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Benchmarking in Nursing Care
Benchmarking in Nursing Care
Benchmarking in Nursing Care
MD2
Associate Professor and Head of the Conservative Division, Vasa Central Hospital, Vasa, Finland
Correspondence
Lisbeth Fagerstrom
Svenska Yrkeshogskolan University
of Applied Sciences
Seriegatan 2
Vasa 65320
Finland
E-mail: lisbeth.fagerstrom@syh.fi
Aim The aim of the study was to explore the possibilities of benchmarking with the
RAFAELA system. In this study, comparisons are made between: (1) costs for
one nursing care intensity point; (2) the nursing care intensity per nurse; (3) the
relationship between nursing care intensity per nurse and (4) the optimal nursing
care intensity.
Background During the period from 1994 to 2000 a new system for patient
classification, the RAFAELA system, was developed in Finland.
Methods 86 wards from 14 different hospitals in Finland took part in the study.
Results The costs for one nursing care intensity point on the adults wards were on
average 7.80. The average workload was 25.2 nursing care intensity points per
nurse. The optimal nursing care intensity was exceeded during 49.5% of the days
and under during 20% of the days.
Conclusions The study shows that benchmarking with the RAFAELA system
provides many opportunities for the nurse managers resource allocation and their
personnel administration.
Keywords: benchmarking, nursing care intensity, patient classification system, personnel
staffing and scheduling
Accepted for publication: 25 August 2006
Introduction
Benchmarking is a fashionable word within many
branches today, but within nursing care and nursing
research, systematic benchmarking is fairly undeveloped and has not been researched. The basic idea with
benchmarking as a method for developing an organization is to learn from others and preferably from the
best of the organizations that can show the best results
within the area (Camp 1993, Kaivos et al. 1995). What
could be a good resource allocation within nursing
care?
During the period from 1994 to 2000 a new patient
classification system (PCS), the so-called RAFAELA
system, was developed in Finland. Already at the end
DOI: 10.1111/j.1365-2934.2006.00728.x
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
The interest for careful monitoring of costs and personnel resources has increased and the need for computer systems for cost and activity monitoring is also
growing (Ruland & Ravn 2003). The patients need of
good care and fair resource allocation are current
international questions (Needham 1997, Partanen
2002). In Finland, the benchmarking activity started
within nursing care for the elderly with the Resident
Assessment Instrument (RAI) system, which has been
developed for the planning and evaluation of long-term
nursing care (Noro et al. 2001). This benchmarking
concept includes patient-related information, for
example, patient structures, dementia, depression,
ability to function, quality indicators as well as information about costs and personnel recourses for each
unit.
In this study, a concept will be presented for
systematic and national benchmarking that has
been developed for secondary health care with the
help of the RAFAELA system in Finland. Results
from a sub-study concerning resource allocation with
the help of the RAFAELA system will also be presented here.
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 683692
Aims
The overall aim of the study was to explore descriptively if benchmarking using the RAFAELA system can
be an administrative tool for nurse managers within
resource allocation, as the information from the abovedescribed benchmarking concept provides possibilities
for comparisons between specialized areas and between
hospitals (university hospitals/regional hospitals and
local hospitals).
Sample
The study was performed within the frames of the
national research project Finnish Nursing Care Intensity benchmarking within nursing care (in Finnish:
Finnhoitoisuus hoitotyon benchmarking) and the data
were gathered from the period of 01.01.2001 to
31.12.2001. A total of 86 wards from 14 different
hospitals in Finland participated in the benchmarking
study. These 14 hospitals were divided into three different categories: (1) university hospitals (E, L, M); (2)
regional hospitals (A, B, C, I, K, N); (3) local hospitals
(D, F, G, H, J). Finland is divided into five university
hospital districts that are responsible for the highly
specialized and most expensive care. These districts are
then divided into 21 health care districts. Within each
health care district there is a regional hospital that is
responsible for the specialist-led health care. Many
smaller local hospitals have been closed down during
the past 10 years, mainly because of economic reasons,
as small units have been seen as expensive to run.
The following specialized areas were represented: dermatology (three wards), geriatric (one),
Table 1
Critical indicators for benchmarking with the RAFAELA system
Indicators
(A) Ward-related information
Type of activity/specialized area
The ward activity character
Central patient groups
Organization of the nursing care
Personnel employment structure/skill mix
Nursing personnel wage costs, both according
to budget and the accounts
Reliability percentage for nurses classifications
for each ward
(B) Information on NCI
The daily NCI
The NCI/N and per ward
The hospital stays related to each patient
Examples
NCI per patient and calendar day, NCI per areas of needs (AD),
the patient's sex, age, etc.
