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WHO/HRB/98.2Distr.: Limited

English only

Workload indicators of staffing need (WISN)

A manual for implementation

World Health OrganizationDivision of Human Resources Development and Capacity BuildingGeneva, Switzerland1998

WHO/HRB/98.2Distr.: Limited

English only

Workload indicators of staffing need (WISN)

A manual for implementation

Prepared for the World Health Organization

by

Peter J. ShippInitiatives Inc.

BostonUSA

World Health OrganizationDivision of Human Resources Development and Capacity Building

Geneva, Switzerland1998

AcknowledgementsThe manual Workload Indicators of Staffing Need (WISN) has been developed and field-tested bythe World Health Organization with financial support through the voluntary contribution from theGovernment of Japan to the Division of Human Resources Development and Capacity Building. Its contribution is greatly appreciated.

© World Health Organization

This document is not issued to the general public, and all rights are reserved by the World Health Organization (WHO). The documentmay not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. Nopart of this document may be stored in a retrieval system or transmitted in any form or by any means - electronic, mechanical or other -without the prior written permission of WHO.

The views expressed in documents by named authors are solely the responsibility of those authors.

Table of contents

Introduction.........................................................................................................................................1

Section A – The WISN method and its uses ......................................................................................3

1. The need for a new method......................................................................................................... 3

2. The basis of the WISN Method................................................................................................... 5

3. Features of the WISN Method .................................................................................................... 6

4. How the WISN Method works: differences and ratios ............................................................. 11

5. Using the WISN Method: identifying priority situations.......................................................... 12

6. Using the WISN Method: improving the current staffing situation.......................................... 13

7. Using the WISN Method: human resource management and planning .................................... 18

8. The constraints and limitations of the Method.......................................................................... 19

Section B – Steps in design and implementation of the method ......................................................23

1. Starting the process: setting the objectives ............................................................................... 23

2. Choosing the basic design of the procedure to be implemented ............................................... 26

3. Setting up the implementation group ........................................................................................ 28

4. Procedure for establishing standards of professional performance........................................... 31

5. Mobilizing commitment to the WISN Method ......................................................................... 32

6. Collecting and handling the data............................................................................................... 32

7. Plan and budget for operating the new procedure in regular use .............................................. 34

8. Workplan and budget for implementation ................................................................................ 35

Section C – Technical factors...........................................................................................................37

1. Determining available working time per year........................................................................... 37

2. Setting Activity Standards ........................................................................................................ 43

3. Turning Activity Standards into Standard Workloads .............................................................. 56

4. Using standard workloads and allowance standards to calculate staffing requirements........... 61

5. Computerization of the WISN calculations .............................................................................. 67

Annex A – Staffing requirements for time-specified posts ……………………………………… 69

Annex B – Instructions for groups which are setting activity standards ………………………… 71

Section D – Examples of WISN activity standards already usedfor individual staff categories ...........................................................................................................77

____________________________________________________________________________________________________________________ Introduction

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IntroductionThis Manual sets out all the activities which are necessary in order to design and implement theWISN Method in a country. The material in this Manual is based on the experience and results ofimplementing the WISN Method in Papua New Guinea (supported by the Asian DevelopmentBank), in the United Republic of Tanzania (supported by DANIDA through WHO), in Kenya(supported by USAID); in Sri Lanka (supported by the World Bank); and also in six othercountries: Bahrain, Egypt, Hong Kong, Oman, Sudan and Turkey which participated in a field trialof an early draft of this Manual (supported by WHO headquarters and the WHO Regional Officefor the Eastern Mediterranean).

The Manual is divided into four sections:

Section A – The WISN method and its usesA description of the principles and the main policy/management uses of the method. This sectionhas two main purposes. First, it provides an overall picture or context for those who will designand set up the procedure, so that they can better understand how the different tasks contribute tothe overall result. Second, it provides material which can be used to explain to potential users ofthe results, and to others who will be involved in the implementation, how the method operates andhow it can be used to improve their work.

Section B – Steps in design and implementation of the methodHow to carry out the implementation of the method. The section describes a step-by-stepprocedure for designing and installing the WISN Method and how these may be fitted together intoan overall work plan for the implementation exercise.

Section C – Technical factorsHow to deal with the technical/mathematical aspects of the method. This section covers the settingof activity (time) standards for government health staff, how to translate these into standard(annual) workloads for use in the WISN calculations, the calculation procedures to be used, andthe use of computers in performing the calculations and producing tables of results.

Section D – Examples of WISN activity standards already used for individual staffcategories

This section lists the Activity Standards which have been used for staff categories andsubcategories in countries which have either implemented the WISN Method or which for otherreasons have set Activity Standards for their health staff. Because conditions and circumstancesvary so much from one country to another, these figures are offered for guidance only.

In normal circumstances, a “Manual for Implementation” like this is of interest and comes into useonly when a decision has already been made to undertake an exercise to implement a newprocedure. However, the WISN Method is novel, it produces information which has not beenavailable before now, and it is based on a principle (setting activity times or standards for healthstaff) which has not been used in health services, although it has been widely employed inmanufacturing and commercial organizations for many years. The senior staff concerned may wellfind that they require information about the basis of the method, its operation, its results and theiruses before they can come to the initial decision on whether to implement the method.

Workload indicators of staffing need – A manual for implementation _________________________________________________________________________

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Although this document covers all the normal requirements for a Manual of Implementation, it alsotakes account of this unusual situation where the method is entirely novel. The material in sectionsA and B is set out so that it can be summarized and/or edited in order to provide decision-makerswith the background information on how the WISN Method works and how the results can be used,should this be necessary, in order to help them take the initial decision on whether to implementthe method. This material can also be used to prepare presentations for managers, administratorsand others who will be the eventual users of the method and its results.

__________________________________________________________________________________________ Section A – The WISN method and its uses

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Section A:The WISN method and its uses

This section sets out a description of the principles on which the WISN Method is based, whatinformation it can produce, and how this information can be used by health managers andadministrators in order to improve the current health personnel situation, for example, how todeploy the available health staff more effectively, and also how to plan for future improvementsin services and in human resource management.

Contents

1. The need for a new method ................................................................................................ 3

2. The basis of the WISN Method .......................................................................................... 5

3. Features of the WISN Method............................................................................................ 6

4. How the WISN Method works: differences and ratios.................................................... 11

5. Using the WISN Method: identifying priority situations ................................................ 12

6. Using the WISN Method: improving the current staffing situation ................................ 13

7. Using the WISN Method: human resource management and planning .......................... 18

8. The constraints and limitations of the Method ................................................................. 19

1. The need for a new methodFor many years there has been a need for a rational method of setting the correct staffing levels inhealth facilities. In earlier decades, when developing countries first addressed the issues of humanresource planning and management in their health services, they used population ratios (numbersof doctors, nurses, etc. per 1,000 population). For a time this was sufficient to tackle the majorproblem of the period - assessing the overall staffing requirements and the training loads for healthservices in the country. Later, attention naturally shifted to the more detailed question of thestaffing of individual health facilities, and standard staffing schedules were used (fixed patterns ofstaff for health posts, health centres, district hospitals, etc. in the country). While both thesemethods were useful in their time, they have serious disadvantages. Population ratios do notdistinguish between the employment of health staff in the different services in an area, for example,the numbers of nurses who should be employed in referral hospitals, district hospitals, healthcentres, health posts, etc. With standard staffing schedules the distribution of the facilitiesthemselves is also a major factor; for example, a district may have well-staffed facilities, but fartoo few of them.

But most important, these methods do not take account of the wide local variations which are foundwithin every country, such as the different levels and patterns of morbidity in different locations,the ease of access to different facilities, the patient attitudes in different parts of the country to theservices provided, and the local economic circumstances. All these factors considerably affect thedemand for services in an area and at individual facilities, and therefore they affect the staffinglevels actually required to meet the demand. The WISN Method frequently shows that staffingrequirements vary widely between health facilities of the same type, according to their workloads.Staffing norms based on population ratios or standard staffing schedules are usually set somewherein the middle of this range. This leads to overstaffing in some facilities and under staffing in


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others. Those facilities which are unable to cope with their workloads (because they have only thestaffing norms or standard staffing schedules) apply for more staff, and frequently get an increasebecause the request is in fact justified. Once this precedent has been established, other facilitiesalso seek staff increases even though their staffing levels are in fact adequate for their workloads. Thus the authority of the norms or standard staffing schedules disappears and their value inpersonnel management and control is lost.

Health administrators have long sought a method of calculating health staffing requirements whichdoes not have these disadvantages. Furthermore, as national health staffing establishments andtraining volumes have been brought under some degree of control, health administrators have beenturning their attention to further issues, for example, the optimal deployment of staff, particularlyto rural areas; the equitable deployment of staff in accordance with the demands actuallyexperienced; and the optimal determination of staff categories, particularly with a view to reducingthe large number of staff categories found in some countries.

In many countries ministries of health are experiencing a double pressure. On the one hand thereis a strengthening popular demand for better health services to an ever-increasing population,coupled with a stronger and more detailed interest from the population at large (and particularlyin the national news media) in both the performance of the country's health services and the equityof its distribution. On the other hand, resources for health are at best increasing slowly; in mostcountries they are at a standstill or even reducing. Certainly resources are not keeping pace withthe increase in demand. Health administrators must attempt to achieve maximum coverage ofservices (extending into the rural and remote areas where the unit costs of service delivery arehigher) with greater impact (by improving current effectiveness levels), equity in the provision ofservices (i.e. overall staffing deployment according to demand) and economy of operation (in staffcategories, numbers and mix).

Until now there has been no technique available which will calculate:

� the optimal allocation and deployment of current staff geographically, i.e. allocating staff toprovinces within a country, districts within a province, areas within a district, and so on,according to the volume of services which are being delivered and the different types of healthstaff which are required to deliver these services;

� the optimal allocation and deployment of current staff functionally, i.e. allocating staff betweenthe different types of health facilities or different health services in the country as a whole, ina province, in a district, in an area, etc., according to the volume of services which are beingdelivered and the different types of health staff which these services call for;

� the optimal staffing patterns and levels (categories and numbers) in individual health facilitiesaccording to local conditions (morbidity, access, attitudes) and not based on national averages(population ratios and standard staffing schedules);

� the optimal staff categories and their activities, i.e. identifying where combining existing staffcategories or creating new categories will achieve maximum health impact with maximumeconomy.

The WISN Method will produce all these types of results.

The pressing need now is to ensure that questions of the optimal allocation and deployment of staffcan be answered at two levels – at the national/provincial level, so that staff can be allocated ordistributed to districts equitably; and at district level, so that staff can be deployed to differentlocations, services and facilities to best effect. In addition there are longer term strategic issues


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which must be tackled at the national level, concerned with volumes of training and determiningthe optimal staff categories to employ in the health services.

In order to provide useful information to both medical and non-medical administrators at all levelsof the health service in these times of economic stringency and staff shortages, the new techniqueshould be:

� simple to operate, using data which is already collected and available;

� simple to use, so that the results can contribute to staffing decisions at all levels of the healthservice;

� technically acceptable, so that health service managers are prepared to use the results in theirdecisions;

� comprehensible, so that the results will be accepted by non-medical managers, e.g. finance,planning, personnel administration;

� realistic, so that the results will offer practical targets for budgeting and resource allocation.

The WISN Method will meet all of these requirements.

2. The basis of the WISN MethodThe WISN Method is based on the work which is actually undertaken by health staff. Every healthfacility has its own pattern of workload which may include inpatients, surgical operations,deliveries, outpatients, clinics of various types, health education, home visits, outreach activities,inspection visits, etc. Each type of workload calls for effort (i.e. time) from specific health staffcategories. For example, a supervised home delivery requires the time of a midwife or trainedtraditional birth attendant; a hospital outpatient may require time from a nurse (preparation andrecording), a doctor (examination), a laboratory technician (performing tests), a dispenser (fillinga prescription), and so on, depending on the medical practices and procedures which are followedin the country. Sometimes treating a case requires time from several different staff categoriesworking together as a team, for example, in performing a surgical operation.

For each type of workload (inpatient, outpatient, MCH clinic, etc.) we can set an ActivityStandard. This is a unit time for each staff category - how much time on average a case, aprescription, etc. should take each staff category which is involved in it, working to acceptableprofessional standards. Alternatively we can set a standard rate - how many patients, laboratorytests, etc. can be dealt with to an acceptable standard of performance per hour or per day. This unittime or rate will differ, depending on the type of work (inpatients, outpatients, clinics, home visits,etc.), on the category of staff dealing with the clients (on average ward nurses spend longer per daywith hospital inpatients than doctors do) and also on the type of facility (more complex cases arereferred to the higher level hospitals where on average they take more staff time per case).

This Activity Standard, an activity time or a rate of working (either can be used), can now beconverted into the equivalent annual workload, that is, how much of this type of work could bedone by one person in a year working to these professional standards and also making dueallowance for time spent on vacation, holidays, training, sickness absence, etc. This equivalentannual workload is called the Standard Workload.

The amount of each type of work done in a health facility in a year is reported in its annualstatistics. Thus applying the Standard Workloads (annual work rates) to these annual statistics willshow how many staff in each category are required in order to accomplish this workload to


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acceptable professional standards. This figure is the staffing requirement of the facility calculatedaccording to the WISN Method. The formula is:

Workload in the facility (service statistics)

Standard workload (for one staff)= Staffing requirement

To be useful to decision-makers and managers, this figure of calculated staffing requirement mustbe compared with the actual staffing level in the facility in order to identify where the shortagesand surpluses are, and how big, by staff category, in each health facility. Actual staffing figuresmust therefore be available for the WISN calculations. Sometimes these staffing figures are notcompiled with the annual service statistics, and must be collected as a separate exercise.

3. Features of the WISN MethodThe WISN Method takes account of the different type or complexity of care offered in differentfacilities. For example, the treatment of an inpatient in a teaching hospital is usually more complexand time-consuming than it is in a district hospital or a health centre. For this reason the wardnurse spends longer in total each day with a patient in a teaching hospital than the nurse in a districthospital does. This is reflected in the different unit times or rates set for inpatient care in thesedifferent facilities. By using these unit times or rates, the calculations will show, for example, thatmore ward nurses are required in a teaching hospital for the same number of inpatients as comparedwith a district hospital or health centre. Calculations always show that more doctors are requiredin the higher level referral hospitals for the same reason – each patient takes more doctor time onaverage. A similar result is obtained with clinic attendances in teaching hospitals as comparedwith, say, district hospitals.

However, where one particular activity is performed in the same way in all health facilities, e.g.immunizations, then the same Activity Standard, i.e. the same unit time or rate (and its annualequivalent the Standard Workload), is used for this activity in all facilities.

Thus a number of different Activity Standards may be used for one activity for technical reasons,for example, to allow for more complex cases being treated in some health facilities. However,no adjustment in Activity Standards is made because of location. In the calculations the sameActivity Standard for each activity is applied to all facilities of the same type, for example, healthcentres, throughout the country. This means that the calculated staff requirements in each type offacility are based on the same medical standards throughout the country. This is the basis of thecalculated equitable distribution of staff; it is the staff distribution which will offer the samestandard of service in health facilities of the same type.

The method can be applied to health facilities and services run by voluntary agencies, commercialorganizations, private practitioners, etc. provided only that their annual service statistics and theiractual staffing levels are available for the calculations. The results can be used to compare on aconsistent basis the relative staffing levels in government facilities and all these other facilities.

The method can be used by managers and staff in charge in individual facilities (health posts,health centres, hospitals, etc.) if this is preferred. These results will show how the current levelsof each staff category employed in the facility compare to the staffing levels which should beemployed according to the national Activity (professional) Standards in order to cover the annualworkload in the facility. For this use, where managers and staff in charge apply the methodthemselves, only simple calculations would be possible, and these can be set out on a pro forma;an example used for nursing staff in health centres in Papua New Guinea is shown in Fig.1. The


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pro forma specifies what figures must be entered on the sheet (the workloads and current staffinglevels) and lays out the calculations (involving only simple arithmetic) in such a way that they canbe accomplished by clerical staff with very little training. Alternatively these simple calculationscan be done by the staff at district level, where the service statistics for individual facilities areheld.

On the other hand, the calculations are particularly appropriate for computers in the sense that theycan be set up (programmed) on such machines by computer operators (rather than the moresophisticated computer programmers) using the standard facilities provided in widely availablecomputer packages (spreadsheets or databases). Thus the WISN calculations could be performedon a central computer which can be programmed to produce the results for each health facility,together with district, regional and national summary tables. This centralized approach is certainlybest where annual statistics for individual facilities are already sent to and held at the centre, andits advantages may make it worthwhile to have these annual statistics sent to the centre where thisis not already done. In larger countries these calculations could be carried out at regional level,with the results sent on to the centre for consolidation into national tables.

The method uses whatever service statistics are currently available rather than calling for specialdata-collection systems to be set up, which is usually both time-consuming and expensive. Thususing the WISN Method will extract extra information from the statistics which are alreadycollected at present and so offers an increased benefit from the current expenditure of resourcesin collecting these regular statistics. The method is flexible in that it can take advantage of anylater improvement in these statistics, for example, wider coverage or greater detail, and therebyproduce more comprehensive or detailed WISN results. It can also highlight where changes in thestatistics would have the greatest effect in improving the quality of the WISN informationprovided.


