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  2. 2. 2  CRITICAL THINKING OVERVIEW OF FISCAL MANAGEMENT Resources, such as personnel, supplies, and equipment, are critical to accomplishing the goals and objectives in a health care delivery organization. The two major functions that are important are budgeting and resource allocation (particularly staff). Nursing managers are involved in all aspects of resource management. Successful resource management is supportive of a fiscally strong organization and quality care. FISCAL PLANNING Fiscal planning is the formal plan for managing the financial resources. The balance of expenditures and revenues are projected during a specific period of time, usually annually. Allocation of projected expenses is also part of the budget. Goals and objectives are critical to the development of a realistic budget, as well as the monitoring of the budgetary expenses through control procedure. FISCAL MANAGEMENT GOALS The goal of fiscal management is to maintain fiscal records and procedures of the agency that provides protection for the resources of the agency as well as records and procedures which generate economy, effectiveness and efficiency of the operation. PRIORITY OBJECTIVES IN FISCAL MANAGEMENT 1. Record keeping which protects the agency and its clients from misuses and/or abuse of its resources. 2. Fiscal management that establishes economy in purchase and operations of the agency and its programs. 3. Fiscal management that readily accesses information for purpose of decision making. 4. Fiscal record keeping that provides the agency’s constituents and the general public with accountability for its operations in an easily understandable format. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  3. 3. 3 5. Detailed budgeting of all activities to ensure that each program is satisfactorily funded and that costs are substantiated and equitable. ROLES OF FISCAL MANAGEMENT TRADITIONAL APPROACHES The purpose of fiscal management is to handle and be responsible for all money matters (financial records, accounting, collections, controls, investments expenditures conformed to laws and administrative directives, property inventories, debt services and other items and value. (Hjelte and Shivers, 1973) CREATIVE APPROACHES This includes the responsibility of aggressively seeking out resources for the agency and exploiting them for the benefit of the agency, staff and consumers. A Nursing Budget allocates resources for nursing programs and activities to deliver patient care during a fiscal year. (Hjelte and Shivers, 1973) FISCAL YEAR Is the accounting period covering twelve (12) consecutive months over which a company determines earnings and profits. The fiscal year serves as a period of reference for the company and does not necessarily correspond to the calendar year. BUDGET FOR THE FISCAL YEAR WILL INCLUDE: 1. PERSONNEL - salaries and wages, benefits, insurance premiums, retirement, allowances, consultancy (honorarium). 2. OPERATIONS – supplies such as drugs, central supply, office supplies , equipment according to clients confined and treated, house-keeping engineering, if supplied by contractor or not. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  4. 4. 4 3. TRAINING AND RESEARCH – supplies, equipment, honoraria LEADERSHIP ROLES IN FISCAL PLANNING 1. Is visionary in identifying or forecasting short and long term unit needs, proactive rather reactive fiscal planning. 2. Knowledgeable about political, social, and economic factors that shape fiscal planning in healthcare today. 3. Demonstrates flexibility in fiscal goal setting in a rapidly changing system. 4. Anticipates, recognizes, and creatively problem –solves budgetary constraints. 5. Influences and inspires group members to become active in short and long range fiscal planning. 6. Recognizes when fiscal constraints have resulted in an ability to meet organizational or unit goals and communicates this insight effectively, following the chain of command. 7. Ensures that client safety is not jeopardized by cost containment. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  5. 5. 5 DEFINITIONS OF A BUDGET Budgets and budgeting can be defined depending on the individual or organization. To budget is generally to determine how much cash is available to an individual / organization. A Budget is a dynamic management tool. It should have flexibility to allow for new unforeseen needs or opportunities. A budget will: • Reflect the financial needs, resources (revenues and expenses) and allocations for specific programs/department. • Document how funds are spent and where revenues are realized. • Form a standardized format for ease of comprehension by employees, managers and investors. • Provide a means for evaluation of programs and services on goals and objectives of the agency. A Budget is the annual operating plan, a financial “road map” and a plan which serves as an estimate of future costs and a plan for utilization of manpower, material and other resources to cover capital projects in the operating programs. A Hospital Budget is designed to meet future service expectations, to provide quality patient care at minimum cost. A Nursing Budget is a plan for allocation of resources based on preconceived needs for a proposed series of programs to deliver patient care during one fiscal year. A Budget Plan for health care institutions, which is simply a plan for future activities, generally consists of Four Components: 1. A Revenue Budget is summarizing the income the management expects to generate during the planning period. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  6. 6. 6 2. An Expense Budget is describing expected activity in operational financial terms for a given period of time. 3. A Capital Budget outlines the programmed acquisitions, disposals and improvements in the institution's physical capacity. 4. A Cash Budget consists of money received, cash receipts and disbursement expected during the planning period. Budgetary planning is important for: • Analyzing activities for appropriateness • Focusing on the future rather than just the present • Anticipating problem or opportunities in time to deal with them • Reinforcing motivation to work toward organization goals Budget functions are to plan, manage ongoing activities, and control spending. The organization must consider the following questions during all phases of budget planning. • Do the benefits justify the costs? • Is the budget consistent with the organization’s goals and objectives? • Is the budget reasonable and realistic? • Will the organization revenues be able to support the budget? BUDGET APPROACHES Managing Resources: How to Manage your Existing Budget? 1. Review health facilities vision, mission, objectives and its relation importance of budgeting. 2. Identify / discuss steps in preparation of budget showing: a. Monthly goals HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008 to the
  7. 7. 7 b. Outline specific actions that will be taken c. Target date or time frame d. Return of investments e. Price Index 3. Manage intra – organizational network. To complete an effective Budget statement, it is essential to have a working link with different departments / cost centers / key people within the organization. E.g. 1.Review of stock levels of hospital supplies to ensure that they are not wasted and misused. 2. Develop a model to display why require an X amount of staff, to defend staffing levels and requirements. 3. Determine patient dependency to determine the patient need, planned nursing hours, available nursing hours and the cost of nursing for each patient. 4. Manage and Control Spending a. Identify Controllable and Non controllable Costs as well fixed and variable costs. e.g. A controllable cost is an increase in price by a supplier, use less expensive supplier could control this. A non controllable cost would be a general increase in the cost of utilities such as electricity, water etc. b. Monitor Spending Keep a file of all budget statements received; expenditures trends can be highlighted and examined. TYPES OF BUDGETING The two most basic types of budgeting are the CENTRALIZED and DECENTRALIZED approaches to budgets. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  8. 8. 8 Centralized Budget – centralized budgeting is developed and imposed by the comptroller, administrator and/or director of nursing with little to no consultation with lower level managers. Decentralized Budget – Decentralized budgeting, has the middle level manager involved in the planning and budgeting process. COMPONENTS OF TOTAL INSTITUTIONAL BUDGET The components of total institutional budget are: 1. Manpower Budget – this consists of the wages and salaries of the regular employees and the fees paid to outside registries through which the institution contracts short-term employees. 2. Capital Expenditure Budget – this involves the large expense of purchasing of lands, buildings, and major equipment meant for long-term use. 3. Operating Budget – this indicates the cost of supplies, minor equipment repair and maintenance as well as other overheard expenses. TYPES OF BUDGET • Capital Expenditure: Long-range budgets (usually three years) that involve physical changes (e.g., space renovation, major equipment, inventories, and furniture) and the purchase of major capital item. Priorities need to be established for this item. Assets will depreciate over time. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  9. 9. 9 • Operating: Short-term budgets (per fiscal year or annually) that allocate funds for day-to-day activities of the organization. Expenses/costs that are included are utilities, small equipment, medical and non-medical supplies, and personnel expenses. Cost center are used to track these types of expenses. Projected revenues are also identified in the operating budget. Revenues come from payment sources (insurance/MCOs, government/Medicare/Medicaid, private pay); contribution; and other income, such as interest, rent, and the sale of property or equipment. • Cash: Budget that accounts for the monthly expenditures and receipts to the department and/or organization. Cash flow is an important element. Operations are based on a complexity of fiscal considerations. • Personnel: Budget that allocates expenses related to personnel. Types of expenses are salary, social security, vacation and holidays. Education, unemployment, workman’s compensation, and other benefits. The critical aspect of personnel budget planning is the forecasting of staffing needs for the specified time period of care provided (e.g., 24 hours a day, 365 days of hospital, but the forecasting/time period varies for home care and other types of settings). TYPES OF INSTITUTIONAL BUDGET DEPENDING ON MANAGEMENT PHILOSOPHY There are many different types of institutional budgeting, the appropriateness of which to a given milieu may depend on such things as the philosophy of the incumbent management or the exigencies of a given situation. 1. Open-Ended Budget – An open-ended budget is characterized by a single cost estimate for each program in the proposed unit. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  10. 10. 10 2. Fixed Ceiling Budget – A fixed ceiling budget is one in which the uppermost spending limit is set by the top executive who then asks managers to develop budget proposals for individual units. 3. Flexible Budget – A flexible budget, in contrast, contains several financial plans for each level of activity or for different operating conditions. Top management can select the budget or shift the spending level upwards or downwards, whichever is best for optimum productivity. 4. Performance Budget – A performance budget is based on the functions and activities of personnel involved in the operation budgeted. In a nursing care management setting this may refer to direct nursing care activities, supervision of nursing staff, and quality control, among other things. 5. Program Budget – On the other hand, in a program budget costs are computed for a program as a whole or the entire program itself (e.g. a home care program, an outreach program, etc.), rather than for individual activities or functions. 6. Zero-Based Budget – A zero-based budget justifies in detail the cost of all programs, both old and new, in every annual budget preparation. 7. Sunset Budget – A sunset budget is designed to "self-destruct" within a prescribed period to ensure cessation of the funded program at a predetermined date. BUDGETARY PROCESS The budgetary process involves determining and developing a plan for the area of responsibility and reviewing, analyzing, and controlling the operation and plans of the Department. This can be done by: 1. Review of pertinent provisions in the current General Appropriation Act. 2. Identify sources of funds (general, national, city, municipal, provincial, special, revolving trust). HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  11. 11. 11 3. Review current appropriations and actual expenditures for the current year. 4. Study proposed changes in other departments which might affect the nursing service budget. 5. Estimate required expenditures for the coming year for supplies, materials, equipment, repairs and replacement. 6. Estimate personnel salaries and benefits, as well as, savings derived from unusual leaves. 7. Estimate cost of Human Resource Development and Research Programs. 8. Translate information into pesos and submit official forms to the Chief of Hospital for approval and inclusion in the general hospital budget. The budgetary process is an ongoing one. It begins with the identification of who is responsible for developing and monitoring the budget. Ultimately, the organization’s governing board is responsible, but many of the administrative staff members participate and have responsibilities, including the chief executive officer, chief fiscal officer, nurse executive, and managers. Operational goals and objectives are set that correspond with the organization’s mission, goals and objectives, as well as the organization’s strategic and operational plans. It is easy to view the budget as another paper report or plan, but it must be a live document, one that changes as needed, and it must be monitored. A cost center is a unit or department within an organization that has specified expenses. Examples of this would be the cardiac care unit, the pharmacy department, nursing services, or admissions. Each one would have a budget that would then be used to develop the overall budget for the organization. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  12. 12. 12 There are four major phases in the process: Planning: Gathering information related to goals and objectives, setting priorities, conducting an environmental assessment, and identifying financial objectives. Development of the budget: Collecting and analyzing data from past budget, allocating amounts based on priority, and approving the operational and capital budgets. Implementation and monitoring: Analyzing variances and adjustments during the fiscal period, negotiating and revising the budget as necessary, allocating departmental and cash budgets. Evaluation: Obtaining performance reports and analyzing efficiency STEPS IN BUDGETRAY PROCESS 1. Assess what needs to be covered in the budget. Budgeting today generally reflects all inputs from all levels of the organization. 2. Develop a plan. Fiscal Year – a budgeting cycle set for 12 months Fiscal year may not coincide with the calendar is then broken down into quarters or subdivided into monthly, quarterly, or semi-annual periods. Select optimal time frame for budgeting. 3. Implementation and Monitoring Ongoing monitoring and analysis occur to avoid inadequate or excess funds at the end of the fiscal year. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  13. 13. 13 4. Evaluation Reviewed periodically and modified as needed throughout the fiscal year. Managers develop a more historical approach to budgeting as they grow more adept at predicting the unit’s budgetary requirements. Developing Plan for the Area of Responsibility Each senior nurse / supervising nurse develops a budget plan for the area of responsibility every quarter of the ensuing year with the first quarter broken down into months. Example: Allotment for the 1st Quarter P 90,000 1ST Month – P 30,000 2nd Month – P30,000 3rd Month – P30,000 The budget plan should include the number and the kind of personnel, their salaries, fringe benefits, the number of patients to be served, the activities within the area, and the kind of care the patients are supposed to receive. Operating expenses shall include among other things, the number and the kind of supplies, repairs maintenance, books, and in service education Table 1. Income : P900,000 Expenditure: Salaries P350,000 Purchases P50,000 Rent P 50,000 Total: P450,000 Analyzing and Controlling the Prepared Budget HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  14. 14. 14 A reporting system is devised such that monthly reports show how much has been spent on what and whether it exceeded the budget or not. Over expenditure must be controlled. Review the Budget Plan Review the plan for maximum efficiency and cost saving or corrective actions. BENEFITS OF THE BUDGETING PROCESS There are several advantages derived from the budgeting process. Budgeting affords planning, coordination and comprehensive control of resources. 1. Planning – Budgeting stimulates thinking in advance. It leads to specific planning such as the volume and type of services, the number and type of personnel as well as the volume and the type of equipment and supplies required as well as the corresponding cost. The process likewise stimulates action and interaction with all concerned parties. From the process of budgeting one can learn a good deal about planning. 2. Coordination – Budgeting also encourages coordination among the different persons involved in the process, from the top to bottom. It has a balancing effect on the total and the expected venue. The continuous exchange of information up and down the organizational ladder is encouraged, and in many instances the team approach is stimulated or developed. 3. Comprehensive Control – A budget fosters comprehensive control for those responsible for managing it. This is because in assessing whether a budget is realistic or not, an administrator is able to evaluate quality and initiative in performance. He is able to set standards and compare these standards with actual expenditures and revenue. Through budgeting the HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  15. 15. 15 manager is able to define fixed and predetermined goals through the budget, and is also able to initiate cost consciousness. FACTORS AFFECTING BUDGET PLANNING Budget planning is determined by the specific type of activity for which it is implemented. Nursing service has very specific parameters, activities and needs which from the basis of budget planning. The basic factors to be considered in budget planning are the type of patient/s, the kind or class of the hospital, the policies on personnel and equipment, standards of nursing care and nursing supervision. 1. PATIENT The nature of the patient's needs is primary consideration in budget planning. These needs are determined by the condition of the patient, the length of stay in the hospital and the acuteness of the illness. Categorizing the patient is made through the type of care given by the physician such as medical, surgical, maternity, pediatric, and geriatric among others. The method of patient assignment can be functional, case, team, or primary. The severity of the illness serves as the basis for length of stay in the hospital. 2. HOSPITAL OR HEALTH CARE FACILITY The available facilities and resources with which to address the needs of the patient are also factors in budget planning. In nursing management, these concerns include the size of the hospital, specifically its bed occupancy and capacity. Bed capacity must be enough to accommodate the possible HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  16. 16. 16 number of patients. Other aspects of a hospital to be considered include its physical layout, the size of the wards or units, the Nurse's Station, the treatment rooms, and other relevant facilities and resources available such as equipment and supplies. 3. PERSONNEL These facilities would be useless without the personnel to utilize them, and so it is important to be well-acquainted with personnel policies in place, such as the salaries paid to nursing personnel, leave benefits enjoyed by the personnel, i.e. whether these leaves are confined to those required by law or include others, and provisions for staff development programs including instructional staff and training structures available, e.g. periodic seminars for staff. 4. STANDARD OF NURSING CARE AND SUPERVISION This consists of the cost of training and maintaining personnel and acquiring equipment that will be needed by the health care facility, based on the volume of patients and the nature of their needs. It begins with documentation of the nursing care method employed which refers to reports. The manager determines whether the method of patient assignment shall be functional, on a case basis, on a team basis or to a primary nursing method. She identifies what labor-saving devices and equipment are necessary. There must be a determination of the amount of centralized service provided such as sterile equipment, centralized oxygen service and line supply. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  17. 17. 17 The manager determines the affiliation of nursing students or medial students to the system, considering that as a rule, inexperienced students need more supervision, equipment and supplies. TOOLS IN BUDGETING AND MANAGEMENT OF RESOURCES 1. The budgeting process of the organization. 2. Determine the number of full-time equivalent of nurses necessary to staff the unit. 3. Compute the salary and non-salary budget including salary increases and other various factors. 4. Monitor the variance over the budget period and identify negative variances responding promptly and appropriately. 5. Understand the extraneous factors such as changes in technology or direct or indirect cost that may be assigned to their budget. 6. Encourage the staff to monitor resources used including time and supplies. FACTORS THE AFFECT NURSING SERVICE BUDGET 1. Types of patient admitted. 2. Personnel policies such as hours/day on duty per week, vacation, sick leaves, Medicare/Philhealth. 3. Size of hospital, number of patient services given. 4. Kind and amount of care. 5. Proportion of nursing care provided by the professional nurse and nursing aides. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  18. 18. 18 6. Amount and quality of supervision available and provided, job description and job classification. 7. Methods of assignment whether functional, care, team, primary. 8. Methods of performing nursing procedures, charting, record keeping. 9. Standards of nursing care. 10.Physical layout of hospital and labor saving devices. 11.Responsibility of nursing service for non-nursing functions such as dietary or housekeeping. 12.Method of reporting required by the administration whether simple or complex. 13.Method of appointment of medical staff size and activities, frequency of treatment and orders. 14.Affiliation with medical, nursing and midwifery school. CLASSIFICATION OF COSTS Fixed: A cost that does not change with volume, which is typically the number of clients. Examples of fixed costs are installment payments for equipment and overhead expenses. Variable: A cost that changes based on volume. Examples of variable cost are those items used in the operating room, which would change based on the type and number of cases, medication, and, in some cases, staff costs. Direct: Costs that can be identified for a specific service or product. Indirect: Costs that cannot be linked or associated with any specific service or product. Office supplies are a good example. For example, it is difficult to say HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  19. 19. 19 that the use of office supplies is associated with the revenue or income associated with treating 10 cardiac clients. COMPENSATION FOR SERVICES Fee-for-service: The provider charges for services given and is paid by the insurer (or in some cases, the client may pay, but that is less common). The method was the traditional payment method, but is not used as much today. Per Diem rates: payment that is fixed and based on each day of service, such as $600 per day in the hospital. Case rates: Payment that is based on the type of case, such as a flat fee for an appendectomy or vaginal delivery. Diagnostic Related Groups (DRGs): Classification system implemented by the federal Medicare system. DRG categories are used to assign predetermined reimbursement based on the client’s medical diagnosis, age, complication, procedures, and other factors. Capitation: Prepayment per enrollee/member of the plan to a provider who will then provide specific services, when required, to the enrollee/member. This is usually a monthly payment. If the enrollee/member does not require any services, the provider still keeps the payment. The incentive is to provide less care, rather than more care. This payment method is very common with managed care organizations. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  20. 20. 20 Resource-based relative value scale (RBRVS): Method used by Medicare, in addition to DRGs. It is used to determine payment for primary care provider services both for procedures and cognitive services (e.g., office visits) REPORTS AND VARIANCES ON BUDGET ANALYSIS Various types of reports that are important in the budgetary for health care organization include: Budget variance report: Describes the status of the budget, what has been spent, and the revenues. A monthly review of the budget is critical in the ability of an organization to stay on the target with the budget. Is the unit spending too much money or below what is expected? These are the variances, the difference between the projected and the actual expenditures in the budget. Managers need to analyze them and determined the causes for the variances. Adjustments may need to be made in the budget, or in the implementation of the budget. Are revenues below what was expected? For example, are there fewer admissions? This can be a major problem for management. Productivity report: Provide data about the number of staff hours worked per unit of service (such as client days or client visits) in terms of allocation of human resources. Payroll report: Cites employee earning and hours worked per day period and consider in such factors as vacation and sick time. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  21. 21. 21 Supply variance report: Lists the utilization of supplies and compares it with the budgeted amount. RESOURCE ALLOCATION Productivity Productivity is the ratio of output (product and services) to input (resources consumed). It is important to maximize productivity of resources to preserve the quality of products and services. Factors affecting input are the characteristics of the staff (e.g., experience, stability, interpersonal communication, time management, variable or fixed staffing), and client factors (e.g., age, acuity level). Other factors include the extent of the treatment setting, unit layout, equipment, supplies, and management. Factors that affect outputs are acuity, client satisfaction, medical records, and client education. Examples of output are the number of emergency room visits, primary care provider office or clinic visits, deliveries, inpatient admission, meal served to client, home visits, and days spent in the hospital. Assessment of productivity requires reviews of budget, client acuity system, personnel and level of staffing, client satisfaction, and quality improvement monitoring. Effectiveness and efficiency are important elements of productivity. Effectiveness is taking the necessary steps to achieve objectives. It is a managerial goal. Critical sources of data about effectiveness include quality improvement data, performance appraisal, evaluation of nursing care provided, and the data from external reviews, such as the Joint Commission on Accreditation of Health Care HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  22. 22. 22 Organizations. Efficiency is doing the right things correctly. It integrates effectiveness and economy, meeting the outcomes with the minimum resources to reach goal. STAFFING AND SCHEDULING Staffing and scheduling are important functions that directly impact the quality of patient care. Staff member are concerned about their schedules, workload, and the amount of time and staff that are available for the client. Scheduling is done in many different ways. Scheduling may be centralized, done by a nursing service or a specific office for the entire health care organization; or decentralized, which means the divisions or units of the organization do it. A third type of scheduling is self-scheduling, whereby staffing criteria are developed and mutually agreed upon by the staff. Staff members appoint the schedule themselves, which often requires negotiation and cooperation of the person involved. Self scheduling has been very successful in many setting due to the autonomy and self-determination involved. Additionally, self-scheduling facilitates work attendance. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  23. 23. 23 Scheduling Advantages Disadvantages Method Permanent Fewer health problems, less Day shift most desired, evening Absenteeism, greater job and night shift staffed mostly Satisfaction, can plan social life Flextime with new graduates Improves weekend coverage and 12-hour shifts correlated with reduces turnover, more time to relax Alternating/ greater fatigue This type of scheduling could be Increased stress and physical Rotating advantageous if entire work group complaint, reduced work or teams that are compatible are quality, higher turnover, rotated rotation of personnel is disruptive to work groups Block/ Reduced fatigue, sick time reduced, Somewhat inflexible Cyclic schedule is known in advance, staff rigid scheduled treated fairly, decreases floating, HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  24. 24. 24 improves continuity of care Variable Census determines staffing, less Dependent on a valid reliable need to call in unscheduled staff client-classification system Standards of Productivity and Staffing Staffing requirements are based on a standard unit of measurement for productivity. One of the most commonly adopted standards in many hospitals is a client classification system. This method of quantitatively estimating client care needs and staffing requirements to provide necessary care is based on census and acuity level. Once an appropriate system is develop and adopted by the institution, the number of nurse care hours can be assigned for each classification. The standard formula for calculating nursing care hours (NCH) per patient day (PPD) is the number of nursing care hours in 24 hours divided by the client census. NCH = Nursing hours worked in 24 hours PPD Client Census For example, the client census is 20; the number of nursing care hours needed for each acuity level and the number of client at each level is as follows: Category I = 2.3 hours (8 clients) HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  25. 25. 25 Category II = 3.0 hours (4 clients) Category III = 4.2 hours (4 clients) Category IV = 5.1 hours (4 clients). Now we can calculate the number of nursing care hours per client: The total number of nursing care hours equals 67.5 hours. This was determined by multiplying each category ( acuity level ) by the number of clients falling into that category ( Step 1 ), and adding all of the hours from the four categories together ( Step 2 ). Then, the total number of nursing care hours is divided by the number of clients (Step 3). Step 1 Multiply each category (acuity level) by the number of clients falling into that category. Do the math: Category I = 2.3 hrs. x 8 clients = 18.4 hrs. Category II = 3.0 hrs. x 4 clients = 12 hrs. Category III = 4.2 hrs. x 4 clients = 16.8 hrs. Category IV = 5.1 hrs. x 4 clients = 20.4 hrs. Step 2 Then add all of the hours from the four categories together. 18.4 + 12 + 16.8 + 20.4 = 65.3 hours Step 3 HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  26. 26. 26 Divide the total number of nursing care hours by the number of clients receiving care. The total hours are 67.5 divided by 20 clients equals, 3.38 hours per client for that day. 67.5 (Nursing Care Hours) _____________________ = 3.38 20(Client census) Nursing units are generally budgeted at so many hours per client per day. Calculating the number of nursing care hours required for any given day can assist the manager in determining if the unit is understaffed or overstaffed. HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  27. 27. 27 FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATOR FINAL EXAMINATION Answer the following comprehensively: 1. Why is it essential to consider goals and objectives when developing a unit budget? 2. What does the nurse manager need to do during each phase of the budgetary process? 3. Discuss the importance of the following management functions in the delivery of a quality health care service: a. b. c. d. Planning Organizing and staffing Directing Controlling 4. As a director of nursing, you are reviewing your home health agency’s budget reports. What reports would you review and why? 5. What is the difference between effectiveness and efficiency? 6. As you consider productivity for a hospital unit, what are three examples of outputs that would be important to review? 7. If you have (a) some staff members who work 8-hour shifts based on 5day workweeks, (b) some who work evenings and nights in the same pay period, and (c) others who work the 12-hour shifts based on 3-day workweeks, what types of scheduling do these staff members have? HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008
  28. 28. 28 8. Explain how each of the various tools of financial management operates to attain efficiency, effectives, and economy in strengthening the fiscal position in your nursing service department. 9. Why is the study of Fiscal Management important? Select any theory and discuss comprehensibly its practical application to your chosen field of specialization? HENRY PAUL M. SANTOS, RN, MAN, DMS FISCAL MANAGEMENT IN NURSING SERVICE ADMINISTRATION University Of Makati-College of Nursing 2008