Optimal NCI level, exploratory power of the PAONCIL study, NCI/N
and per calendar day
DRG and length of the hospital stay
NCI, nursing care intensity; DRG, diagnosis-related group; PAONCIL, Professional Assessment of Optimal Nursing Care Intensity Level.
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 683692
685
Results
Presentation of wage costs for NCI
The information of each patients NCI and period of
hospital stay was combined with wage costs for each
ward. This made it possible to analyse carefully the
costs per NCIP. Wage costs in relation to the number of
beds were analysed and the average wage cost for one
bed was 30 028 on adults wards and 53 431 on
childrens wards. It was also possible to calculate the
wage costs for the nurses per patient according to the
benchmarking concept. On the adults wards the wage
costs per patient and calendar day were 96.50 and on
childrens wards these costs were more than double, i.e.
206.90.
The average costs for one NCIP on the adults wards
varied from 6.30 to 8.40, and the average was 7.80
(see Table 2). The average price for one NCIP on childrens wards was remarkably higher, i.e. 13.20, which
is explained through a much higher personnel density
on childrens wards compared with adults wards (see
Figure 1).
A cost comparison between the hospitals E, I and N
that were participating with 1315 wards shows
remarkable differences. At the university hospital E one
NCIP cost 9.60, when the regional hospitals I and N
have a cost of 8.90 and 7.20.
A closer analysis of the cost level for nursing care load
on a regional and local hospital level (B, G, H, J, K)
with 47 participating wards, gives us an average price
of 8.80 for one NCIP. The average price for one NCIP
at the participating university hospitals was 10.40, i.e.
18.2% higher costs for highly specialized nursing care.
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 683692
Table 2
The wage costs per nursing care intensity (NCI) point per specialized area and per hospital (AN), in
Specialized areas
Dermatology
Geriatrics
Gynaecology-obstetrics
Surgery
Neurology
Ophthalmology
Oncology
Orthopaedic-traumatology
Paediatrics A
Paediatrics B
Paediatrics C
Pulmology
Rheumatolgy
Mixed wards
Internal medicine
Mean
6.1
10.5
10.6
6.0
7.6
15.2
9.1
6.3
9.1
9.5
10.8
10.8
17.2
10.2
14.1
9.1
8.4
10.2
2.3
7.5
5.2
13.1
16.4
7.5
7.1
7.1
7.9
8.6
Mean
5.4
6.6
18.5
6.7
14.0
9.5
8.0
6.0
8.0
7.3
6.9
10.6
16.3
9.3
5.9
7.4
7.2
8.1
8.9
7.8
14.5
4.6
8.0
9.2
6.2
7.0
7.2
6.8
9.4
12.2
8.5
8.7
8.2
7.5
7.0
8.4
7.3
7.4
13.7
9.7
16.2
8.3
8.4
6.3
7.7
9.0
50
20
40
15
Mean NCI per nurse
9.5
9.5
8.6
7.4
8.5
9.6
8.9
6.7
8.3
J
10.1
8.7
8.4
6.7
8.4
5.2
14.1
10
30
20
5
10
n= 3
10 5
11
13
Figure 1
The wage costs per nursing care intensity (NCI) point per specialized
areas, in (total number of wards 83).
0
n= 3
A
6
B
1
C
2
D
10
E
1
F
4
G
4
H
14
I
4
J
7
K
2
L
7
M
13
N
Hospital
Figure 2
Mean nursing care intensity (NCI) per nurse, per hospital (78 wards).
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 683692
687
Table 3
The mean nursing care intensity (NCI) per nurse, in points per specialized areas and per hospital (AN)
Specialized areas
Dermatology
Geriatrics
Gynaecology-obstetrics
Surgery
Neurology
Oncology
Ortopaedic-traumatology
Paediatrics A
Paediatrics B
Paediatrics C
Pulmology
Rheumatology
Mixed wards
Internal medicine
Mean
26.9
24.5
16.1
24.1
29.1
20.7
24.1
25.4
15.0
18.7
10.3
20.4
22.8
23.8
20.3
38.6
26.0
33.6
14.3
27.1
12.2
25.3
23.9
27.6
17.1
21.0
11.7
20.6
24.0
24.4
12.9
23.5
27.1
27.1
24.7
23.2
25.5
22.8
25.0
22.3
27.1
13.5
15.6
27.0
24.3
25.9
26.5
14.3
15.4
21.4
27.5
23.8
25.5
17.7
37.1
28.9
12.9
28.9
23.5
29.1
28.4
25.1
Mean
24.4
26.4
23.0
25.9
24.1
24.9
26.7
14.0
19.3
12.0
25.4
23.6
27.1
26.0
22.8
NCIP/N, was 25.2 on the adults wards. On the childrens wards the average was 15 NCIP/N. The optimal
NCI/N, which had been decided earlier with the help of
the PAONCIL-method, was on average 2027 NCIP/N
on the adults wards and 1320 on the paediatric wards.
The NCI/N was analysed in relation to the fixed
optimal NCI level of each ward and Figure 3 shows the
number of days the NCI/N exceeded the optimal NCI
level (its upper limit). The variations between wards
and hospitals are shown in Table 4. The situation on
the five neurological wards participating in the study
was extremely problematic (89%); the work situation
was also problematic for the nurses on the internal
medicine (65%) and on the mixed wards (62%). In
general, the optimal NCI/N was exceeded on the childrens wards on 39.7% of the days and on the adults
wards 49.5% of the days. Finally, it can be stated that
120
28.6
11.7
22.5
20.0
26.4
25.8
19.2
24.8
24.3
12.7
100
80
60
40
20
0
20
5
6
3
3
6
7
2
2
1
3
4 10
n= 1
derm
surg
oncol
pedA pedC
reuma inter med
gyne-obst
neur orthop-trau pedB
pulm
mixed
Figure 3
Number of days in percentage when the nursing care intensity (NCI)
per nurse were above optimal level and per specialized areas (total
number of wards 53).
Table 4
Number of days in percentage when the nursing care intensity (NCI) per nurse were above optimal level, per specialized areas and per hospital
Specialized areas
Dermatology
Gynaecology-obstetrics
Surgical
Neurology
Oncology
Ortopaedic-traumatology
Paediatrics A
Paediatrics B
Paediatrics C
Pulmonary
Rheumatology
Mixed wards
Internal medicine
Mean
688
63
41
39
42
84
41
19
49
8
18
34
24
40
93
84
67
34
52
78
3
42
18
22
43
28
43
70
26
32
58
63
68
33
56
43
73
98
98
32
46
50
73
58
41
47
67
65
52
Mean
42
26
43
89
38
55
34
67
18
42
33
62
65
48
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 683692
Table 5
Number of days in percentage when the nursing care intensity (NCI) per nurse were below optimal level, per specialized areas and per hospital
Specialized areas
Dermatology
Gynaecology-obstetrics
Surgical
Neurology
Oncology
Ortopaedic-traumatology
Paediatrics A
Paediatrics B
Paediatrics C
Pulmonary
Rheumatology
Mixed wards
Internal medicine
Mean
87
22
29
14
2
23
19
14
21
16
19
11
32
14
49
44
9
74
18
57
37
16
34
74
24
4
25
35
19
2
31
18
17
Discussion
The base for benchmarking should be comparable data,
which requires clearly defined terminology and variables as well as methods (see Holcomb et al. 2002). The
reliability concerning patient classification was decided
based on the reliability degree for parallel classification,
which in this study was 77%. Concerning the credibility
of the study, it should also be taken into consideration
that the data collection according to the developed
concept was made for the second year in a row and the
material from 2001 was estimated as reliable.
The part of the workload depending on the NCI was
10.8% higher on the regional and local hospital level
than on the university hospital level. To be able to
reliably discover more in detail if these results are general in Finland would require that the same type of
wards and enough number of patients per specialized
area would participate, i.e. similar wards with regard to
their special features.
Comparisons between specialized areas have their
limitations in practice, for example, wards that are
called surgical wards can be different from each other in
certain areas. This can be explained through the size of
the hospital and its opportunities for specialization and
7
16
15
23
4
11
32
23
8
4
14
Mean
19
37
16
1
24
15
28
13
54
18
38
10
6
20
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 683692
689
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd, Journal of Nursing Management, 15, 683692
& Bond 2003, Hegney et al. 2003), one could ask if the
negative picture of the nurses work situation that quite
often appears in mass media has already influenced the
shortage of personnel. With more old people in society
and an increased need for nursing care, the question
about personnel resources is already a burning issue
today, which in turn speaks for benchmarking with the
RAFAELA system as a necessary tool for the nurse
managers.
Conclusions
The RAFAELA system has been evaluated as userfriendly and the opportunity to use a national benchmarking system provides added value to the branch,
and this in turn has increased the interest for the system
among nurse managers and decision-makers in Finland.
Benchmarking with the RAFAELA system provides
nurse managers with many opportunities in their
decision processes concerning cost and productivity
analysis and resource allocation. Resource allocation
based on NCI is a condition for qualitative nursing care.
Based on this study, it can be stated that benchmarking
with the RAFAELA system is a well-functioning
administrative tool for nurse managers and decisionmakers on different levels of the health care and hospital organizations of today.
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