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Figure 1 – Pro forma used for nursing staff in health centres in Papua New GuineaNote: Use annual figures for the most recent complete year (Jan-Dec)

Province: Southern Highlands HC Nipa Year: 1986

District: Nipa

Workload Calculation Recommendednursing officers Workload Calculation Recommended

CHWs

Admissions Admissions

1 291 / 600 = 2.15 1 291 / 300 = 4.30

Outpatients** Admissions

18 014 / 11 000 = 1.64 18 014 / 6 500 = 2.77

Total clinicAttendances*** Admissions

20 764 / 700 = 2.97 20 764 / 9 000 = 2.31

Supervised births

275 / 150 = 1.83 Total 9.38

Total 8.59

Nursing officers ACTUAL

7 / Total 8.59 = ISN 0.81

Community health workers ACTUAL

11 / Total 9.38 = ISN 1.17

* CHWs = Community health workers including nurse aides, aid-post orderlies and orderlies workingin the centre.

** Outpatients do not include clinic attendances.

*** Total clinic attendances = new attendances and reattendances at antenatal, family-planning and childhealth clinics.

Some essential work activities never appear in the annual statistics, for example, record keeping,administration, supervision, staff management, etc. Full allowance for the workload caused bythese activities is made in the calculations.


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This approach is perfectly general and can be used for all health staff. However there is an easierand better way of calculating the requirements of hospital ward staff (mainly nurses). It is not easyto add up the durations of all individual contacts between nurse and inpatient to give the averageamount of time a nurse (or other category of ward staff) should give to each inpatient during a 24-hour period. Rather the nurses are asked to specify the number of inpatients (occupied beds) forwhich a nurse on duty should be responsible, e.g. one registered nurse per 16 occupied beds, onenurse aide per eight occupied beds. These figures can vary according to the shift (morning,afternoon, night) and the type of ward (medical, paediatric, etc.) One major advantage of thisapproach is that it is much easier for nurses to estimate how many inpatients they can coveradequately when they are on duty than it is for them to add up the total average time which shouldbe spent with each patient totalled over three shifts during a 24-hour period. And the results arefound to be more accurate as well.

The general WISN Method as applied to nurses (setting Activity Standards in terms of contact timerather than inpatients covered) is based on a similar principle to the many methods currently usedfor calculating immediate nurse staffing requirements for a particular ward. These methods dividethe inpatients into a number of dependency levels and specify the nursing effort (time) required byinpatients at each level, usually derived from work study observations. These are more detailedand sophisticated calculations which require detailed statistics (numbers of inpatients at eachdependency level) and produce detailed results, e.g. how many nurses of each type are required inWard 4 tomorrow morning?

The general WISN Method can also be applied to non-medical staff, e.g. administration, office staffand support staff (laundry, kitchens, cleaners, drivers, etc.) Some of these calculations are basedon the service statistics, for example, for laundry and kitchen staff, but the remainder are based onother data, e.g. the number of cleaning staff depends on the size of the facility, the number ofpersonnel administration staff depends on the number of staff employed, and so on.

In using annual statistics, the method calculates the average staffing levels required throughout theyear in order to cope with the recorded workload, even though the work is frequently seasonal withhigher workloads in some months than in others. In doing this the method corresponds to thepracticalities of the situation in that the staff employed in a facility are expected to cope with theworkloads as they arise, in the heavy months as well as the light. There is no regular procedurefor posting extra staff to facilities in their busier months. However, it would be possible to extendthe WISN Method to calculate what the seasonal staffing levels should be at different times of theyear, if ever these results should have a practical use for managers and administrators.

The practical use of the method by operational managers also requires figures for current staffingin each of the health facilities covered by the WISN calculations. Sometimes these figures are notreadily available at the centre and a special data collection exercise must be undertaken to obtainthem from the district offices.

The WISN Method is based on setting unit times or rates of working for the different activitieswhich are undertaken by different staff categories. These unit times or rates are in effect qualitystandards. Specifying 15 minutes per antenatal examination by a doctor, or specifying oneregistered nurse on duty during the afternoon shift per 12 occupied beds in a hospital ward, impliescertain standards of health care quality and therefore certain codes of professional practice andstandards of professional performance.

There can be a significant practical advantage in addressing the question of what unit times or rates(Activity Standards) to use for each staff category employed in the health service. The nursingcadre frequently has a written code of professional practice, that is, Activity Standards, which can


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be translated into Standard (Annual) Workloads for each nursing category. On the other hand,many other cadres have no similar document, and setting Activity Standards for staff categorieswithin these cadres (for the purpose of the WISN Method) can be made the first step in settingexplicit national standards for staff performance and also producing written codes of professionalpractice for these other cadres.

Sometimes the national standards of performance and professional practice which are officially setin a country are much higher than current practice and would therefore require staffing levels inhealth facilities which are very much higher than the current numbers employed. While these highstandards of health care quality are very desirable, it may in practice be impossible within the nextfew years for the country to achieve them, that is, to recruit, train and pay sufficient staff to achievethem. They could be considered as longer-term staffing and health care quality targets. The WISNMethod can assist in the planning to achieve these longer-term targets (see point 7 below). However, the results produced by the WISN Method are also intended for immediate use bymanagers and administrators in order to improve the current operation of health services. TheActivity Standards which are set for staff in a WISN exercise (and hence their StandardWorkloads) should not be too far from the current average conditions in the country. Otherwise,the results (the calculated health workforce requirements) will be too high to be considered asrealistic staffing targets for individual facilities, districts, provinces and the country as a whole. Such exaggerated results will not be of practical use in dealing with current problems and so willnot get any serious consideration from managers and administrators, who are mainly concerned toimprove the current situation. Activity Standards which are set only somewhat higher than thecurrent average professional practice in the country could be used to calculate interim or temporarystaffing targets; these figures would correspond to an improved standard of performance andprofessional practice which could be achieved in the medium-term future in the light of the currentcircumstances of the country.

If the standards of performance and professional practice are set too high by comparison with thecurrent situation, they produce figures for staffing requirements which are far too high to be usefulto managers and administrators. However, the method also produces from the same datacomparative figures of workload pressures, for instance, which facilities are under the greatestpressure and therefore most in need of support; these results remain valid however realistic orotherwise the standards of performance and practice used in the calculations may be.

It should be noted that the WISN Method calculates the staffing levels required to provide healthservices according to certain professional standards in the country. If a facility has these staffinglevels, it does not necessarily mean that the staff there are working to these standards – that is amatter for the supervisors concerned. Rather, what the calculation says is that in this situation thereare sufficient staff resources in the facility to provide the volume of health services which areshown in its annual statistics according to the professional standards laid down for these services.

The method can also be used as part of the annual budgeting process. The salary and staffestablishment component of budget submissions can be compared with the correspondingcalculations of staffing requirements, for instance, the number of staff required to deliver existingservices to acceptable professional standards, in order to evaluate and/or justify existing posts aswell as any requests for new ones. If required, this calculation can be done for individual staffcategories and for individual health facilities.


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4. How the WISN Method works: differences and ratiosFrom the actual staffing level in a particular facility and its calculated staffing requirementaccording to the WISN Method, two separate figures are calculated.

The difference, i.e. actual - calculated.

This shows the level of shortage or surplus. For example, if the actual number of nurses in afacility is six and the calculated requirement to meet the current volume of work according to theStandard Workload is eight, then there is a shortage of two nurses in the facility to meet acceptableprofessional standards of service delivery. The six nurses in post are working under some pressureto cope with the nursing workload in the facility, which is actually enough for eight nurses. Or ifthe actual number of midwives in a facility is 10 and the calculated staffing requirement accordingto the Standard Workload is eight, then the facility employs two midwives more than it requiresin order to meet its midwifery workload to acceptable professional standards. (This is not to saythat two midwives are idle in the facility, but rather that the facility can deliver a higher quality ofservice, for instance, more midwifery services and care to patients, than other facilities which donot have such a surplus.)

There is a very important point here. When we use the WISN Method to calculate staffingrequirements, these figures are not based on some theoretical need for staff according to the healthstatus or morbidity statistics in the population, or according to desirable staffing patterns in healthfacilities. With these more theoretical methods, a calculated staff shortage (e.g. less staff in postthan the standard staffing pattern calls for), says nothing at all about the work pressures in thefacility. But staff requirements calculated by the WISN Method are based on the work which isactually being done in the health facilities, for instance, the number of patients who are actuallybeing treated and the number of clients who are actually being served in the facilities. In thesecases a calculated shortage of staff in a facility actually does mean pressure of work on thoseemployed in the facility, which almost invariably leads to a reduction in professional standards. Afigure measuring this pressure of work is given by the ratio.

The ratio, i.e. actual/calculated.

This ratio is called the Workload Indicator of Staffing Need (WISN) and gives its name to themethod as a whole.

If the WISN ratio is 1.00, i.e. actual staff = calculated staffing requirement, then the current staffis just sufficient to meet the workload according to the professional standards which have been set.

If the WISN is less than 1.00, then the current staff is not sufficient to meet these standards. Continuing with the example above, if a facility has six nurses but is calculated to need eight, thenthe WISN for this category is 6/8 = 0.75 or 75%, and only 75% of the required staff are availableor only 75% of the standards can be achieved.

If the WISN is greater than 1.00, then there are more than enough staff to meet the standards set. For example, the facility mentioned above has 10 midwives but is calculated to need only eight;the WISN for this category is 10/8 = 1.25 or 125%, and there is an excess of 25% in the midwivesabove the number needed to achieve the standards set.

The WISN ratio is one of the novel features of this method. It shows the degree of pressure whicheach staff category is under in coping with the annual workload it is actually dealing with in thefacility.


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5. Using the WISN Method: identifying priority situationsThe two figures – the difference and the ratio (WISN) – are used in combination and each has itsown function.

The difference between the two figures shows how big the imbalance (shortage or excess) is, andwhere it is. It shows which facilities have a shortage in a particular staff category and whichfacilities have an excess (as compared with calculated requirements) in the same staff category. It is used for planning where any new staff should be posted and also for determining how staff canbe redeployed between facilities (to the extent that this is possible), in both cases with the aim ofachieving a more equitable distribution of staff and overall a more cost-effective service.

The ratio (WISN) shows where the workload pressure is the greatest and where it is the least, andso where it is most urgent to take action in order to adjust staffing levels. It is used for identifyingwhich facilities should have priority when considering staffing changes (both increases orreductions).

For example, compare the following two situations:

� a shortage of three nurses in a health centre where there are seven nurses but there should be10 to cope with the workload. WISN = 7/10 = 0.7, i.e. 70% of staff requirements available,30% understaffed;

� a shortage of 10 nurses in a hospital where there are 90 nurses but there should be 100 to copewith the workload. WISN = 90/100 = 0.9, 90% of staff requirements available, 10%understaffed.

The nurses in the health centre are under much greater work pressure (30% understaffed) andtherefore merit more urgent attention than the nurses in the hospital (10% understaffed). Unfortunately the larger shortage (of 10 nurses in the hospital) would usually command attentionover the smaller shortage (of three nurses in the health centre), particularly when the larger figureis backed by the authority of the hospital director or matron. These calculations offer an objectivemethod of prioritising situations of staff shortage, that is, identifying where the need is greatest andso offering assistance in making decisions on staff deployment, for example, where best to postnew staff.

The same calculations can also be used to prioritise situations of staffing excess as well, that is,identifying those places where staff can most easily be spared. For example, consider thefollowing two situations:

� an excess of four nurses in a health centre where there are 12 nurses employed but thecalculations show that only eight are needed to cope with the workload. WISN = 12/8 = 1.5,i.e. 150% of staff requirements available, or 50% excess;

� an excess of 20 nurses in a hospital where there are 120 nurses employed but the calculationsshow that only 100 are needed to cope with the workload. WISN = 120/100 = 1.2, i.e. 120%of staff requirements available, or 20% excess.

In most instances the manager or administrator concerned would consider reducing the number ofnurses in the hospital ("They have well over 100 nurses, they will not notice a reduction somuch ...”) rather than in the health centre. However, the four extra nurses in the health centre givea much greater degree of overstaffing (50% excess) and therefore some of these staff should be


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considered for transfer before reducing the 20 extra nurses in the hospital (20% excess). If thehealth centre gave up two nurses and reduced its staffing to 10, then:

Actual staff = 10Calculated requirement = 8WISN = 10/8 = 1.25, i.e. 125% of staffing requirements available, or25% excess.

This reduction of two nurses would bring the excess of the health centre nurses (25%) to beroughly the same as the excess of the hospital nurses (20%). Thus if any nurses are to be movedin order to relieve shortages elsewhere then, from the viewpoint of equity, moving two nurses fromthe health centre should be considered before moving any nurses from the much larger number inthe hospital.

These examples show how the combination of difference and ratio (WISN) offers an objectivebasis for making what are always difficult decisions of staff allocation, deployment, posting andtransfer.

These examples also show that the method can be used to compare directly the staffing situationsand workload pressures in different types of health facility (e.g. nurses in a health centre and in ahospital), even where the staff category concerned may be engaged in different activities in thesefacilities.

6. Using the WISN Method: improving the current staffing situationThe examples above show how the difference between the actual staffing levels and the calculatedstaffing requirements in one health facility denotes the shortage or excess of staff in the facilityaccording to the actual workloads and the professional standards laid down in the country. Theratio between actual and calculated staffing levels (WISN) shows whether these staff are workingunder pressure in coping with these workloads and how much pressure there is on them, that is, towhat extent the professional standards can be upheld in the facility.

For example, in one country employing the WISN Method two categories of nurse (nursing officersand nursing aides) are employed in health centres. Nursing officers deal with inpatients,outpatients, clinic attendances and deliveries; nursing aides deal with inpatients and outpatientsonly. In one health centre the results of WISN calculations for one year were as shown in Table 1.

Table 1 – Results for nursing staff in one health centre

Actual staff Required staff WISN ratio Difference

Nursing officers 6 8 0.75 -2

Nursing aides 10 8 1.25 +2

From these results the health centre manager concluded:

a) the shortage of two nursing officers balances the excess of two nursing aides; the total nursestaffing of the health centre is correct but it is incorrectly allocated between the categoriesaccording to their tasks (job descriptions);


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b) it is likely that wherever possible some of the tasks of the overburdened nursing officers inrelation to inpatients and outpatients are being undertaken by the nursing aides (with anexcess of staff), who also attend these patients.

Similar calculations can be done for all staff categories in each health facility in a district, aprovince and the country as a whole.

By comparing the calculation results (ratios and differences) for a group of such facilities, amanager can identify whether there are any staffing inequities between the facilities and, moreover,what can be done to improve the situation. In particular, the manager can determine:

a) which staff categories in which facilities are under pressure, how much pressure they areunder, and how big the staffing deficit is at each facility;

b) which facilities have staff in excess of their workload requirements, and how big the excessis at eachfacility;

c) what staff movements (transfers) would bring about a more equitable distribution of staffin the group of facilities;

d) which facilities should be considered first in these possible staff movements;

e) how many extra staff are required to bring the total staffing in the group of facilities up tothe level which corresponds to acceptable professional standards;

f) where any new staff should be posted in order to achieve maximum impact on the qualityof services provided.

A further example from the same country shows a summary of the results for nursing staff in fourhealth centres in the same district. These include those given above in Table 1, which are shownas health centre A in the following Table.

Table 2 – Example of a district summaryNursing officers Nursing aides

Healthcentre

Actual staff Staff reqd. WISN ratio Short/surpl.

Actualstaff

Staff reqd WISN ratio Short/surpl.

A 6 8 0.75 -2 10 8 1.25 +2

B 4 4 1.00 0 6 7 0.86 -1

C 7 7 1.14 +1 8 11 0.73 -3

D 9 9 1.22 +2 15 18 0.83 -3

Districttotals

29 28 1.04 +1 39 44 0.89 -5


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From these figures the district medical officer concluded:

a) the district has about the correct number of nursing officers in its health centres, but they arenot optimally distributed. It would be very desirable, if it were possible, to transfer twonursing officers from health centres C and/or D to health centre A;

b) the district has a net shortage of five nursing aides in its health centres, but even so thesituation could be improved by transferring up to two of these staff from health centre A.The highest priority for employing extra nursing aides is at health centre C; although bothC and D are three nursing aides short, those in C are under the greater pressure (only 73%of nursing aides in post) as compared with D (83% of nursing aides in post). In fact thepressure on nursing aides in D (83% staffing, three short) is about the same as in B (86%staffing, although only one short), because B is much smaller.

The results show:

� how the workload pressure in each facility can be compared with the average of the group;

� where the staff shortages or workload pressures are greatest for the different staff categories;and therefore

� where new staff in each category should best be posted or where staff transfers would improvethe overall situation.

In other words, these results are used to identify staffing inequities between facilities and moreoverthey can also be used to determine what specific actions can be taken in order to achieve equity inthe situation.

This will work even if there is an overall staff shortage in a group of facilities. For example, themost equitable distribution of the 39 nursing aides shown in Table 2 can be calculated using theWISN Method. The results are shown in Table 3, which sets out the actual situation (repeated fromTable 2) and also the calculated equitable distribution of these staff among the four facilities.

Table 3 – Equitable distribution of nursing aidesActual situation Equitable distribution

Healthcentre

Actual staff Staff reqd. WISN ratio Short/surpl.

Equitstaff

Staff reqd EquitWISN

Staffmovements

A 10 8 1.25 +2 7 8 0.83 -3

B 6 7 0.86 -1 6 7 0.86 0

C 8 11 0.73 -3 10 11 0.91 +2

D 15 18 0.83 -3 16 18 0.89 +1

Districttotals

39 44 0.89 -5 39 44 0.89

The calculated staff requirements in the four facilities remain the same, since this is based on theworkloads at each of them. The ratio between the calculated equitable staffing and the calculatedstaffing requirement (called the Equitable WISN) lies between 0.83 and 0.91 for the differentfacilities; this is the most equitable distribution of these staff that can be achieved in this situation. The final column of the Table shows that it can be achieved by transferring three staff from health


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centre A, two of these to health centre C and one to health centre D. The calculation shows whatis the most equitable distribution of the available staff which would enable all facilities in a groupto work under an equal degree of pressure.

The same approach can be used to review the workload pressures and the corresponding staffinglevels within a large facility, for example, the allocation of nurses to wards or departments in alarge hospital. This would identify instances of over- and under-staffing and determine what wouldbe an equitable distribution of staff. This is worthwhile only where there are large staff categoriesin a health facility.

These calculations can be extended to compare staffing levels and workload pressures in severaldifferent types of health facility in a district, for example, health posts, health centres, hospitals,MCH clinics, etc. The results will show:

a) which staff categories in all these facilities are under the greatest pressure and therefore aremost in need of support;

b) what transfers of staff within the district would give a more equitable distribution of staffbetween the facilities and a greater health impact if the same staff category is employed inseveral different types of facility.

Some shortage categories are employed in only one facility, for example, X-ray staff or laboratorystaff may be employed only in the district hospital, and no transfers within the district are possible. The calculations show which of these staff categories is under the most severe work pressure andtherefore which requests for extra staff should be pushed the hardest. The calculations also supplya mathematical justification for such requests.

Another powerful feature of the method is that the results for each staff category can be aggregatedat different levels of the health service to produce the total in post, total calculated requirement,total shortage/excess and average WISN (workload pressure). Thus the results can be producedfor each health centre in a district, together with the district totals and average, as shown inTable 2. Then these district totals and averages can be listed for each of the districts in a region,together with the regional totals and averages. Finally these regional totals and averages can belisted for each of the regions in the country, together with the national totals and averages. Suchaggregated results can also be produced for each type of health facility (health posts, hospitals,MCH clinics, etc.) or each category of staff (doctors, nurses, pharmacy staff, etc.) throughout thecountry. Additionally, the results for all types of health facility in a district can be combined toproduce a comprehensive picture of the health staffing in a district, for instance, the total in post,total calculated requirement, total shortage/excess and average WISN (workload pressure). Thesefigures can also be aggregated to produce similar comprehensive pictures of the health staffing foreach region and for the country as a whole.

Such aggregations are very powerful tools for human resource management in a district, a regionor in the country as a whole. However, such aggregations can give really accurate results only ifthe figures are comprehensive, that is, they cover all the relevant health facilities which shouldcontribute to the tables. If an aggregation is based on statistics from only a proportion of the healthfacilities which should be covered, then the results can give useful information on WISN ratios(workload pressures) in the country, depending on how representative are the health facilitieswhich are covered by the figures. However, such calculations can give only an estimate of the realstaffing requirements (by correcting for the missing facilities), and hence only an estimate of thereal recruitment rates and training volumes which would meet these requirements. Of course, if


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nearly all the health facilities return their statistics then this estimate will be fairly accurate andcertainly sufficient to offer the basis of realistic recruitment and training plans.

An important aspect of these aggregated figures at all levels is that they take account of how thelocal conditions (population, morbidity, access, attitudes, etc.) differ at each separate facilitycovered in the calculations and how these variations affect the demand for services in differentfacilities. For example, where these local conditions lead to a low demand for services, thecalculated staffing requirement by the WISN Method will be correspondingly low.

These WISN results can be used as the basis for allocating staff from the centre to regions, fromregions to districts, and to individual facilities within districts. In addition these figures are usedto guide future recruitment and training plans.

The calculations may show that there is a widespread and major imbalance between two relatedstaff categories, e.g. a shortage of qualified nurses and a surplus of nursing assistants. Thisfrequently signals that the surplus category may well be undertaking some of the activities of theshortage category, e.g. nursing assistants performing injections instead of nurses. This shift ofactivity occurs because of the pressures in health facilities from patients who are waiting for thistreatment. If such a shortage is expected to persist, it may be prudent to consider changes in thetraining of staff (in the example, training nurse assistants to give injections). This can also workin the reverse direction, for example, nurses performing essential cleaning or bed-making activitiesin hospitals where there are persistent shortages of nursing assistants. Here the results show theextent to which there is an inefficient and uneconomic use of highly trained professional staff.

Poor service quality and cost-effectivenessIn some situations the WISN results show that staff are under extreme workload pressure(calculated staff requirement much larger than current staffing, WISN ratio small). This may arisebecause the number of established posts in the facility is too small, or because most of theestablished posts are vacant or, in some countries, because most of the staff are on secondmentelsewhere. These results mean that because of the workload pressures the staff are spending muchless time on average on each activity (e.g. patient consultation) than is set by the Activity Standardsand this indicates that the quality of the service being delivered is very much poorer than thequality of service (acceptable professional standards in the circumstances of the country) on whichthe Activity Standards are based. This is the situation, for example, in a health centre with onedoctor where the staffing requirement according to the workload is calculated to be four doctors(WISN ratio 0.25). If the Activity Standard for outpatient attendances in this facility is eightminutes, these results mean that the doctor spends on average only two minutes with eachoutpatient.

In these days of cost-effectiveness and value for money, countries may wish to establish someminimum average times for certain activities on the argument that with shorter times the serviceis too ineffective and not worth the money it is costing. This would be equivalent to setting aminimum WISN ratio, which may differ depending on the staff category and type of health facility. If there is a health facility where there are WISN ratios less than this minimum level for a categoryof staff and where there is no prospect of posting more of these staff, its situation should beexamined as a matter of priority. In some facilities there may be a compensating excess of staff ina related staff category who undertake extra tasks (not in their job description) in order to equalisethe workload between staff categories. If a severe staff shortage in one category and loss of itsservice quality occurs more generally in the country, it is a signal to consider alternatives, forexample, restricting the shortage category to perform only their more highly skilled tasks and


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transferring their remaining tasks to another category in more plentiful supply; or allowing vacantposts which are established for the shortage category to be occupied temporarily by staff in anothercategory; or changing the designation of some established posts which are continually vacant inthe facility in order to open them to another staff category in more plentiful supply; etc. All ofthese would require professional, administrative, financial and perhaps union approval.

7. Using the WISN Method: human resource management and planningThe first use of the WISN Method in a country is usually to review the current staffing levels inrelation to the current workloads in health facilities using current medical procedures to currentprofessional standards, as described above. However, once the method is established, a wholerange of further uses are then available to assist in planning health services and to help solvespecific management problems as they arise.

The first calculations are based on current workloads, i.e. actual demand for health services.

a) By inserting in the calculations the anticipated workloads of planned future services e.g.resulting from a planned increase in Primary Health Care services, the method will show thestaffing requirements in each category corresponding to future planned increases or otherchanges in health services.

b) By inserting in the calculations what health services will meet the health needs (rather thanthe demand for services) of the population, the method will show what the ideal healthstaffing in the country should be.

The first calculations are based on the current professional standards set for each staff category.

a) Comparing the current staffing levels with the current workloads will show what is thecurrent professional performance, i.e. to what extent these desired professional standardscan now be met by each staff category, and which categories are most in need of support inorder to achieve them.

b) By inserting in the calculations new workload standards corresponding to improvedprofessional standards for some categories, the method will show how many extra staffwould be required in these categories in order to achieve the improved standards.

The first calculations are based on current conditions of employment, i.e. working hours, annualvacation, sickness and other absence, etc., and also off-the-job training time required by currentin-service training policies.

a) By inserting in the calculations the figures corresponding to changed conditions ofemployment for some categories, i.e. a shorter working week, increased vacation, etc., themethod will show how many extra staff would be required in these categories in order tomaintain services if these changes were introduced or to what extent services would beexpected to deteriorate if no extra staff were made available.

b) By inserting in the calculations the off-the-job training time required by new in-servicetraining policies, the method will show how many extra staff would be required in thesecategories in order to maintain services with these changes or to what extent services wouldbe expected to deteriorate if no extra staff were made available.


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The first calculations use unit times or rates which are based on staff following the current medicalpractice using currently available equipment.

a) By inserting in the calculations the new unit times or rates corresponding to new medicalpractices, the method will show what effect these changes would have on the requirementfor each staff category concerned, e.g. what staff savings or redeployment could be expectedfrom new medical procedures.

b) By inserting in the calculations the new unit times or rates corresponding to the use of newmedical equipment, the method will show what effect these changes would have on therequirement for each staff category concerned.

The first calculations are based on the unit times or rates of the current staff categories undertakingtheir currently prescribed functions. By reviewing the range of these functions for each category,their workloads and the overlap between the work done by different staff categories, the results canbe used to identify:

a) where there is a major imbalance and it would be an advantage to transfer functions betweenexisting categories of staff;

b) how best to allocate new functions to existing or new categories of staff, if new services orprocedures are to be introduced;

c) whether it would be an advantage to rationalize, i.e. reduce the number of existing staffcategories, and also how many staff would be required in the remaining staff categories tocover the same workload;

d) what would be the staffing (and therefore financial) consequences of creating a new staffcategory to take over specified functions from existing staff categories.

8. The constraints and limitations of the MethodThe WISN Method is a management tool for improving decisions at all levels of the health serviceabout the provision, allocation and deployment of staff. Its calculations and results are based onthe annual service statistics. These statistics in effect provide a summary picture of a facility'sworkload over the whole year. These factors can impose a number of constraints and limitationson the method and the results it produces, mainly related to the use of the annual service statistics. Most of these constraints and limitations can be dealt with in the calculations.

In using annual statistics, the accuracy of the method is determined by the accuracy of the statisticsthemselves. Where the initial record-keeping in a facility is poor, the results will be inaccurate,almost invariably in the direction of under-recording workload and hence under-estimating thestaffing requirements of the facility. However, if the WISN Method comes into general use andmanagers, staff in charge, etc. come to realize that their staffing allocations are based on theirannual service statistics, the record keeping will improve and the errors may even move in theopposite direction of ove-recording.

Annual statistics are usually produced by aggregating monthly returns and it is not uncommon forsome monthly returns to be missing from the records at the end of the year. This particular


20_________________________________________________________________________________________

situation is not a problem. The method automatically allows for incomplete records and bases thecalculation on the monthly returns which are available.

In using annual statistics, the detail which can be achieved in the initial results of the calculationsis determined by the detail which is available in the statistics themselves. Initial calculations ofthe requirements for a staff category are based on statistics of the activities (workload) of thesestaff. If two similar staff categories undertake the same activities (or if the different activities theyundertake are combined and reported as a single figure in the annual statistics) then calculating theseparate requirements for each category is not immediately possible. In these cases, calculationsbased on this single figure would produce a single figure showing the combined requirement forthe two staff categories. A further step in the calculation is then necessary in order to produce therequirements for each staff category separately. For example: in one country which hasimplemented the method, two categories of nurses undertake the same activities in health posts. Calculations based on the annual statistics for these activities show the combined requirement forthe two categories. The managers there have also decided that the activities undertaken by bothcategories should be 60% by one of the staff categories and 40% by the other. A further step inthe calculation divides the combined requirement in the ratio 60:40, to produce a figure for therequirement for each of the two staff categories separately.

The level of detail in the statistics can also affect the accuracy of the results. For example, wherethe service statistics show a single figure for antenatal examinations, the Standard Workload isbased on an average unit time or rate for all antenatal examinations. However, the firstexamination of an antenatal client should take longer than the subsequent visits. Where thestatistics show separate figures for first visits and subsequent visits, a different unit time or rate canbe used for each of these two figures to produce a more precise figure for the staffing requirementfor this activity of antenatal examinations. Exactly the same effect occurs in the treatment ofoutpatients, with the first visit usually taking longer than subsequent visits. Again, some servicestatistics show a single figure for all laboratory tests performed whereas others show the numbersof haematology, bacteriology, parasitology, etc. tests separately. Using an appropriate unit timeor rate for each type of test in the calculations gives a more precise figure of the requirement forlaboratory staff as compared with using one overall average unit time or rate together with a totalfigure for all laboratory tests. These more detailed calculations would also show directly therequirement for staff working in haematology, bacteriology, parasitology, etc. in the laboratories,where this specialization is warranted.

In using annual statistics, the method calculates retrospectively, what the staffing levels shouldhave been last year, when the statistics were collected. This is usually not a serious practicalproblem since facility workloads change relatively slowly in step with catchment populations andeconomic circumstances. If necessary a percentage correction can be made to the results to allowfor the annual trend in a facility's workload.

Sometimes lack of materials can reduce the workload in a facility. If such shortages are relativelyfew and minor during the year, their effects can usually be ignored. But if the shortages are majorand long-lasting, then the recorded annual workload in the facility is determined not by the demandfor services in the locality but by the lack of materials. For example, if no X-ray films are availablein a hospital for much of the year, then the X-ray machines cannot operate and the recorded annualnumber of X-rays taken in the hospital may reflect how much film was available rather than howmany patients needed X-rays. Similarly, if there is a longstanding shortage of drugs, the recordedvolume of workload in the dispensary (e.g. number of prescriptions filled) may reflect more thedrug supply situation than the number of patients who were given prescriptions and should havebeen served. In both cases the results of the ordinary WISN calculations will show the number of


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staff required which corresponds to the low workload figures, that is, the staff which would berequired while such shortages continue.

Of course, when supplies increase the recorded workload will also increase and the WISNcalculations will show how many staff are required in the new situation. However, it may beunacceptable to wait for a whole year before calculating the new staffing requirementscorresponding to an improved supply of materials. If it is known that supply shortages areseriously limiting the volume of health services which are being delivered, so that the annualstatistics show figures lower than they would otherwise be, then special adjustments can be madeto the WISN calculation. For example, the workload figure used in the calculation can be anestimate of what the volume of services should be (or is expected to be when the supply positionimproves) rather than what it currently is.


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___________________________________________________________________________ Section B – Steps in design and implementation of the method

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Section B:Steps in design and implementation

of the methodThis section covers the basic steps in implementation. It sets out the administrative arrangementsfor designing and implementing the WISN Method in order to achieve two objectives: first, so thatthe new procedure will function effectively; and second, so that its operation and results will beintegrated with the ongoing management and budgeting procedures. It describes the main activitieswhich must be undertaken during implementation and how these may be fitted together into anoverall workplan for the implementation exercise.

Contents

1. Starting the process: setting the objectives...................................................................... 23

2. Choosing the basic design of the procedure to be implemented ...................................... 26

3. Setting up the implementation group ............................................................................... 28

4. Procedure for establishing standards of professional performance .................................. 31

5. Mobilizing commitment to the WISN Method................................................................. 32

6. Collecting and handling the data ...................................................................................... 32

7. Plan and budget for operating the new procedure in regular use ..................................... 34

8. Workplan and budget for implementation........................................................................ 35

For convenience this Manual assumes that the Ministry of Health (MOH) or its equivalent in thecountry, is commissioning the work to design and implement the WISN Method, and that it willprovide most of the resources (staff, materials, transport) in getting the new procedure up andrunning. In countries where the initiative is being taken by another body (Regional or ProvincialHealth Authority, health consortium, etc.), the name of this body should replace “Ministry ofHealth” or “MOH” in what follows.

1. Starting the process: setting the objectivesThe decision to implement the WISN Method and to set specific objectives for the new proceduremust be approved by the most senior staff in MOH for two reasons:

a) Use of the results: resource allocation decisions, particularly those concerning staff, aretaken at the highest levels of MOH and frequently involve strongly-held views and hard-fought battles. A new technique which aims to provide an objective basis for making manyof these decisions must be approved by the staff at these senior levels. Otherwise, if itsresults are unwelcome in these decision-making processes, it will not be used there and itwill not then command respect at lower levels. The method must secure top level supportand a public commitment to use its results if it is to operate effectively.


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b) Coverage: the method can be applied to all facilities, services, staff, areas, etc. A decisionto exclude some parts of the health service from the calculations, and therefore from anassessment of the service quality and equity of staff distribution in them, requires a top-leveldecision.

Considering the novelty of both the WISN Method and the information it produces, these top leveldecision-makers may require some background on the basis of the method, its operation, its resultsand their uses before they can come to the initial decision on whether to approve theimplementation of the method. This background material will be found in Section A of thisManual.

Once the decision to implement the method has been taken and backed by the most senior staff,it is necessary to set specific objectives for the exercise. The objectives which are set at this stageshould include:

� the services and types of health facility which are to be covered by the WISN procedure;

� the geographical areas to be covered;

� the staff categories to be covered (which in the first instance should be health professionals, notstaff without health training);

� the use of the results - who will use them, and for what purposes.The decision-makers may choose a phased implementation of the WISN Method and set initialobjectives which will cover only part of the total health service. This phased approach may be bystaff categories. Covering the largest cadres first gives the maximum pay-off for a given amountof effort. For example, the initial implementation in Papua New Guinea covered nursing staff inall rural health centres, urban clinics and hospitals and also aid post staff; these comprised 87% ofthe total government health staff in the country. The method was later extended to otherparamedical staff (laboratory, X-ray, pharmacy, anaesthesia, physiotherapy, occupational therapy)throughout the country and then to hospital-based doctors. It may be desirable to cover first thosestaff categories which have priority staffing problems. In Kenya the method was applied first tohospital technical staff where major mismatches between supply and demand were suspected(radiographers, laboratory staff, pharmacy staff and physiotherapists) and the work was laterextended to hospital doctors, nurses, etc. In Sri Lanka the method was first applied to dental staffbecause there was very strong support from the most senior level of the cadre and also detailed andcomprehensive dental service data was readily available. These results provided to senior staff inother cadres a convincing demonstration of how the method works and its value.

Alternatively the phased approach can be geographical and/or by type of health facility. Theimplementation work can start in a few localities, e.g. districts, and then expand in a number ofcarefully planned phases to cover the whole country. For example, the initial implementation inTanzania covered all staff categories in the health centres and dispensaries in two districts (oneurban and one rural) in different regions. The method was later extended to all health centres anddispensaries in the remaining districts in the two regions. Subsequently all hospital staff in the tworegions were covered. Finally the method was extended to all health facilities in the remainingregions in the country.

A phased implementation which starts in a fairly small way with a few staff categories and/orgeographical area and/or types of facility has two main benefits. It allows the implementationgroup (see point 3) to learn from direct experience how best to do their job. It also provides earlyexamples of in-country results which can be used to good effect when introducing the method


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subsequently to other locations, staff categories, types of facility, etc. in the later phases of thework.

It is usually best to complete the implementation for MOH services before considering extendingit to other government health services (armed forces, prison health services, etc.) or to non-government health services (provided by missions, companies, plantations, privately-owned healthfacilities, etc.)

It is also important to consider how the results are intended to be used, and by whom, as part of theobjectives of the exercise. There are a number of possibilities here:

� the centre e.g.the Ministry of Health, and within that:

� service departments, e.g. curative services, PHC, etc., to monitor the allocation and deploymentof staff to different types of health facility and geographical areas, to identify particularsituations of staff shortage/excess, to determine how best to deploy each staff category inrelation to actual requirements;

� vertical programmes, e.g. malaria, to monitor the allocation and deployment of staff in relationto workload in different geographical areas in the country, and to determine how best to deploystaff in relation to actual requirements;

� personnel administration, to monitor the overall deployment of different staff categories in thecountry, to have a rational basis for reviewing requests for staff increases and determining theposting of new staff, to have a rational basis for reviewing requests for staff transfer and tocontrol the transfer of staff in accordance with actual service requirements, to have quantitativeestimates of the shortages in each staff category;

� finance, to secure a quantitative basis for the salary and other emoluments component of annualbudgets, to be able to provide figures for the service effects of proposed budget increases orcuts;

� planning, to have estimates of the staffing requirements by category for planned services orproposed changes to them;

� provincial and/or district health offices, and the service, personnel, finance and planningfunctions at province and/or district level, particularly for countries with decentralised services. The decision on the use of the results at these levels will depend on the responsibilities andauthority delegated to each of these levels. The WISN results can only be used in practice atthose levels which have the responsibility and authority for one or more of the following:posting new staff, deployment of existing staff, transferring staff between facilities, settingstaffing targets, health workforce planning);

� large hospitals, for the allocation of staff to Departments and wards;

� ministry of local government (if local health services are part of local government services);

� ministry of education, if it is responsible for the teaching hospitals, school health services, etc.and approves their budgets, deploys their staff, etc.;

� any other government ministry which has the responsibility for providing a significant amountof health services and also controls the budget for these activities, e.g. the armed services, theprison service, etc.;

� public services commission or its equivalent, to monitor the medical activities undertaken byhealth staff categories and their workloads, consider the need for changes in the number andscope of health staff categories;


26_________________________________________________________________________________________

� missions and other health NGOs, company/plantation health services and private healthorganizations which employ substantial numbers of staff in order to provide health services tothe population at large, to employees, etc.

� medical and other professional bodies and trades unions for health staff.

This is an exhaustive list of those organizations, bodies and groups in a country which could findthe results of the WISN Method useful. It covers all the possibilities which usually arise. However,only the most important of them should be included in the initial objectives. The purpose of thelist above is to offer a number of suggestions from which to choose those organizations, etc. whichshould be selected as the first set of users of the results of the WISN Method.

2. Choosing the basic design of the procedure to be implementedOnce the objectives have been established it is necessary to consider one major aspect of theprocedure which will be used in the implementation – whether it will be manual or computerized. This must be done before it is possible to determine the timetable and the resources required forimplementing the method.

The WISN procedure which is to be implemented is best considered as being divided into threemain activities:

1. Collecting the data to be used in the calculations.

2. Performing the calculations and producing the tables of results.

3. Using the results in management decisions.

When the procedure has been established as a regular component of the annual cycle of operations,the first two activities are performed once a year, as soon as the new set of annual service statisticsare available. The third activity is continuous and always uses the most recent set of WISN resultsavailable.

In deciding on the system to be implemented in the country, there is one major choice to make -how and where the calculations are to be performed – and there are two principal options toconsider in making this choice.

One option is manual calculations, in which each health facility which is to be covered in theexercise could carry out its own calculations to produce its own results for its own use. Theseresults are sent to the next higher level (e.g. district health office) to be consolidated with similarresults from other facilities to produce the aggregated tables of district results (totals, averages andcomparison of units) for use by the district health team. These district tables of results are then sentto the next higher level (for example, provincial health office) for consolidation and use by theprovincial health team, and so on up to the MOH. This way of doing the calculations calls for thedesign and printing of a set of pro formas (one for each staff category) for all the individualfacilities. At each facility the data items (annual service statistics and actual staffing) are enteredand the calculations (simple arithmetic only) are performed. An example of such a pro forma,which was used in Papua New Guinea, is shown in Fig.1, Section A. (Whether this is a practicableoption depends on the calibre and educational level of the staff in charge of the health facilitiesbeing covered in the exercise; in rural health facilities in some countries this option could not beconsidered.) In addition, a separate set of pro formas must be designed and printed for each levelof aggregation of the results (district, province, MOH).


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An alternative here is for the manual calculations for each facility to be performed by the clericalstaff in the district health offices (where the annual service statistics and actual staffing levels foreach facility are usually available); the results for each facility are then sent to the facilities forlocal use. These results for each facility are combined by the district health office staff to produceaggregated tables of district results for use by the district health team. They are also sent to thenext higher level, as described above.

The other option is to use computer calculations in which the data (annual service statistics andactual staffing for each facility) are sent to a centre (MOH if computers are available there) and theresults for each province, district and facility are printed out and sent back to them. It isundoubtedly easier, cheaper and more reliable for computers to do the calculations and to print outtables of results for each province, district and the individual facilities. By using computers it isalso relatively easy to do more complex and sophisticated calculations in order to extract moreuseful information from the data. The main disadvantage of this choice is the large volume of datainput into the computer which must be done at the centre. If computers are available at provinceor district levels, the data input and calculations can be done there (using standard computerprogrammes supplied by the centre), with printed tables of results sent to the lower levels anddiskettes of data sent to the higher levels for aggregation. In Tanzania the data sheets for eachhealth facility were sent by the district health offices to MOH to be entered into a computer, andthe printed-out tables showing the results for each facility and district totals/averages were sentback to each district.

In considering which of these two approaches to use, it is important to consider what must beaccomplished and what it costs in order to implement each of them.

Manual calculations1. Pro formas for the calculations, one for each staff category employed, must be designed and

printed; different pro formas are needed for each type of facility (clinic, health centre,hospital, etc.) and also for each level of the health service at which results will be produced(facility, district, province, centre).

2. Instruction booklets on how to complete each of these pro formas (for each staff category,for each type of facility, and for each level of the organization) must be written and tested.

3. A sufficient quantity of pro formas and booklets must be printed to supply all the facilitiesand all the district and provincial offices covered by the exercise.

4. Training sessions will be necessary in each district to introduce the pro formas to those staffwho will fill them in and to go through the instruction booklet with these staff using workedexamples. For the implementation exercise the pro formas and booklets to be used in thefacilities can be distributed during this training. In subsequent years, when the same proformas will be used, no training is necessary so the pro formas will have to be distributedto the facilities by a different method.

Computer calculations1. The implementation exercise will need the services of an individual who is able to use

spreadsheets, in order to design and enter the data input format and the calculation formulae.


28_________________________________________________________________________________________

2. Both in the implementation exercise and also in subsequent years there will need to be accessto a computer with a spreadsheet programme (Lotus 1-2-3, Excel, etc.), and the method callsfor the purchase of a number of diskettes each year for data storage (one per district).

3. The annual service statistics and actual staffing levels of individual facilities must be madeavailable for input into the computer from the most convenient source. Sometimes thesestatistics are already available at the centre and perhaps some of them may even have beencomputerized. At worst they are available in the district health offices. It is rarely cost-effective to arrange to collect them from individual facilities. If the annual statistics forindividual facilities are not compiled from their monthly figures in the district health officesit may be necessary to design and send out a form to each district office on which themonthly figures are copied from the files by the district health office staff and returned tothe centre. Normally completing these forms, which are then used as computer input sheets,requires no special training.

4. The annual service statistics and actual staffing levels of each facility must be input into thecomputer. This procedure is not difficult to perform, but it does require individuals who arecapable of focused attention and of maintaining their application to a task.

Although either computers or a purely manual method can be used, the computer-based system isa good deal cheaper in running costs, significantly faster in operation and much more powerful andreliable in doing the calculations. Also most MOHs have at least one computer with a spreadsheetpackage on which the calculations can be done once a year. The remainder of this manualdescribes the implementation of the WISN Method based on using a computer to perform thecalculations and to produce the tables of results. A manual method using specially designed proformas for the calculations follows exactly the same principles, although some of the practicaldetails of operation are different.

3. Setting up the implementation groupThe implementation group is the name given to all those who are concerned with the design of thenew procedure and its implementation according to the objectives which have been agreed. Theimplementation group consists of two sets of people:

� the steering committee, whose functions are to set the policies for the work within the agreedobjectives, to approve strategies for implementation, to agree workplans and budgets for thedevelopment, to monitor progress, and to maintain an overall supervision of the work;

� the implementation manager and his/her task force, whose function is to do the job.

The steering committeeNormally the primary responsibility for designing and implementing the WISN Method in acountry is given to one MOH department or unit, e.g. planning department, health manpowerplanning unit, personnel department, etc. A senior member of MOH whose responsibility includesthis department or unit should be the chairman of the steering committee. The implementationmanager should be a member of the department or unit which has been selected to carry out theimplementation.

The steering committee should consist of:


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� representatives of the providers of the information: representatives of the MOH functionaldepartments responsible for the type of health facilities and/or the Provinces and Districts inwhich the initial implementation is to take place. Thus if the objectives specify that the ruralhealth services are to be covered in the first implementation, then a representative of the MOHdepartment responsible for these services should be a member of the steering committee. Ifimplementation is to start in one specific province or district or a number of them, thecorresponding provincial or district health officers should be members of the steeringcommittee. (If there are also central (MOH) Departments responsible for the health servicesin geographical areas, then representatives of those departments which cover the areas of initialimplementation should also be members of the steering committee.)

� representatives of the users of the results: representatives of the organizations, bodies andgroups which are to be initial users of the results of the WISN Method, according to theobjectives which have been set for the initial implementation. This will very likely includemany who are also providers of information.

The chairman, responsible for the department or unit undertaking the implementation of themethod, is also responsible for the budget which is giving the major support to this work.

The implementation managerThe steering committee must appoint an implementation manager to be responsible overall to thesteering committee for the implementation of the WISN Method and also for its integration intothe management and budgeting procedures of the organization, that is, the institutionalisation ofthe new procedure. The implementation manager will be a senior officer in the department or unitselected to undertake the implementation exercise. The implementation manager must be asufficiently senior officer to have access to the senior decision-makers in the MOH, and also havesufficient status to command respect from Provincial and/or district health officers, staff in othergovernment departments, representatives of the health professions, etc. The implementationmanager acts as the secretary of the steering committee.

The task forceThe task force is led by the implementation manager and consists of:

� full time core staff, drawn largely from the implementation manager's own staff and located inthe task force office;

� full time or part time technical resource persons, e.g. a statistician, a computer operator, etc.,usually seconded from another group to work in the task force office;

� liaison persons, undertaking some local activities as and when necessary, e.g. arrangingmeetings, obtaining documents or information, etc., in the cooperating MOH departments andthe initial provinces/districts.

The task force usually starts with whatever staff and other resources the implementation managercan mobilize by his/her own ingenuity and enterprise. The actual task force requirements becomeclear when the workplan for the implementation exercise is produced.


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Administrative locus of the WISN implementation activityThe steering committee and the task force are intended to be temporary groups which exist duringthe implementation of the WISN Method for the sole purpose of achieving that implementation.When this is completed, the WISN activity should be a regular annual procedure (like budget andtraining school intakes) located in personnel or planning or some other appropriate department. Forexample, if the health service statistics are computerised, the WISN results could be producedautomatically as a sub-programme of the annual statistics, and the WISN function could be partof the health information system.

The manual recommends a steering committee function to oversee the exercise and a task force(executive function) to carry out all the activities required (set Activity Standards, collect data, setup computer spreadsheets, input data, produce results). Often these functions are performed by aSteering Committee and Task Force set up for the purpose. But for convenience the WISNexercise may be integrated into an ongoing programme of work, for example, producing apersonnel plan for one or more categories of health staff, reviewing the budgets and establishedposts (staffing review) in some or all health facilities, planned reduction in the number of healthstaff categories, etc.

There are both potential advantages and disadvantages in integrating the implementation of theWISN Method into an ongoing (usually larger) programme of work.

Advantages: if the ongoing programme already has high-level backing within the ministry and asubstantial budget, the WISN task force has the use of this authority (access to senior staff at thecentre and in the provinces) and resources (office space, transport, photocopying, computers) inorder to undertake its activities without having to establish or procure them for itself.

Disadvantages: the aims of the ongoing programme will be at least wider and perhaps evendifferent from the aims of a WISN steering committee and task force. If a task force is appointedfrom within the ongoing programme, the skills and capabilities (and also the interests) of the staffmay not be directly relevant to the tasks of WISN implementation. In addition, if one or moreexisting working groups are given the extra responsibilities of a WISN task force, their focus onthe aims of the ongoing programme may delay, constrain or even negate progress on WISNimplementation.

Liaison between steering committee and task forceIt is very desirable for the liaison between the steering committee and the task force to beinstitutionalized. This is done in Egypt, where the leader of the task force is the secretary of thesteering committee, and in Oman, where the Director General of Planning is a member of thesteering committee and the Director of Planning is the leader of the task force.


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4. Procedure for establishing standards of professional performanceThe workload standards to be used in the calculations are based on standards of adequateprofessional performance and service delivery. If these professional standards (Activity Standards,see A.3) are to be applied nationally and the results are to be useful, they must be realistic. It is ofcourse understandable that a country would like to have the best medical services for itspopulation. However, if Activity Standards for the exercise are set too high they will producecalculated staffing requirements which are very large and quite beyond the country's capacity,either to train them or to employ and pay them, in the near or medium term future. The ActivityStandards set in the exercise must be practicable in the circumstances of the country, that is, theymust be achievable in the medium-term future, if the results are to have any practical value as abasis for current managerial decision-making. These practicable standards can be considered ifnecessary as a set of intermediate targets. When these intermediate standards have been achieved,higher professional standards can be set as new targets for achievement and the WISN calculationsare then repeated to produce new staffing requirements.

Furthermore, the standards which are set must be authoritative, that is, they must have the backingof senior and respected individuals who can speak on behalf of a cadre. One way of achieving thisis for the standards for a cadre to be set by a group of selected senior staff in the cadre who havea wide-ranging and long experience of the duties and working activities of the cadre, for example,a group of nurses each in charge of several rural health facilities who themselves have worked ina number of such facilities, a group of senior laboratory technologists in charge of the majorhospital laboratories in the country, a group of hospital matrons from different types of hospital(district, provincial, national, teaching), a group of medical officers each with some years ofexperience of working in different types of hospital in the country, a group of consultants andprofessors from one specialty in the teaching hospitals (at this level each medical specialty mustbe dealt with separately; similarly the specialist hospitals must be dealt with separately as well). Each of these groups of staff is expected to bring to bear professional expertise ("how should thingsbe done?") and recent working experience and/or observation ("how much of this is practicable?")concerning their cadre. Each such "cadre group" should include a representative of the relevantdepartment of MOH which deals with the cadre being considered.

An alternative approach which has been found successful, particularly for hospital staff, is to invitethe senior staff from all departments or units in a facility to work together to set the ActivityStandards for all the staff categories who work in their own and similar facilities. Thus all thesenior staff in a hospital could be invited to a workshop in which carefully selected working groupsdraft the Activity Standards for all the cadres employed in the facility; these standards are thendiscussed and approved in plenary session. Representatives of the relevant MOH departmentsshould also attend the workshop. In using such a "facility group" it is usual to select a hospital, etc.which is generally reckoned to have a good performance in order to set Activity Standards. Theaim is to use the results of the workshop as the national standards for the staff employed in thistype of facility in the country.

The detailed instructions and guidance for producing Activity Standards are the same for bothapproaches - cadre groups or facility groups. They are given in Section C.2. This procedureestablishes the Activity Standards which are to be used for all the staff categories which will becovered in the implementation of the WISN Method. Setting the Activity Standards which are tobe used in the implementation exercise is a task which must be fitted into the early part of theworkplan for the implementation exercise.


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Sometimes a cadre has already established its own standards of professional practice. For example,in many countries the nursing cadre has produced a handbook of nursing standards (or practice)which stipulates for each category of nurse the number of hospital inpatients which should besupervised per ward nurse on duty (which may differ for different types of hospital and/or wardand/or shift), the number of outpatients which can be treated per day, and the number of clinicclients which can be seen per day (which may differ for different types of clinic). Normally someitems in these handbooks or standards of practice can be converted directly into Activity Standardsfor use in the WISN Method. Also the health services research groups in some countries havecarried out job analyses or work study exercises on certain staff categories and can supply accuratetimings for various activities.

5. Mobilizing commitment to the WISN MethodThere is one further activity which must be undertaken during the implementation exercise. If theWISN Method is to succeed in the country, it will be necessary to mobilize the commitment of thepotential users of the WISN results which the method produces. Unless the results will be used toimprove the management and operation of health services in the country, the work should not beundertaken. It should be emphasized that the WISN Method produces an entirely new type ofinformation (workload pressure) as well as detailed information not normally available (staffshortage/surplus for each staff category in each health facility). Therefore managers at severallevels (national, province, district) must be trained in how to use the WISN results for their owndecision-making. This is best done in half-day or one-day workshops for groups of up to 20 at atime, although larger groups have been used successfully. In these workshops the material inSection A is presented, using examples and results from the country itself wherever possible. Aftereach segment of the presentation the participants split into working groups to review sample tablesof results and identify what management action they call for. These workshops should bescheduled soon after the implementation exercise has begun so that some tables of results from thecountry itself are available for demonstration and for working group exercises.

It can also be most desirable (depending on the circumstances of the country) for representativesof the professional bodies (for doctors, nurses, dentists, etc.) and of any trade unions representinghealth staff to be invited to these workshops as participants, so that they can understand what thenew method is and how the results are to be used.

6. Collecting and handling the dataBefore starting to plan and budget for the implementation exercise, there are two major factorswhich must be investigated and decided - how the most recent set of annual statistics from healthfacilities are to be assembled for input into the computer, and what resources will be required forcomputerizing this data and producing the results.

Collecting the dataAssess the possible sources of the data required (annual service statistics and actual staffingnumbers for each facility) and how the data can be obtained. This could require visiting a numberof district health offices to investigate:

a) the service statistics which are received from health facilities and stored: do all facilitiesmake statistical returns? are those which are received complete or are some items or evensome months missing? how promptly are they received? do the district health offices


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actually aggregate the annual statistics for each facility from the monthly figures? howaccurately is this done (e.g. are missing months ignored)?

b) data on the actual staffing in health facilities: is it complete? up-to-date?

c) the form in which the statistics are held: are summary sheets prepared which contain theworkload data required by the WISN Method? if so can these sheets be borrowed orphotocopied for computer input?

d) is there adequate administrative and clerical capacity in the district health offices toundertake various activities, e.g. to assemble the statistics for each facility from the files, totranscribe these statistics from the records to computer input sheets?

e) the practical scheduling of the activities in (d): are there other priority activities which willoccur in the district health offices during the planned period of the implementation exerciseand which would cause difficulty or delay?

f) what transport will be available for visits to district health offices and provincial healthoffices to arrange for and/or undertake the collection of the data?

When the answers to all these questions have been assembled, it will be possible to make aninformed judgement on the best method of collecting the data for the WISN calculations, and alsoto set out the reasons for justifying this judgement to the steering committee.

If all the data (service statistics and staffing for each facility) is already available at the centre, thispart of the investigation will be easier and less time-consuming.

Producing the resultsAssess what resources will be required to computerize the data and to what extent these resourcesare available:

a) Which computers might be used? How much spare capacity do they have? Would anyregular production jobs they may have clash with developing the WISN spreadsheets andrunning the calculations? It might be possible to identify the computer which will be usedwhen the new WISN procedure is in regular operation but also it could be desirable to usea different computer during the implementation, e.g. a computer used for research, whereaccess for setting up and testing the computer calculations may be easier.

b) Which staff with a knowledge of spreadsheets could be available to set up the WISNcalculations on the computer? Under what circumstances or arrangements can they be madeavailable for the task?

c) What arrangements must be made for the task force to supply its own materials (paper,printer ribbons, etc.)?

Answers to the questions are necessary in order to decide on how to computerize the data andjustify these decisions to the steering committee.


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7. Plan and budget for operating the new procedure in regular useBefore undertaking the detailed design and planning to set up the new procedure it is mostdesirable to look briefly beyond the implementation activities and consider how the procedure willoperate in subsequent years when it is established as a regular component of the annual cycle ofoperations in the health services. The results of this assessment could affect what is to be doneduring the implementation exercise. The questions which should be addressed here are:

1. Who will be responsible for the effective operation of the procedure? Which unit willperform the annual exercise of obtaining service statistics for each facility to be covered,entering these service statistics into a computer, and printing out the tables of results? Whichunit will respond to particular enquiries and requests for calculations during the remainderof the year? (These could be two different units.) Where will the unit(s) fit in theorganogram?

2. Will the procedure require employing extra staff? (This is most unlikely since it occurs onlyonce a year soon after the beginning of the financial year, when the annual service statisticsfor the previous year become available.) What staff will be used in operating the newprocedure? What will their respective tasks be? What changes will be required to existingjob descriptions?

3. What will be the annual direct costs of operating the procedure, e.g. obtaining computerdiskettes to store district data, etc.? On whose budget will these costs appear?

4. Which computer will be used? (The computer will be used fairly intensively for thesecalculations for a few weeks each year when the new set of annual service statistics becomesavailable.)

5. How is the data to be collected each year? Where from? By what means? How long beforeall the data is received at the centre? If it is to be collected at district health offices, are thereother priority activities which occur annually in the district health office at the same time asthe new set of annual service statistics becomes available thus delaying the WISN datacollection?

At this stage some of these items must be estimated, but the exercise of doing so is most valuablein clarifying and sharpening ideas about what alternatives should be considered and what will bepracticable in the circumstances of the MOH. This in turn will help determine what should beimplemented.

A brief description of how the new procedure is intended to operate once it is established shouldbe included with the implementation workplan and budget which is put to the steering committeefor its consideration (see below).


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8. Workplan and budget for implementationThe workplan for the implementation activities should cover the following steps:

1. Determine the Activity Standards for the categories of staff to be covered in the exercise (asset out in the objectives, see point 1). These figures are a vital part of the calculations andmust be available before any WISN results can be produced. This will entail holding a half-or one-day meeting for each cadre or a two- or three-day workshop to cover all the cadresin one type of facility, e.g. hospitals. The two different approaches are described in point4. This should be one of the first activities in the workplan schedule.

2. Convert the Activity Standards set by the professionals (unit times, rates of working, fixedtime allowances, etc.) for each staff category into the corresponding standard (annual)workload figures to be used in WISN calculations. These calculations are set out in SectionC.3. This must be completed before the calculations can be set up on the computerspreadsheets.

3. Set up on the computer the data entry format and the calculations of staff requirements foreach type of health facility (see Section C.5). This must be done after 1 and 2 arecompleted. The computer set-up should be tested on the first data collected, to ensure thatit is working correctly.

4. Obtain the data (annual service statistics and current staffing levels) for entry into thecomputer. Whether this comes from district health offices or is already at the centre, it isbest to secure a small amount first and use it to test the computer set-up before committingthe task force to the whole of the planned data-gathering exercise.

5. Enter all the data for one District and produce the first district summary table, i.e. listing theresults for all the facilities of one particular type in the district with district totals andaverages (see example, A.7). This tests the instructions in the computer for producing thetables and provides results for the first training sessions of the users (see step 7 below).

6. Enter the data for the remaining districts to be covered in the implementation exercise andproduce the results according to the objectives which have been set for the exercise (districtsummaries, province summaries, national summary as appropriate).

7. Design the training for user managers (materials and exercises for a half- or one-day event). This is described in point 5. It should be scheduled into the timetable soon after the firstdistrict summary table is produced (see step 5 above) so that these results can be used intraining.

8. Schedule into the workplan regular progress reports to the steering committee.

9. Present the final results and a brief description of the exercise to the steering committee.

If districts are to be covered separately and in sequence, it is most desirable for the workplanschedule to allow sufficient time to produce the results from the first district(s) and to have themavailable as examples when working in the subsequent districts.


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Once the workplan (list of activities to be undertaken, their sequence and the effort required foreach) has been produced it is then possible to determine jointly the task force staffing requirements(numbers and skills), other resource requirements (access to a computer, computer materials,transport, etc.) and the timetable for the workplan. These items are interdependent - the larger thetask force the shorter the timetable (within limits). From the workplan a detailed budget should beproduced; this will presumably follow the government budgeting regulations of the country (travelallowances, per diem, etc.)

The workplan and budget for implementation and a brief description of the proposed design of theWISN procedure being implemented should be presented to the steering committee for its approvalbefore implementation starts.

______________________________________________________________________________________________________ Section C – Technical factors

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Section C:Technical factors

This section describes how to deal with the technical/mathematical components which underlie thewhole method and which apply to calculating the Staffing Requirements for all staff categories.

Contents

1. Determining available working time per year .................................................................. 37

How to calculate for each staff category, the amount of time available per yearfor delivering health services, taking account of the time spent on training, vacations, sickness and other absences.

2. Setting Activity Standards................................................................................................ 43

How to set the Activity Standards for the main activities and functions undertaken byeach staff category employed in health facilities.

3. Turning Activity Standards into Standard Workloads ..................................................... 56

Translating Activity Standards (activity times, rates of working, time allowances)into the equivalent Standard Workloads (the volume of work done in one year) for usein the calculations.

4. Using standard workloads and allowance standards to calculate staffing requirements .. 61

The procedures and format for performing the WISN calculations.

5. Computerization of the WISN calculations...................................................................... 65

The principles and main guidelines for implementing the computerization of theWISN calculations and producing tables of results.

Annex A – Staffing requirements for time-specified posts ........................................................ 69

Annex B – Instructions for groups which are setting activity standards .................................... 71

1. Determining available working time per yearThe WISN Method is based on the calculated Standard Workload for each staff category in eachtype of health facility. This Standard Workload is the amount or volume of work in deliveringhealth services which can be accomplished during the course of a year by a competent andmotivated staff member working to acceptable professional standards. Health professionals candeliver their services only during the time which they actually spend on the job, that is, allowingfor time spent away from their duties during the year on vacation, sickness absence, training, etc.

The calculation of the time which is available from staff to undertake work tasks is designed tocover all situations including those countries where the working days are not all of equal length,e.g. a short day is worked before or after the weekly break, and also in order to cover those staffwho undertake shift or night working.


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The calculation of the health personnel required to perform the current workload (i.e. to deliver thevolume of services which is shown in the annual service statistics) must take account of the factthat sometimes employees are quite legitimately not available to deliver services at their normalplace of work throughout the whole year because of:

1. Vacation: assumed to be a fixed number of working days per year according to regulations;the length of annual vacation may be different for different staff categories.

2. Public holidays: assumed to be a fixed number of working days per year according toregulations, which is the same for all staff categories.

3. Off-the-job training: courses, conferences, workshops, study tours, etc. which are (or shouldbe) approved in advance according to staff development policies. This is usually not a setnumber of days per year for each staff member, and so an average per staff member mustbe obtained, which may differ according to staff category. The average may be obtainedfrom training statistics if they are available. Alternatively it is frequently good enough tohave this average estimated for a staff category by the group which is setting the ActivityStandards (unit times or rates) for the category (see Section C.2 below).

4. Sickness and all other absence: an estimated average number of days absence per year whichmay differ according to staff category. The average number of days per staff member maybe obtained from personnel statistics if they are available. Alternatively it is frequently goodenough to have this average estimated for a staff category by the group which is setting theActivity Standards (unit times or rates) for the category (see Section C.2 below).

The steps in the calculation are the same for every staff category:

a) total the number of days per year for the items 1-4 above; this is the average number ofworking days per year on which a staff member is not available for delivering services andfor which a correction must be made;

b) divide the total from (a) by the number of working days in the week (e.g. 5, 5.5 or 6) toobtain the equivalent number of weeks in the year for which a correction must be made;

c) subtract the result in (b) from 52; this gives the number of weeks in the year on average forwhich this category of staff is available to undertake normal service delivery activities;

d) multiply the result in (c) by the statutory number of working days in a week (5, 5.5 or 6 asin (b) above); this gives the average number of days in the year for which this category ofstaff is available to undertake normal working duties;

e) multiply the result in (d) by the statutory number of working hours in a full working day; thisgives the average number of hours in the year for which this category of staff is availableto undertake normal working duties.

Example 1

The working week is six days of six hours per day, i.e. 6 days x 6 hours per day = 36 hours perweek. All staff categories:


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� have five weeks annual vacation

� are away from the job for training on average for two weeks per year

� have on average 10 days per year of sickness and other absence.

In the country there are 12 days statutory public holiday per year.

Calculation1. Vacation days/yr (5 weeks x 6 days/week) = 30

2. Public holidays days/yr 12

3. Training days/yr (2 weeks x 6 days/week) = 12

4. Absences days/yr 10

a) TOTAL unavailable days/yr 64

b) Unavailable weeks/yr (divide by 6) 10.7

c) Available weeks/yr (subtract from 52) 41.3

d) Available days/yr (multiply by 6) 248

e) Available hours/yr (multiply by 6) 1,488

Usually statistics are not available on training days and absence days per year (items 3 and 4above), and it is necessary to obtain estimates for each staff category which is being covered in theWISN calculations. These estimates are best supplied for each staff category by the groups settingthe Activity Standards for the staff category (see Section C.2).

The figures shown in items (c), (d) and (e):

41.3 available weeks per year

248 available days per year

1,488 available hours per year

are actually the same piece of information (available time per year) expressed in three differentways - in weeks, days and hours. It is useful to calculate all three figures. They are frequently allused in the calculation of Standard Workloads because some unit times, rates or allowances willbe set per week, some per day and some per hour.

Sometimes unit times, rates and allowances are set per month, e.g. pharmaceutical assistants in thecountry spend two days per month for stocktaking in dispensaries. The average available workingtime per month (averaged over the year) is calculated from:

Available working time per month =Available days per year

12


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Thus the available working time per month in the example above is:

248 days/year

12= 20.7 days/month

If pharmaceutical assistants in the country spend two days per month stocktaking, then this activityoccupies:

2/20.7 = 0.097 = 9.7%

of their available working time.

Example 2

The working week is five days of eight hours per day and one day of four hours, i.e. 5.5 days or44 hours/week. A senior staff category (A), e.g. medical officer

has six weeks annual vacation;is away from the job for training on average for three weeks per year;has on average five days per year of sickness and other absence.

A more junior staff category (B), e.g. medical aide

has four weeks annual vacation;is away from the job for training on average for one week per yearhas on average 15 days per year of sickness and other absence.

There are 10 days statutory public holiday per year for all staff.

CalculationCategory A

(Medical officer)Category B

(Medical aide)1. Vacation days/yr 6 x 5.5 = 33 4 X 5.5 = 222. Public holidays days/yr 10 103. Training days/yr 3 x 5.5 = 16.5 1 x 5.5 = 5.54. Absences days/yr 5 15a) Total unavailable days/yr 64.5 52.5b) Unavailable weeks/yr (divide by 5.5) 11.7 9.5c) Available weeks/yr (subtract from 52) 40.3 42.5d) Available days/yr (multiply by 5.5) 222 234e) Available hours/yr (multiply by 8) 1,776 1,872

Although calculations for only two staff categories are shown here, more columns could be usedto perform the corresponding calculations for as many different staff categories as is necessary, i.e.where there are different figures in any of the items 1-4.


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The figures shown in items (c), (d) and (e) for Category A, i.e.




are actually the same piece of information (available time per year for staff in Category A)expressed in three different ways – in weeks, days and hours. The corresponding figures for theavailable time in a year for staff in Category B are:




The average available working time per month for these staff categories is:

Category A: 222 days/year

12= 18.5 days/month

Category B: 234 days/year

12= 19.5 days/month

The results of calculating the average available working-time per year for different staff categoriescan be used directly to calculate the Staffing Requirements of posts which must be mannedaccording to a fixed time pattern rather than according to workload, for example, an officereceptionist post which must be staffed continuously throughout the year during normal workinghours irrespective of the number of callers, a hospital pharmacy in-charge post which must bestaffed while the pharmacy is open for business irrespective of the volume of dispensing beingdone, a security guard post or an intensive care unit post, which must be manned day and nightcontinuously throughout the year. Examples of these calculations are shown in Annex A.

On-call serviceOne type of working arrangement, on-call service, does not fit into the calculations of availableworking-time per year given above. In on-call duty, staff are available for service during officialoff-duty hours at nights and weekends and they work during this period only when there is ademand for their services. This is frequently the arrangement with laboratory and X-ray staff inthe smaller hospitals, particularly those which operate 24-hour accident and emergency services,and also with midwifery staff. Arrangements for on-call service differ. Sometimes the on-call staffare available within the health facility itself; they are provided with a room there but they are notdisturbed until their services are required. Alternatively, particular staff are nominated as beingon-call and are brought in from their own homes when needed. The question arises as to whatlevels of staffing are required to cover on-call service as well as duty during normal working hours.

The accommodation arrangements for staff on on-call services are irrelevant to the WISNcalculation. The sole factor of importance is the method of recompense used for on-call duty. Twomain methods are used: time off in lieu and extra payment.


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In some countries a proportion of the on-call duty time is given as time off in lieu. This proportionmay be 100%, i.e. the whole of the on-call time is counted as duty time, so that a night on-call(4.00 p.m. – 8.00 a.m., i.e. 16 hours) is followed by two days (8-hour shifts) off. More usually thearrangement is that a night or week on-call is followed by one day or week off, since normally theworkload at night is very light. For WISN purposes the actual duration of the on-call time isignored and the time off in lieu is counted as ordinary working time. Thus if a facility uses on-callduty as a permanent feature of its staffing arrangements, then the calculation of its StaffingRequirement has two components:

� staff required to cope with the normal workload as shown in the service statistics, calculated bythe WISN Method;

� the staff equivalent of the time off in lieu.

For example, a large health centre schedules a particular category of staff for day duty on rota forseven days a week and covers all (365) nights by having one person on-call with the following dayoff. This on-call duty requires extra staff, which is equivalent to 365 days service per year. Suppose, for the sake of example, that staff in this category are available for duty on average for234 days per year, like the medical aides in the example earlier. Then the extra staff required is365 / 234 = 1.56 staff. The calculated Staffing Requirement for the facility is then:

staff requirements according to the WISN Method based on service statistics PLUS

an extra 1.56 staff for the on-call duty.

This does not mean that one or two staff are appointed solely for on-call duty but rather that theon-call duty is shared among all the staff and this will be possible only by employing one or twomore staff.

If the on-call time is recompensed by payments (at whatever rate) and not by any time off in lieu,then it is not counted as part of the WISN calculations. In effect, the extra on-call duty time isprovided by staff out of their own off-duty time and does not affect their ordinary working time.

Other types of arrangement, e.g. a different amount of time off for the on-call duty, on-call dutyat weekends only, etc. is treated in the same way by focusing solely on the average amount of timeoff in lieu which is given in a year, and the extra staff which will be required to cover it. If it is amixed arrangement, with both extra payments and time off in lieu, only the time off in lieu isincluded in the WISN calculations.

Scheduled/actual working hoursIn nearly all countries there are situations where the actual hours worked by staff are less than thescheduled working hours specified in the conditions of service or the contract of employment. Thismay be general or it may apply to only certain categories of staff and/or certain types of healthfacility and/or certain locations. One possible reason for this is that the public attends for treatmentonly at particular times. For example, in one rural health facility with working hours 8.00 am to3.00 pm (seven hours/day), the public attended only 8-10 am and 1-3 pm, that is four hours/day. Or the staff themselves may curtail their working hours because of private practice or otherearning activities, or because it is the custom and practice, etc. In all these circumstances thequestion arises as to how to frame the WISN calculations, i.e. whether to use the formal contractedhours (e.g. seven hours/day) or the actual working hours (e.g. four hours/day) in order to set theStandard Workloads (the amount of work one staff can do in a year).


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The decision as to which to use depends on whether the situation is outside the effective controlof the MOH. For example, it would be realistic to use the attendance times of the public, say fourhours out of seven hours per day, in the short term because these are determined by social orcultural factors, although the ministry may attempt to change these in the medium to long term byan education process to encourage the public to attend during the current dead periods, or it mayattempt to reduce the financial burden of the situation by instituting part time employment of staff(e.g. 08.00-10.00 and 13.00-15.00 daily) if possible. If the situation is theoretically within theauthority of the ministry, e.g. staff leaving early to attend to private practice or other activities, thedecision is more difficult. Using the formal working hours gives results of what the governmentis entitled to – it shows the staffing which the government is entitled to expect will do the job, i.e.carry out the workload to an acceptable professional standard. This is usually strongly favouredby departments of finance. Using actual working hours shows the staffing levels that will berequired if the current situation continues. This is usually strongly favoured by local managers.

As an entirely separate issue (from which time to use in the calculations) is the question of how tocalculate the results if the actual working hours are used to set Standard Workloads. The manualshows how to set up the calculations using formal or contract working hours. To use actualworking hours in the WISN calculations there are two options:

1. Insert the actual working hours instead of the formal working hours in the calculation of theworking time available per year as set out in the manual. This will probably mean repeatingthese calculations for several different categories of staff.

2. Use the formal working hours in the calculation of the working time available per year asset out in the manual and include the "missing" hours, i.e. the formal or contract hours perday which are not worked, as an extra allowance in the later calculation of StandardWorkloads (see Section C.3). The WISN Method is already set up to take account ofdifferent allowances for different categories of staff. This extra allowance can easily beadjusted in the calculations if the situation should change.

2. Setting Activity StandardsAn Activity Standard must be set for each type of health care activity. An Activity Standard is aunit time (or rate) for a health care activity – how much time, on average, performing anexamination, filling a prescription, taking an X-ray, etc. should take to complete by qualified staffwho are working to acceptable professional standards. These Activity Standards are a vital factorin the WISN calculations; they have a direct effect on all the results that are produced. Also,setting these Activity Standards is a novel procedure in virtually all countries and so the staff whoundertake it must be carefully oriented before the procedure and guided during it if they are toperform the task successfully. For these reasons the procedure to use in setting Activity Standardsis set out in some detail.

The Activity Standards for health staff in a country are usually set by working groups of senior andknowledgeable staff with substantial experience of the work for which the standards are being set. Two different types of working group can be used to set Activity Standards:

� a cadre group, which consists of the senior and knowledgeable staff in a cadre who set theActivity Standards for all the staff categories in their own cadre working in all the differenttypes of health facilities in which the cadre is employed in the country. Using this approach,each cadre employed in the health service requires a cadre group to set its Activity Standards;


44_________________________________________________________________________________________

� a facility group, which consists of the senior and knowledgeable staff in a health facility whichis generally reckoned to have good performance. Together the group sets the ActivityStandards for all the staff categories who work in this type of health facility in the country. Intheory each type of health facility requires a facility group to set the Activity Standards of thestaff employed in it. However, in practice if the activities carried out in one type of healthfacility are very similar to those carried out in another, e.g. dispensary/health centre orregional/national hospitals, one facility group can produce the Activity Standards for the staffin both types of facility, even where the Activity Standards for an activity may be different inthe two types of facility.

In order that these groups can perform their task and produce results which will be useful in theWISN calculations, the participants in these groups must be oriented to understand the steps in theprocedure:

a) What is an Activity Standard?

b) What is the scope of their task, i.e. which staff categories and facilities are they to cover inproducing Activity Standards?

c) What are the main activities or functions (components of workload) for each of these staffcategories in each type of facility in which they are employed?

d) Setting an Activity Standard for each of the main activities or functions (components ofworkload) in each type of facility.

e) Estimating the amount of time spent away from the working situation on staff training anddifferent types of absence.

Each of these steps is explained in the following subsections, which could be used as theintroductory material/presentation to these groups.

a) What is an Activity Standard?

The Activity Standard for a particular activity is the time it would take a trained and well-motivatedmember of a particular staff category to perform the action to acceptable professional standards inthe circumstances of the country (its medical practices, equipment available, etc.). In the WISNMethod, all Activity Standards are set in terms of the time taken to perform certain actions or therate at which these actions should be performed.

b) What is the scope of the group's task, i.e. which staff categories and facilities are to becovered?

Activity Standards can be set for a cadre by a group of senior and knowledgeable staff in the cadre. This is known as the "cadre group" method. The group sets the Activity Standards by reviewingthe work of each of the staff categories in the cadre in each type of health facility in which theywork in the country. For example, a pharmacy group setting Activity Standards in one country setout its task as follows:


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Pharmacy groupStaff categories senior pharmacist; pharmacist; pharmaceutical assistant;

pharmaceutical attendantFacilities national hospital; regional hospitals; district hospitals; health

centres

In setting out its task, the group took account of the fact that:

a) Senior pharmacists are employed as the person in charge of pharmaceutical services in thenational and regional hospitals. The job of the senior pharmacist is the same in national andregional hospitals, so only one set of Activity Standards is required for this staff category.

b) Pharmacists are employed in the national, regional and district hospitals. The job of apharmacist is the same in a national and a regional hospital (mainly filling prescriptions) buthas extra tasks and responsibilities in a district hospital (where the pharmacist is the personin charge of the pharmacy), so two sets of Activity Standards for pharmacists are requiredfor this staff category.

c) Pharmaceutical assistants are employed in the national, regional and district hospitals andin health centres. The job of a pharmaceutical assistant is the same in national, regional anddistrict hospitals but has extra tasks and responsibilities in a health centre (where thepharmaceutical assistant is the person in charge of the pharmacy).

d) Pharmaceutical attendants are also employed in the national, regional and district hospitalsand in health centres. The job of pharmaceutical attendants in cleaning, replenishing stocks,etc. is the same in all the health facilities.

The Activity Standards to be determined by the group were then set out in a table:

Senior pharmacist national/regional hospitals

Pharmacist 1. national/regional hospitals2. district hospitals

Pharmaceutical assistant 1. national/regional/district hospitals2. health centres

Pharmaceutical attendant national/regional/district hospitals/health centres

Similarly the laboratory group set out its task as follows:

Laboratory groupStaff categories laboratory technologist; laboratory technician; laboratory

assistant; laboratory attendant

Facilities national hospitals; regional hospitals; district hospitals; healthcentres

The group determined that the job (and hence Activity Standards) of laboratory technologist wasthe same in the national and regional hospitals (where a pathologist is in charge of the laboratory)


46_________________________________________________________________________________________

but different in district hospitals (where the laboratory technologist is in charge); that the laboratorytechnician has one job (set of Activity Standards) in hospitals and a different job (set of ActivityStandards) in health centres where the laboratory technician is in charge; and that the job (ActivityStandards) of a laboratory attendant in cleaning, replenishing stocks, etc., is the same in all healthfacilities.

As before, the Activity Standards to be determined by the group could then be set out in a table:

Laboratory technologist 1. national/regional hospitals2. district hospitals

Laboratory technician 1. national/regional/district hospitals2. health centres

Laboratory attendants national/regional/district hospitals/health centres

Doctors groupFollowing the same procedure, the doctors group set out its task as follows:

Staff categories consultant; registrar; medical officer; medical assistant; ruralmedical assistant

Facilities national hospitals; regional hospitals; district hospitals; healthcentres; health posts

Here again the job of each staff category (and hence its Activity Standards) was differentdepending on the type of health facility. For example, consultants in the national hospital undertookmore complex cases (more time per case) and more research (larger time allowance for thisactivity) than the consultants working in the regional hospitals, while in the district hospitalsconsultants are in charge of departments and so have a major management function there (requiringa corresponding time allowance); registrars work only in the national and regional hospitals, wherethe training posts are available; medical assistants work in district hospitals and also in healthcentres (where they are in charge); rural medical assistants work in health centres and also in healthposts (where they are in charge).

The Activity Standards to be determined by the group could then be set out in a table:

Consultants 1. national hospital2. regional hospitals3 district hospitals

Registrars national/regional hospitals

Medical officers 1. national/regional hospitals2. district hospitals

Medical assistants 1. district hospitals2. health centres 2. district hospitals

Rural medical assistants 1. health centres2. health posts2. district hospitals


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A cadre group can be set up for any cadre employed in the health service, in order to set theActivity Standards for all the categories of staff in the cadre in all the types of health facility inwhich they are employed in the country.

Alternatively the Activity Standards can be set for all the staff categories employed in one type offacility by a group of senior staff who between them are knowledgeable about all the activities ofall staff categories employed in this type of facility. This is known as the "facility group" method. These groups set out their task by listing all the staff categories which are employed in this typeof facility, for which Activity Standards must be set. Some examples are:

Health post groupStaff categories rural medical assistant; MCH aide; nursing assistant; nursing

attendant; health assistant

Health centre groupStaff categories medical assistant; rural medical assistant; MCH aide; nurse

midwife; nursing assistant; nurse attendant; laboratory assistant;medical records assistant; health assistant; cooking staff;laundry staff; driver; watchman

The same method can also be used for clinics and other relatively small health facilities. However,when this facility group approach is used for hospitals, particularly the larger hospitals, it wouldbe unwieldy and inefficient to follow exactly the same format. A list of the staff categoriesemployed in a large hospital is exceedingly long and must be divided up in some way to make thework practicable. The most convenient way of doing this is to combine the two methods, that is,first to make a list of all the hospital staff categories (the facility group approach) and then to dividethe list by cadre (the cadre group approach). For example, the task of setting Activity Standardsfor the laboratory staff in a large hospital was set out as follows:

Regional hospital: laboratory groupStaff categories laboratory technologist; laboratory technician; laboratory

assistant; laboratory attendant

and the task of setting Activity Standards for the radiography staff was also set out simply:

Regional hospital: radiography groupStaff categories senior radiographer; radiographer; radiographic (darkroom)

assistant

However some staff categories in a large hospital, e.g. nurses, work in many different locations anddo many different jobs. For this reason the regional hospital nurses group had a rather larger task,which was most conveniently set out in the facility/cadre group format, as follows:


48_________________________________________________________________________________________

Regional hospital: nurses groupStaff categories nursing officers; nurse midwives; registered nurses; enrolled

nurses; nursing assistants; nursing attendantsFacilities general medical wards; paediatric wards; psychiatric wards;

maternity wards; general surgery theatres; obs. & gynae.theatres; eye surgery; outpatient clinics; MCH/FP clinics;ophthalmic clinics; psychiatric clinics; accident & emergencydepartment; intensive care unit.

It is a major task to set Activity Standards for all the different combinations of nurse staffcategories and the types of work they do in a large hospital. One simplification which is frequentlyused is to group together types of ward or types of clinic and set average Activity Standards foreach of these groupings, e.g. the wards (general medical/paediatric/psychiatric wards but notincluding maternity wards); maternity wards; all operating theatre work; all clinics; etc. Evenwhere this simplification is used the situation is still fairly complicated because different nursingcategories are employed in each of the working situations. These complications are best clarifiedby setting out a matrix (two-way table) showing the staff categories down the side and the facilitiesor working situations along the top. An example from one country is as follows:

Nurses group Wards Operatingtheatres Maternity Acc. &

emergency Clinics

Nursing officer x x x

Nurse midwife x x

Registered nurse x x x x

Enrolled nurse x x x

Nursing assistant x x x x x

Nursing attendant x x x x

Each "X" denotes a set of Activity Standards which had to be produced. In some cases theactivities of a nursing category, e.g. nursing attendant, are the same in several working locationsand the same Activity Standards can be used in all of them.

The same situation arises with the medical staff in a large hospital (several different categories ofmedical staff working in a number of different situations), and the same approach of setting thetask out in matrix form works well in this case also.

In one country four main facility groups were assembled:

Health post group: comprising eight district-level staff and people in charge of health centres withlong experience of supervising health posts, and representatives of MOH departments.

Health centre group: comprising ten district-level staff and people in charge of health centres withlong experience of supervising health centres, and representatives of MOH departments.

District hospitals group: comprising the senior staff from all departments in one high performancedistrict hospital, and representatives from the regional health team and MOH.


_________________________________________________________________________________________ 49

Regional and national hospitals group: comprising senior staff representing all departments fromthe national hospital and the best regional hospital, together with representatives from MOH.

The health post group met and took half a day to complete its work on setting Activity Standardsfor the five staff categories (listed above) employed in the health posts. Subsequently the healthcentre group, which included many of the same individuals, took one day to complete its work onsetting Activity Standards for the thirteen staff categories (listed above) employed in health centres;some of the categories, e.g. driver and watchman, could be dealt with very quickly.

The meeting of the district hospitals group and of the regional and national hospitals group tookthe form of workshops. In these, an initial plenary session introduced the task, explained itscontent and described the procedures to be used (based on the material set out earlier in thissection). Then the participants listed all the cadres/staff categories and working situations(wards/clinics/theatres etc.) to be covered. Participants were then divided into a number ofworking groups at each session, and each working group produced the Activity Standards for oneof the cadres employed in the hospital. In each workshop session the chairman and secretary ofeach working group both came from the cadre being considered by the working group. TheActivity Standards produced by each working group were reported back to a plenary meeting ofthe workshop for consideration and approval. Some cadres (radiography, pharmacy) occupied aworking group for half a day, but others (doctors, nurses) took a full day or more. The workshopfor the district hospitals group lasted three days, and for the regional and national hospitals groupfive days.

In addition each of the specialist hospitals, i.e. TB hospital, eye hospital, etc., set up its own groupof senior staff which was joined by representatives of MOH. Each of these specialist hospitalgroups set the Activity Standards for all the staff categories employed in their own hospital. Wherever possible these Activity Standards were the same as those set out for staff in the nationalhospitals.

Whichever method (cadre group or facility group) is being used to set Activity Standards, eachgroup should first set out the task it is to tackle under the headings of:� staff categories, in order to list all the different types or grades of staff it is to cover;

and where appropriate

� facilities, in order to list all the different working situations it is to cover.

Only then should the group decide which jobs are the same so that the same Activity Standards willapply. It is very desirable to draft out beforehand a list of the staff categories and facilities for eachcadre group, facility group or working group in a workshop so that it can start its task by correctingthe draft lists if necessary and thereby understand the extent of its work from the start.

c) What are the main activities or functions (components of workload) for each of these staffcategories?

Having decided which staff categories/working situations need to have Activity Standards set, thenext step is to determine what activities or staff functions should be covered by these ActivityStandards. Most staff categories employed in a health facility each has a number of major func-tions or activities which it performs. These are the functions or activities which together take upmost of the working time of the staff concerned. These major functions or activities are called thecomponents of workload for the staff category in the health facility. There are usually not more


50_________________________________________________________________________________________

than three or four components of workload for each staff category. For example, the main tasks ofa pharmaceutical assistant in a district hospital are:

filling prescriptionspreparing materials and cleaning up

These are performed under the supervision of the pharmacist in charge of the hospital dispensary.Each of these components of workload must have its Activity Standard.

However, the components of workload for a staff category depend on which types of health facilitythey are employed in. To continue the example, the same staff category working in a health centre,where the pharmaceutical assistant is in charge, has additional tasks. Not only

filling prescriptionspreparing materials and cleaning up

as in the district hospital, but alsorecording and reportingordering stock, checking deliveries and supervising storage.

The workload of the pharmaceutical assistant in the health centre must take account of these extratasks and the time they take. These two extra components of workload must each have its ownActivity Standard also.

In one country the registered nurses in health centres (where a medical assistant is in charge) havethe following main activities:

inpatientsoutpatientsscheduled clinicssupervised birthsrecording and reporting.

The nursing aides in the same health centres have only two main activities:inpatientsoutpatients.

It is a matter of judgement to decide what level of detail to go to in listing the components ofworkload for a staff category. For example, the main components of workload for a dentalassistant in a district hospital could be listed as:

treating patientssetting out and clearing awayrecording and reporting

and an Activity Standard could be set for each of them.

However the first item, treating patients, could be broken down into:extractionsfillingsscalingpolishing

with each of these items having its own Activity Standard (average time to perform each type oftreatment).


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Similarly the components of workload for laboratory assistants could be:performing testsspecimen collectionrecord keeping.

Here again the first item, performing tests, could be broken down into:haematologybacteriologyparasitologyclinical chemistryimmunoserology

with an Activity Standard (average time to complete) set for each type of test.

This same type of detailing can be done with the components of workload for all categories of staff,e.g. inpatients can be divided into medical/surgical/paediatric/psychiatric etc., filling prescriptionscan be divided into one item/two item/three item prescriptions, etc.

Working in more detail like this gives the possibility of more precise results from the WISNcalculations. However, it does require more effort - both in collecting much more data (frequentlya great deal more) and also in entering this larger volume of data into a computer.

Although the level of effort required for the WISN calculations is an important factor in decidingwhat level of detail to work at in applying the method, an even more important factor is the levelof detail currently available in the service statistics which are regularly collected in the differenthealth facilities and returned by them to the local district or regional health office or to the centre. The WISN calculations can be performed only to the level of detail in the statistics themselves. Ifthese statistics show only the total numbers of dental patients treated and not the numbers receivingeach type of treatment (extractions, fillings, etc.), then the calculations can only be done and theActivity Standards should only be set in terms of the total number of patients treated and not thenumbers of extractions, fillings, etc. which are done. Similarly if a single bed occupancy figureis available for each hospital rather than the occupancy figures for each type of ward (medical,paediatric, etc.), then Activity Standards must be set for nurses in the hospital as a whole ratherthan for individual wards. Such average Activity Standards may be thought of as crude, but theyare much more effective in setting realistic Staffing Requirements than the usual alternatives(population ratios, standard staffing schedules).

d) Setting an Activity Standard for each of the main activities or functions (components ofworkload) for each staff category

When the components of workload have been identified for all the staff categories in each type offacility in which they are employed, each group then sets an Activity Standard for each componentof workload. In undertaking their task, the groups set two types of Activity Standard:

a) Standards for the services and activities which are reported in the annual service statistics,e.g. number of inpatients (or bed occupancy) in various types of ward, number of outpatientvisits, number of clinic patient visits of various types, number of births, number ofmajor/minor surgical operations, number of dental treatments of different types, etc. In thecalculations these standards are applied to the reported workloads which are shown in thelatest annual service statistics. They are called service standards.


52_________________________________________________________________________________________

b) Standards which apply to those activities which are not reported in the annual servicestatistics. This may be because the activities cannot easily be measured, e.g. recording andreporting, stores management, performing ward procedures, attending meetings, generaladministration, etc. Alternatively this may be because the regular collection of servicestatistics in the country does not yet cover these activities, e.g. in some countries the numberof laboratory tests performed in health centres are not reported. An allowance is made inthe calculations for these activities according to the amount of working time they shouldabsorb. These are called Allowance Standards.

The first step in setting the Activity Standards for a staff category working in a particular type offacility is to mark each of its components of workload according to whether it is covered in theregular service statistics which are readily available in the country (and so must have a servicestandard) or whether it is not (and so must have an Allowance Standard).

In many cases a component of workload corresponds directly to an item in the regular servicestatistics:

� inpatients or bed occupancy, for the workloads of doctors, nurses and most ward staff;

� tests performed, for the workloads of laboratory staff;

� outpatient visits, for the workloads of staff in health posts, health centres and the outpatientdepartments of hospitals;

� antenatal examinations, child weighings, immunizations, etc., for the workloads of staff in MCHclinics.

In other cases a component of workload is clearly related to the general level of workload in ahealth facility, but a directly relevant item of data is not collected and included in the regularstatistics. For example, the workload of hospital laundry staff increases directly as the generallevel of workload in the hospital itself increases. In countries where the number of items washedis recorded, the statistics provide an item of data which corresponds directly to the main componentof workload of this staff category. However most countries do not collect statistics on the volumeof laundry processed in hospitals, and so it is necessary to find a proxy item, i.e. an item of datawhich will serve as a proxy measure of the volume of laundry to be done. The item of data mostfrequently used for this purpose is the number of inpatients, or bed occupancy. The group estimateshow many laundry staff would be required to deal with bed linen from 100 inpatients, and this thenserves as the Activity Standard. Similarly, in countries where kitchen staff are employed toprovide food for inpatients and/or staff in health facilities, the number of meals provided per dayis not recorded. However, the number of meals daily can be estimated from the service statisticsas:

3 x (no. of inpatients + no. of staff eligible for meals).

The group sets an Activity Standard as the number of kitchen staff required to prepare 100 mealsper day.

Wherever possible, components of workload should be linked to items in the service statistics,either directly or by proxy. Only if no relevant statistics are collected or if the activity isindependent of the service workload, or very nearly so, should an Allowance Standard be set; theway of doing this is set out later.


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For each of the components of workload which is covered by or linked to an item in the regularstatistics, the group should:

a) specify the statistics item to be used, e.g. outpatient visits, antenatal examinations, homedeliveries, X-ray examinations, clinic attendances, inspections of premises, etc.

b) set an Activity Standard as a unit time for the item, e.g. 10 minutes/outpatient visit, fourhours/home delivery, 15 minutes/X-ray examination, etc.

c) alternatively, for some activities it is easier and more natural to set an Activity Standard interms of a rate of working, e.g. 40 clinic attendances per day for a nurse, six inspections perday for a health assistant, etc.

In setting a unit time as an Activity Standard, e.g. for an outpatient visit, laboratory test, homedelivery, dental treatment, X-ray examination, etc., it is important to include in the unit time all thetasks related to the individual item, e.g. a doctor writing up a patient's notes after the consultation,recording the results of each laboratory test twice (once for the laboratory records and once for thedoctor who sent the sample), setting out and clearing away for each dental patient, etc. The unittime is the average time which should elapse between the start of an item of service activity (out-patient visit, laboratory test, etc.) and the start of the following item of the same activity if allprocedures are working efficiently according to practices of the country and there are no delaysbetween successive items of service activity. Anything done for each patient or item should beincluded in the unit time for each patient or item, e.g. recording and reporting. Anything doneregularly (once a day, a week, a month, etc.) irrespective of service workload, should be coveredby an Allowance Standard, e.g. daily, weekly, etc. reports.

It is normally better, wherever possible, to set a unit time for a component of workload rather thanset a daily or weekly rate, for two reasons. First, it is easier to visualize a single activity (outpatientexamination, laboratory test, dental treatment, etc.) and estimate its duration. Thus an estimate ofan actual elapsed time for an activity is likely to be more accurate than a rate. Certainlydiscussions within groups are more specific and disagreements more quickly resolved. Second,when the groups set a daily rate, for example, it is never quite clear to what extent they areincluding an allowance for other activities, e.g. recording and reporting, setting up and clearingaway, supervision, etc. If it is clear that these allowances are included in the rates set by a group,then the allowances should not be included as separate Allowance Standards in the subsequentWISN calculations.

Hospital ward staff who deal directly with inpatients (mainly nurses) merit a special procedure inthis method. It is possible to use the standard approach and set a unit time per patient for thoseward staff whose main work consists in dealing with inpatients, and this method has been used insome countries. In this approach an estimate is made of the average amount of time in total whicha nurse (or other category of ward staff) should give to each inpatient during a 24-hour period. Thisaverage time is then used as the Activity Standard. However, the Staffing Requirements of wardnurses and other ward staff are best calculated using another type of Activity Standard, which isto specify the number of inpatients (occupied beds) for which a nurse on duty should beresponsible, e.g. one nurse per 10 occupied beds. This figure can vary with the shift, e.g. one nurseper eight occupied beds on the morning shift, one per 12 occupied beds in the afternoon shift andone nurse per 20 occupied beds during the night. It can also vary with the type of ward (it isusually smaller for paediatric wards, e.g. one nurse per five occupied beds, than for general medicalwards, e.g. one nurse per 10 occupied beds, and for intensive care units it can be one nurse for eachoccupied bed.) One major advantage of this method is that it is much easier for nurses to estimate


54_________________________________________________________________________________________

how many inpatients they can cover adequately when on duty than it is for them to add up the totalaverage time which should be spent with each patient totalled over three shifts during a 24-hourperiod. And because the number of inpatients (occupied beds) covered conforms with their directwork experience, rather than the average accumulated time spent with each inpatient over a 24-hour period, these estimates are not only easier for them to make but more accurate as well. Figures for nurse/inpatient ratios for different types of wards should only be set where the regularservice statistics show bed occupancy rates separately for each of these types of ward. If bedoccupancy rates are known only for the hospital as a whole, then groups should set anurse/inpatient ratio for the hospital as a whole.

For each of the components of workload which is not covered by an item in the regular statistics,the group must set an allowance either as a percentage of working time, e.g. 20% for administrationby the person in charge of a laboratory, or as a time allowance, e.g. one hour per day for recordingand reporting by ward nurses, five hours per week for clinical meetings of hospital doctors, twodays per month for checking and replenishing supplies by pharmaceutical assistants in adispensary.

This allowance may apply to all the staff in a particular category, e.g. all doctors in a particulartype of hospital attend clinical meetings for five hours per week; all pharmaceutical assistantsworking in district hospitals spend one hour per day cleaning equipment, utensils, etc. Alternat-ively the allowance may refer to a task or function performed by one or two individuals only in theworking situation, e.g. one nurse in the ward completes the ward returns, taking one hour per shift;two pharmaceutical assistants spend two days per month checking and replenishing dispensarysupplies. The group must state clearly for each component of workload for which an allowanceis made, whether the task or function is performed by a fixed number of staff (one, two, ...) or byall the staff in the category. These two types of allowance (applied to a fixed number of staff orto all staff) require slightly different mathematical formulae in the WISN calculations.

Some jobs consist wholly of activities (components of workload) which are not directly related tothe workloads shown in the service statistics; in other words if the service workloads in thefacilities changed, the workloads of these jobs would not be affected to the same extent. Forexample, the jobs of some staff are wholly or mainly administrative, e.g. staff employed in theMinistry of Health HQ and in regional and district health offices, hospital secretaries, matrons inlarge hospitals, etc. Other staff, usually in the lower grades, may also have jobs which are notdirectly related to delivering health services and therefore are not significantly affected by thevolume of service delivery, e.g. cleaners, messengers, gardeners, watchmen, guards, drivers, etc.But note that the workloads of cooks and laundry staff do depend directly on the number ofoccupied beds, which normally appear in regular hospital statistics.

In addition there may be other categories of staff whose jobs are related to service delivery but nofigures on their activities are collected in the regular statistics, e.g. health educators in somecountries, health assistants in some countries, etc. Since no workload statistics are available forthese categories of staff, calculations of Staffing Requirements based directly on workloads are notpossible.

For all those staff where none of their components of workload is covered by an item in the servicestatistics, a different type of Activity Standard must be set. This standard must be one of thefollowing types:

a) A ratio on other staff, e.g. one medical assistant per four rural medical aides in a healthcentre (for five or more RMAS the management and supervision workload in the health


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centre is too great for one MA), one laboratory assistant per two rural medical aides in ahealth centre (where no laboratory statistics were being collected); one nurse supervisor per30 nurses employed in a hospital. In these cases the number of rural medical aides, hospitalnurses, etc. are calculated from the workload statistics in the health centre, hospital, etc.using the WISN Method, so the number of medical assistants, laboratory assistants, nursesupervisors, etc. are also based on workload, but at one remove;

b) A fixed number per facility, e.g. three watchmen per health centre, one matron per hospital,one nursing attendant per dispensary, etc., whatever the size of facility covered and theworkload in it;

c) A fixed number per item of equipment e.g. one driver per vehicle, two radiographers per X-ray machine (where no X-ray statistics are being collected);

d) A fixed number per administrative unit, e.g. one health assistant per electoral ward, onedistrict medical officer per district, etc...;

e) Staffing according to organizational structure, where a number of senior posts are specified,e.g. director general, deputy directors general, directors, deputy directors, etc. in theministry/department of health, regional offices, etc. (In these structures only the numbersof more junior staff, e.g. at clerical grades, are determined by workload).

In all these cases no separate allowances (for administration, supervision, etc.) are made; thesefactors are already included in the types of standard listed above.

Activity Standards for acceptable alternative proceduresIn some countries different medical services are provided according to the different culturaltraditions of the country (e.g. Moslem, French, Anglo-Saxon) and these may operate differentmedical procedures in order to deal with the same situation (e.g. outpatient attendances). Thesedifferent medical procedures normally take different times to perform, i.e. have different ActivityStandards. Provided all these cultural differences are accepted within the country, then separateActivity Standards should be set for the activities in each of them where they are required. Thereshould be no attempt to set a single representative or average Activity Standard to cover all thedifferent practices which deal with the same medical situation; this would simply give an incorrectresult for the Staffing Requirements in some, perhaps all, types of these facilities.

It should be noted that dividing the working time of a staff category between its components ofworkload, e.g. for a health sub-centre nurse

40% treating outpatients10% health education sessions30% home visits10% school visits10% administration

is not setting an Activity Standard. Such a list shows the expected pattern of activities for thiscategory of staff, but these figures do not show how much work is expected of these staff (how


56_________________________________________________________________________________________

many inpatients per day, how many home visits per day), and hence how many of them would berequired in a health facility in order to deal with its recorded workload.

Setting the unit times, rates and allowances is the most critical step in the whole task of calculatingWISNs. It should be emphasized to groups which are setting these Activity Standards that:

a) The unit times, rates and allowances should correspond to the standard of performancewhich would be expected of experienced and well motivated staff taking into account thegeneral situation or circumstances found in these facilities in the country, e.g. medicalpractices, availability of equipment and supplies. International comparisons should be madewith the utmost care. Medical practices and equipment differ greatly between countries; alsostaff categories with the same title in two countries may be performing very differentfunctions;

b) Although groups are naturally anxious to set highly professional standards of performancein the country, their targets cannot be too far from the prevailing practice otherwise theresulting Staffing Requirements will be so high that they are impracticable and will thereforebe ignored, and the whole WISN exercise will be futile. It is better to set intermediatetargets for Activity Standards which can be improved later as the staffing situation improves.

A sample set of briefing notes and instructions for groups on setting Activity Standards is inAnnex B.

e) Estimating the amount of time spent away from the working situation on staff training andabsence

One component of the calculation of available working time per year (see Section C.1) is makingan allowance for the training time, sickness and other absence times of each staff category. Wherepossible these figures are obtained from staffing statistics or personnel records. However in manycountries this is not possible and an estimate of training time and absence time must be made. Thecadre group or facility group which has sufficient knowledge and experience of a staff categoryto set its Activity Standards, is also best placed to make these estimates of training time andabsence time. For convenience this task is added to the list of tasks for these groups. Theestimates for training time and absence time may be made separately or as a single figure coveringboth, and also they may be set as a percentage of working time or as a number of days or weeksper year.

3. Turning Activity Standards into Standard WorkloadsOnce the expert groups have set the Activity Standards for each staff category in each type ofhealth facility in which they are employed, their task is complete. The service standards are unittimes (e.g. 15 minutes/patient) or rates (e.g. 30 patients/day). The Allowance Standards arepercentages of working time or actual working time (e.g. one hour/day, two days/month, etc.) fora fixed number of staff or for all staff in the category in the working situation. These standardsmust be combined and translated into the equivalent volumes of work per year per employee(Standard Workloads) so that they can be compared with the volumes of workload reported in theannual statistics in order to calculate the numbers of staff required. The Standard Workloads arethe figures which are actually used in the computer calculations to produce the StaffingRequirements. Calculating the Standard Workloads from service standards, and the AllowanceFactors from the Allowance Standards is a job for the task force.


