mortality rate (PMR; i.e., death before 75); life expectancy; standardized mortality rates; mortality from cancer, injury, and chronic diseases; disease incidence; medical conditions associated with poor functional status and poor-perceived health status; low birth weight; and prenatal care outcomes. These indicators capture various dimensions of community health ranging from mortality and morbidity from cancer, injuries, and chronic diseases to disability among youth, medical conditions associated with functional limitations, and restricted activity days among the elderly (O'Brien-Pallas, 2002).

Provider Outcomes include factors such as: provider health status, retention rates, turnover rates, sick time, job satisfaction, and levels of burnout and other individual responses to work and the work environment (O'Brien-Pallas, 2002).

System Outcomes are the consequences in terms of costs (financial and other), benefits, and changes associated with the provision and use of health care resources. Measures include: hospitalization and readmission rates, home visits, expenditures on the various health sectors, the number of people treated in each health sector, the neediness of the population being serviced, case intensity, cost efficiency, discharge efficiency, proportion of acute versus non-acute care, outpatient and inpatient surgery rates, and bed occupancy rates (O'Brien-Pallas, 2002).

Contextual Features include the social, political, geographical, technological and economic context in which general resource allocations and specific HHR allocations are made. These factors influence HHR planning insofar as they represent social choices and limitations on that portion of social resources committed to health and health care. They also draw attention to the broad policy framework within which health and HHR policy must operate. HHR planning decisions are also influenced by the presence or absence of political will to incur the costs of promoting health care system reform among competing priorities. In this country, access to services, including human resources, and population health also depend on geographic considerations. The introduction of new technologies - together with the expectation such advances create - affect the production, supply and efficiency of providers. Economic factors contribute to both the health status of the population, and the degree to which health care needs can reasonably be met. The opportunity costs of providing greater levels of health human resources will always need to be weighed carefully against other social spending priorities. In addition to these contextual factors, planners need to consider the possibility of unanticipated "shocks to the system" which happen from time to time and may influence the health human resource process (e.g., sudden down or up swings in the economy, epidemic disease, catastrophic political or social upheaval) (O'Brien-Pallas, 2002).

Efficient Mix of Resources (Human and Non-human) is simply the number and type of resources that are required to achieve the best health, provider and system outcomes (O'Brien-Pallas, 2002).

The conceptual model provides the basis for health system simulations which, in turn, provide needs-based estimates of HHR requirements aimed at optimizing the range of outcomes of interest. The model is informed by research at the micro, meso, and macro level. This is necessary in order to capture the complexity of the relationship among elements of the health human resource process (O'Brien-Pallas, 2002).

Page details

Date modified: