Clinical care ratios for allied health practitioners: an update and implications for workforce planning

Introduction

Workforce planning for allied health professionals (AHPs) remains challenging in an everchanging healthcare environment.¹ It is limited and lags other professions,² but there is support in the literature for the importance of workforce planning.^1,3–5 The absence of evidence and established systems to determine allied health workforce requirements prevents accurate determination of staffing levels when planning new services and evaluating current models of care.^6,7

It is essential that allied health managers can utilise tools to effectively manage staff workloads, benchmark existing services and plan for new services to ensure a competent and sustainable workforce.^8,9 There is currently no consistent allied health data collection, severely limiting the effectiveness of workforce planning.¹⁰ A consistent approach to quantify, define and enable comparison of workloads of allied health professionals is required.^8,11

Pressure is consistently applied on AHPs to increase their clinical caseloads.^12,13 Workforce planning needs to include an appropriate balance of clinical care and clinical support activities.^14,15 There is an assumption that 100% of an AHP’s caseload is clinical care with a lack of acknowledgement of the clinical support activities essential to meet service requirements, such as accreditation, hospital safety and quality standards, student training, professional development, service development and quality improvement.^8,16

The National Allied Health Casemix Committee (NAHCC) developed a Health Activity Hierarchy (HAH) to provide a consistent and systematic approach to classifying allied health activity, and divided activity into clinical care and clinical support activity.¹⁷ Clinical care includes both direct and indirect clinical care. The Australian Institute of Health and Welfare¹⁸ defines clinical support activity as the allied health service provider’s activity that is not related to the delivery of clinical care. This includes clinical services management, teaching and training and research.¹⁸

The clinical care ratio was developed based on these definitions and measures the time spent on clinical care compared with the time spent on clinical support activities expressed as a percentage of total time worked. Previous studies by the Australasian Allied Health Benchmarking Consortium (AAHBC)¹⁶ collected data from 11 Australian hospitals and demonstrated that the clinical care and clinical support activity components of the AHP’s workload can be quantified, defined and benchmarked with similar roles and according to seniority. This initial work completed on clinical care ratios by AAHBC is widely used by AHPs and has been successfully implemented within all the facilities within the consortium.

Clinical care ratios are an important building block in the development of AHP staffing level models and can be used to compare and evaluate similar roles and modify clinical support activity components leading to cost-effective and optimal service delivery and patient outcomes.¹⁶ Significant changes have occurred since the previous research, these include changes in models of care, roles, scope of AHPs, the allied health workforce profile and clinical governance standards.^1,19,20 Clinical care ratios could also be influenced by other variables apart from profession and experience. This study evaluates clinical care ratio data considering the above changes to service delivery requirements and the workforce profile since the previous study.

Methods

This project was undertaken by members of AAHBC, a group of 19 teaching hospitals in Australia and New Zealand that collect robust allied health activity data for benchmarking and improvement purposes. This benchmarking study received low risk ethics approval (HREC/18/QPAH/141).

AHPs at each facility entered their activity (total time spent performing clinical care and clinical support activity) into a database for each day they worked. The total time spent on clinical care was then compared against the time spent on clinical support activities and expressed as a percentage of total time worked, the clinical care ratio. This data was provided for each staff member who worked for the month of March 2017. Data collected consisted of gender (male/female), staff full-time equivalents (full-time equivalents (FTEs) – part time 1 equals 0–0.649 FTE, part time 2 equals 0.65–0.99 FTE, full time equals 1 FTE) and employment status (continuing or fixed term), and was classified by tier (Table 1) and breakdown of clinical care time versus clinical support activity time. Data was collected across the professions of audiology, nutrition and dietetics, occupational therapy, physiotherapy, podiatry, prosthetics and orthotics, psychology, social work and speech pathology. A template was used for sites to collect this data. Data for 1359 staff were provided, however, the data for 113 staff who were casual or from smaller professions (audiology, podiatry, prosthetics and orthotics and psychology) were excluded due to insufficient numbers for analysis. Data for 1246 staff from the five larger professions were analysed.

As with the previous study, seniority of staff was defined by levels of management and clinical responsibilities (Table 1). Previous research¹⁶ identified that there was large variation in clinical care ratios between individuals in Tier 4, Tier 5 and clinical educators (Table 1) so these roles were not included within this research. Data for FTEs were excluded since the part-time staff were not consistently represented across seniority levels.

Data were analysed for 1246 staff and calculated according to profession, seniority (tiers 1, 2 and 3) and employment status (permanent versus casual staff). A two-way ANOVA was performed to assess the association of clinical care ratios with tier, profession, employment status and gender.

Results

Data for 1246 staff from eight tertiary hospitals in Queensland, South Australia, Tasmania and Victoria were analysed. Table 2 details the number of staff by profession, tier and employment status. Clinical care ratios were calculated by site, employment status, profession, tier and gender. Data were assessed for normality (histograms and box plots) and are presented with 95% confidence levels (95% CI).

There were no interactions between profession and gender (P = 0.185) or employment status (P = 0.412). The relationship between clinical care ratios and profession was modified by tier (interaction term, P = 0.014), meaning that differences in clinical care ratios between professions depended on the tier (Fig. 1). Comparisons between professions within tier can be viewed in Fig. 1 and Table 3. In tier 1, physiotherapy was significantly higher than occupational therapy (0.047 [95% CI = 0.013, 0.080]) and nutrition and dietetics (0.045 [0.004, 0.087]). Within tier 2, nutrition and dietetics were significantly lower than physiotherapy (−0.063 [−0.107, −0.018]), occupational therapy (−0.067 [−0.113, −0.020]) and social work (−0.054 [−0.099, −0.008]). There were no differences between professions within tier 3. In tier 3 clinical team leader, nutrition and dietetics were significantly lower than physiotherapy (−0.280 [−0.399, −0.160]), occupational therapy (−0.300 [−0.431, −0.169]), social work (−0.169 [−0.333, −0.005]) and speech pathology (−0.275 [−0.416, −0.133]).

Fig. 1.

Mean (95% confidence interval (CI)) clinical care ratios (CCRs) per profession across tier. Solid black brackets indicate significant differences between pairs of professions within tier (P < 0.05). Professions: N&D, nutrition and dietetics; OT, occupational therapy; PT, physiotherapy; SW, social work; SP, speech pathology.

There is evidence of a relationship between gender and clinical care ratio (P = 0.022) as well as employment status and clinical care ratio (P = 0.047) when adjusting for other variables in the model. Males had higher clinical care ratios (0.69 [95% CI = 0.66, 0.72] compared with females (0.66 [0.64, 0.68]) and temporary employees had higher clinical care ratios (0.69 [0.66, 0.71]) than permanent employees (0.67 [0.65, 0.68]).

Discussion

This research confirms that the clinical care and clinical support activity of an AHP’s workload can be quantified and benchmarked with other similar roles. Clinical care ratios are dependent on your profession and your tier/seniority. Since the previous research, the clinical care ratio trends remain largely unchanged with physiotherapy having the highest clinical care percentage and nutrition and dietetics having the lowest.

Variation in tiers is expected due to range of experience and increased clinical support activity duties required by more senior clinicians. The trend of clinical care ratios decreasing (that is, clinical care reduces and clinical support activity increases) with seniority is consistent with the previous research.

The main changes observed were decreases with tier 1 occupational therapy, tier 3 clinical physiotherapy, and tier 3 clinical team leader for nutrition and dietetics and social work, although not always statistically significant. It is worth reflecting on what has changed for these cohorts over the last 5 years. It is postulated by AHHBC members that the increased requirements in clinical governance (e.g. compliance with accreditation processes), orientation, mandatory training, competency-based training to manage increasingly complex caseloads and increased service improvement and reporting activities have resulted in this change.

There is increased variability in the clinical team leader roles (tier 3) between professions which is now more reflective of the findings for tier 4 and tier 5 roles in the previous research. It is proposed that with the increased clinical governance and professional governance requirements within the hospital sector, activities that might have been completed by a director (tier 4 or 5), have been delegated to a clinical team leader (tier 3). This means that the clinical support activities completed by these staff could vary between professions depending on their portfolio responsibilities and the experience levels of clinicians within their team. We also expect that the clinical support activity requirements have also increased. It is reported anecdotally that clinical allied health staff are working additional hours to be able to meet both the clinical care and clinical support activity components of their role.

Similar work on allied health capacity planning has been completed internationally^11,15,21 and the importance of defining allied health service capacity has been recognised. It is agreed that when designing the clinical care and clinical support activity components of a role it is important to consider the breadth and whether the role has additional expectations on the clinician. Managers would be remiss to only consider the clinical care expectations of a role when determining staffing requirements, and therefore need to consider the supervision requirements (e.g. receiving and providing supervision and performance reviews), training and professional development (e.g. mandatory training, competencies, professional development and provision of training), quality improvement and research and administration tasks.^8,18

This research confirms that while there is variation between clinical care ratios for professions a broad recommendation can be made for each tier. Entry-level practitioners (tier 1) have less of a clinical support activity burden than staff in higher tiers and therefore are able to complete more clinical care. It was identified, however, that even tier 1 staff are unable to complete as much clinical care as was expected previously. As seniority increases there are more expectations for clinical governance, service improvement, research and quality activities, as well as supervision, mentoring and clinical education of staff and students. Based on this research the previous recommendations¹⁶ have been updated as per Table 4.

These clinical care ratio recommendations allow time for staff to complete essential clinical support activities that are currently commonly completed by allied health staff in unpaid overtime, including professional development, quality improvement and research. Sometimes the above recommendations may need to be allocated across all staff within an area, rather than by individual staff members. It may be appropriate to consider the needs of the service and allocate higher proportions of clinical support activity to a few clinicians. It is important to remember that no allied health clinician can complete solely clinical care, and that clinical support activity always needs to be included when determining staffing requirements. Recommended clinical care ratios are not provided for tier 3 clinical leader/supervisor, tier 2 and 3 clinical educators and tier 4 and 5 roles (Table 1) due to the increased variation in roles at these levels.

Limitations

This research is a snapshot of current practice in large facilities and does not reflect ideal practice. This data only represents the five larger allied health professions across facilities in Australia. Other professions were not included because of the small number of participants.

These recommendations need to be used with consideration of variation in models of care, roles and scope of AHPs, the allied health workforce profile and requirements for clinical governance. There is an assumption that all clinical and clinical support activity data have been accurately recorded by clinicians. Unpaid overtime is also a variable that impacts on the accuracy of data as it could skew the clinical care ratios.

Directions for future work

It is important to continue to collect data about clinical support activity to ensure we can accurately articulate the full requirements of AHP’s workload and responsibilities. The authors have commenced research that looks at what clinical support activity is required within roles and how this effects clinical care ratios. Casemix, financial and patient outcome data in conjunction with clinical care ratios are recommended to make this shift of focus from input to a focus on outcomes to ensure effective and safe value-based health care is delivered into the future. Workforce planning, production planning and business planning frameworks need to incorporate clinical care ratios that provide a balance of clinical care and clinical support activity to ensure safe and sustainable AHP caseloads that support staff wellbeing and optimal patient care.

Conclusion

This research has confirmed that clinical care ratios are a useful tool in workload management and determining staffing levels for allied health professionals. The recommendations from this research provide a starting point that can be finessed with reference to profession, model of care, workforce structure, governance and training requirements. This will lead to increased staff wellbeing and improved patient outcomes.