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The steps in the process are:

a) Calculate the annual volume of activities according to the service standards alone, i.e. activi-ties for which unit times or rates have been set;

b) Calculate a multiplier factor based on the Allowance Standards which apply to all staff inthe category, i.e. activities which are undertaken by all staff in the category;

c) Finally, add in the Allowance Factors for tasks or functions performed by a fixed numberof staff in the working situation.

All the examples shown below are based on figures given in Section C.1, Example 2.

Standard Workloads based on unit timesThe formula for calculating the annual workload (Standard Workload) for an activity based on thetime required to perform the activity (Activity Standard) is

Standard workload for an activity =Available time in the year

Unit time for the activity(Activity standard)

Examples

If the dental screening of a school takes one day and is carried out by a school dental therapist (Cat-egory B staff), who have available working time of 234 days per year, then the Standard Workloadis

234 / 1 = 234 schools/year

This does not mean that a school dental therapist would be expected to carry out 234 schoolscreenings every year. These staff also undertake other activities, e.g. administration, equipmentcleaning and maintenance, etc. Rather it means that each school screened takes 1/234th of aworking year for a school dental therapist.

If a major surgical operation takes on average two hours, the corresponding Standard Workloadfor category A (medical) staff, with available working time of 1,776 hours per year, is

1,776 / 2 = 888 major operations/year

This does not mean that a surgeon would be expected to carry out 888 major operations in a year– (s)he has many other activities which take up working time. All these other activities are allowedfor in the calculations. Major operations are only one component of a surgeon's workload. Theresult shown actually means that one major operation will take up 1/888 of the working year of asurgeon.

For Category B (support) staff a major surgical operation takes on average two and a half hours(15 minutes setting up, two hours operation, 15 minutes clearing away). The correspondingStandard Workload is:

1,872 / 2.5 = 749 major operations/year


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If a minor operation takes on average 15 minutes, the corresponding Standard Workload forCategory A staff is:

Category A: 1,776 x 60 / 15 = 7,104 minor operations/year

There is no setting out and clearing away between minor operations, only at the end of theoperating session, so the average time requirement for Category B staff is also 15 minutes and thecorresponding Standard Workload is:

Category B: 1,872 x 60 / 15 = 7,488 minor operations/year

In addition there will be an Allowance Factor (see later) included in the calculation to cover thesetting out and clearing away time at the beginning and end of the operating session; this time isthe same no matter how many minor operations (workload) are performed during the session.

If a pharmaceutical assistant (Category B) takes on average five minutes to fill a prescription, thecorresponding Standard Workload is:

1,872 x 60 / 5 = 22,464 prescriptions/year

Standard Workloads based on ratesThe formula for calculating Standard Workloads based on a rate for an activity is:

Standard Workload = rate x available time in the yearExample

If a health assistant (Category B) can inspect 10 commercial premises per day, then thecorresponding Standard Workload is:

10/day x 234 days/year = 2,340 inspections/year

This does not mean that a health assistant would be expected to carry out 2,340 inspections everyyear. These staff also undertake many other activities. Rather it means that each inspection takes1/2,340th of a working year for a health assistant.

If a registered nurse (Category A) can deal with 35 outpatient attendances per day, then thecorresponding Standard Workload is:

35/day x 222 days/year = 7,770 outpatient attendances a year

This does not mean that a nurse in the outpatient department would be expected to treat 7,770outpatients every year. These staff also undertake many other activities. Rather it means that eachoutpatient treated will take 1/7,770th of a working year for such a nurse.

Allowance FactorsThere are two types of Allowance Factor:

a) Those which apply to all staff in a particular category, however many are employed in afacility, e.g. one hour per day cleaning up by all pharmaceutical assistants employed in adispensary; all hospital doctors employed in a department attend clinical meetings for 5.5hours per week. This is a Category Allowance Factor.


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b) Those Allowance Factors which apply to a fixed number of staff in a particular category,however many are employed in a facility, e.g. two pharmaceutical assistants undertake stockunloading and storage which occupies them for two days per month; one doctor in eachhospital department produces notes of the clinical meetings, which occupies four hours perweek. This is an Individual Allowance Factor (so called because it originally applied tosingle individuals in a working situation, although it can apply to any fixed or specifiednumber of staff).

Category Allowance FactorsAll category Allowance Factors are converted into percentages. All the separate allowances fora particular staff category working in a particular type of health facility are totalled before beingused to calculate the Staffing Requirements for the category.

Examples

An allowance of 10% for administration is already in the required form of a percentage.

An allowance of one hour per day for all pharmaceutical assistants undertaking cleaning indispensaries is equivalent to:

1 hour/day

8 hours/day= 12.5%

In another country, where the normal working day is six hours, an allowance of one hour per daywould be equivalent to:

1 hour/day

6 hours/day= 16.7%

An allowance of two days per month for all staff (including pharmaceutical assistants) to collecttheir salaries is equivalent to:

2 days/month x 12 = 24 days/year

24 days/year

234 days/year= 10.3%

The total category Allowance Factor for pharmaceutical assistants (daily cleaning + monthlycollection of salaries) is:

12.5% + 10.3% = 22.8%

An allowance of five hours per week for clinical meetings of medical staff in a hospital isequivalent to:


60_________________________________________________________________________________________

5 hours/week

44 hours/week= 11.4%

If all the hospital doctors spend a further 10% of their time on administration, the total categoryAllowance Factor for these doctors would be:

11.4% + 10% = 21.4%

The use of these total category Allowance Factors in the calculations requires the application ofa further mathematical formula. The form of the Allowance Standards which the expert groupsestimate, i.e. actual time or percentage time taken, is designed to make it as easy as possible forthese groups to accomplish their task. However, in order to use these figures in the WISNcalculations a further arithmetical stage required. The complete procedure is:

a) Category Allowance Standards which are specified in terms of actual time (hours/day,days/week, etc.) are converted to percentages;

b) All the percentage allowances for a particular staff category working in a particular type ofhealth facility are added together;

c) The allowance Multiplier to use in the WISN calculation for the staff category in the typeof health facility is computed using the total % category allowance from (b) according to theformula:

total % category allowanceAllowance multiplier =

1-100

1

The computer can be programmed to calculate this multiplier from the list of category AllowanceStandards for a staff category and then automatically include it in the calculations.

Individual allowance factorsAn Individual Allowance Factor indicates the need for a fixed extra Staffing Requirement ratherthan for a multiplier which is applied to the whole of the calculated requirement for a staff categoryin a health facility. For example, a task requiring four hours per week of one doctor's timethroughout the year takes up 4 x 52 = 208 hours per year. The doctor is in Category A (1,776 hoursper year available working time) and so the task requires:

208 / 1,776 = 0.12 whole time equivalent

This fixed amount is added to the total calculated requirement for medical staff in those facilitieswhere this task is performed.

If two pharmaceutical assistants are required to undertake a task for two days per month, the annualworkload of the task is:


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2 staff x 2 days/month x 12 months = 48 days/year

These staff are in Category B (234 days per year available working time) and so the task requires

48 / 234 = 0.21 whole time equivalent

This fixed amount is added to the total calculated requirement for pharmaceutical assistants inthose facilities where this task is performed.

4. Using standard workloads and allowance standards to calculate staffingrequirementsThe calculation of the Staffing Requirements for a staff category employed in any health facilityis performed according to the following steps:

1. For each component of workload (main activity) which has a Standard Workload i.e. it isrelated to an item in the service statistics, apply the Standard Workload to the most recentannual service statistics from the facility in order to calculate the Staffing Requirement foreach of these components of workload.

2. Add together the calculated Staffing Requirements for all these components of workload.

3. Calculate the Allowance Multiplier based on the category Allowance Standards.

4. Apply the Allowance Multiplier from step 3 to the total from step 2.

5. Add the Staffing Requirement for any Individual Allowance Factors which apply.

The steps in the complete calculation of the Staffing Requirements (SR) for each staff category canbe set out on a pro forma for manual calculation or they can be programmed into a spreadsheet. They are as follows:

Volume of activity 1 in a year (from annual statistics) / Standard Workload for activity 1 = [SR1]

Volume of activity 2 in a year (from annual statistics) / Standard Workload for activity 2 = [SR2]

. . . . .

. . . . .

Sub-total [SR(Sub)]

Category Allowance Standard 1 = [CAS1] %

Category Allowance Standard 2 = [CAS2] %

. . . . .

. . . . .

Category Allowance Factor [CAF] %

Allowance Multiplier derived by formula from [CAF]: x [AM]

Intermediate Staffing Requirement [ISR]

Individual Allowance 1 = [IA1] WTE

Individual Allowance 2 = [IA2] WTE

. . . . .


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. . . . .

Total Individual Allowance [IA total] + [IA total]

Calculated Staffing Requirement [CSR]


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Examples

a) Calculating the number of school dental therapists required in a district

Components of Workload: Activity Standards Standard WorkloadSchool dental screening 1 screening/day 234/yearAdministration, all staff 10%

Workload last year:Number of school dental screenings last year = 648

Calculation:

648 screenings / 234 = 2.77

Category Allowance Factor = 10%

Allowance Multiplier = 1 / (1 - 0.1) = 1.11

INTERMEDIATE Staffing Requirement = 2.77 x 1.11 = 3.07 staff

No Individual Allowance Factors

CALCULATED Staffing Requirement = 3.07 school dental therapists

The district requires three school dental therapists to maintain the current level of school screeningachieved.

b) Calculating the number of community health workers (CHW) required in a health post

Components of Workload: Activity Standards Standard WorkloadOutpatients 10 mins/patient 11,232 pats/yrHome visits 12 mins/visit 9,360 homes/yr

Category Allowance StandardTravelling 1.5 hours/day 18.75%

Individual Allowance StandardAdministration, 1 CHW 15% 15%

Workload last year:Outpatients 15,381Home visits 7,437

Calculation:


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15,381 outpatients / 11,232=

1.37

7,637 home visits / 9,360=

0.82

Sub-total 2.19

Category allowance = 18.75%



Individual Allowance Factor: 0.15 x 52 weeks x 5.5 days/week

= 43 days/yr spent on administration

= 43 / 234 = 0.18 staff

CALCULATED Staffing Requirement = 2.69 + 0.18 = 2.87 staff

The health post requires three community health workers for the volume of service it delivers.

c) Calculating the number of medical records officers required in a hospital

Components of Workload: Activity Standards Standard WorkloadOutpatient registration 3 mins/patient 37,440Inpatient admission 10 mins/patient 11,232Inpatient discharge 5 mins/patient 22,464

Category Allowance StandardsShelving returned files 0.5 hours/day 6.25%Compiling daily data 0.5 hours/day 6.25%

Category Allowance Factor 12.5%

Individual Allowance FactorsCompiling patient data, 1 person 2 days/monthAdministration, 1 individual 10%

Workload last year:Outpatients 25,319Inpatient admissions 2,817Inpatient discharges 2,674

Calculation:


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25,319 outpatients / 37,440=

0.68

2,817 admissions / 11,232=

0.25

2,674 discharges / 22,464=

0.12

Sub-total 1.05

Category Allowance Factor = 12.5%




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Individual Allowance Standards:

2 days/month x 12 = 24 days/yr spent on compiling data= 24 / 234 working days/yr = 0.10 staff

0.1 x 52 weeks x 5.5 days/week = 29 days/yr on administration= 29 / 234 working days/yr = 0.12 staff

Individual Allowance Factor = 0.10 + 0.12 = 0.22 staff

CALCULATED Staffing Requirement = 1.20 + 0.22 = 1.42 staff

One medical records officer would be 42% overloaded in this situation. Two staff will be required,and these would be sufficient to cope with a 40-50% expansion of the hospital's workload. Otherthings being equal, this would be an excellent place to post a new and inexperienced medicalrecords officer as an assistant or apprentice where there would be plenty of time for supervision. Alternatively, if local circumstance permit, the figure would justify employing one part-time staff(half time) under the supervision of one full- time staff.

Fractional resultsWhen the calculated Staffing Requirement comes at or near a whole number of staff, as inexamples (a) and (b) above, rounding off to give a practical figure for the staff requirement is noproblem. However, when the calculated Staffing Requirement shows a substantial fraction, as inexample (c), some explicit rounding off rule must be adopted. Rounding down to the next wholenumber produces a calculated Staffing Requirement slightly less than the workload actuallyindicates; rounding up produces a figure for staffing slightly greater than the workload actuallyindicates. One principle which has been used is to round down by amounts of 10% or less forfigures of five or less. This is based on the view that staff should be expected to carry a 10%overload in their work if necessary. This results in the following rule:

1.0 - 1.1 is rounded down to 1; 1.1 - 1.9 is rounded up to 22.0 - 2.2 is rounded down to 2; 2.2 - 2.9 is rounded up to 33.0 - 3.3 is rounded down to 3; 3.3 - 3.9 is rounded up to 44.0 - 4.4 is rounded down to 4; 4.4 - 4.9 is rounded up to 55.0 - 5.5 is rounded down to 5; 5.5 - 5.9 is rounded up to 6

For all larger numbers, fractions are rounded in the usual way i.e. up or down to the nearest wholenumber, as is done for 5.1 - 5.9 in the table. This rounding procedure can be done automaticallyby a computer before printing tables of results.

In the smallest health facilities, particularly in sparsely populated areas, the workloads are smallto the point of being insufficient to keep even one member of staff occupied full time. In thesesituations the calculated Staffing Requirement is less than 1.0 and special considerations apply. Thechoice here is between rounding up to 1, where the staff member would be under utilized, orrounding down to 0 and in effect stopping the service which this category of staff provides andperhaps even closing the facility. This is not a technical matter but rather an administrativedecision, which presumably would take into account the financial costs of maintaining aunderutilised service, achieving national targets of coverage of services, access to alternativefacilities, etc.


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Overlapping staff categoriesSometimes one calculation covers two or more staff categories at the same time, because the mainfunctions of these categories overlap and the workloads undertaken by each category are notreported separately in the service statistics. For example, in many countries the medical assistantor equivalent who is the person in charge at the health centre joins other staff e.g. rural medicalassistants, to deal with outpatients when other duties permit; naturally these outpatients are notlisted separately in the annual statistics but are reported as part of the total workload of the healthcentre. Again, in many hospitals the in-charge in the technical support departments (laboratories,X-ray, dispensary, physiotherapy, occupational therapy) spends some time on management andadministration (for which Individual Allowance Standards are set) and the remainder on the maintask of the department (performing tests, taking X-rays, filling prescriptions, etc.) along with theother staff in the department. In these situations it is usual to calculate the total StaffingRequirement for the department, based on reported workloads and Allowance Factors. This totalStaffing Requirement is subsequently divided between the individual staff categories employed e.g.

7 staff required in a hospital X-ray department according to WISN

calculations = 1 senior radiographer + 6 radiographers

5 staff required in a health centre dispensary according to WISN

calculations = 1 pharmaceutical assistant + 4 dispensers

This principle can also be used to apply a predetermined balance between two or more staffcategories. For example, it is possible to calculate the total ward nursing staff required in a hospitaland then to divide this total between different nursing categories according to a national policy forward staffing. Or if, in the example above, there were a national policy to employ equal numbersof radiographers and radiographic assistants in hospital X-ray departments, then the calculatedStaffing Requirement would be:

7 staff required in a hospital x-ray department according to WISN

calculations = 1 senior radiographer+ 3 radiographers+ 3 radiographic assistants

These predetermined factors (one person in charge + remaining staff, fixed ratios between staffcategories, etc.) can easily be included in the spreadsheet formulae so that a computer would printout the results as shown above.

5. Computerization of the WISN calculationsThis section sets out the principles and main guidelines which should be followed in designing andimplementing the computerization of the WISN calculations; it does not seek to be a mini-textbookof computer operations. Each implementation of the WISN Method will require access to acomputer, for short working sessions spread over a period of some weeks during set-up andimplementation, and subsequently for a relatively short period once a year (when the annual servicestatistics become available). Each implementation will also require the services of a computeroperator who is familiar with the operation of a spreadsheet programme e.g. Lotus 123, Quattro,Supercalc. This operator will be able to follow these principles and guidelines in order to set upthe computer so that:


68_________________________________________________________________________________________

a) Service statistics for individual health facilities are entered into the computer. A pro formais shown on the computer screen specifying the data items to be entered;

b) The computer automatically performs the WISN calculations;

c) The computer automatically prints out tables of results showing individual health facilityStaffing Requirements, district summaries, regional summaries, and national summaries asrequired.

No special computer programming is required; the standard commands in any generally availablespreadsheet package are sufficient for the purpose. If the data collection, input, calculations andprinting of results are centralized in this way, it throws on to the centre the responsibility for theprompt feedback of results, when they are produced, to the regional and district levels.

If a country has computerized its health service statistics, whether on a spreadsheet or databasepackage, much of the work in computerizing the WISN Method is already done. The calculationsand print-outs of WISN results could be an additional procedure carried out on the health statisticsalready held in the computer i.e. a procedure additional to the annual compilation of individualfacility statistics and their consolidation into district, regional and national summaries which arealready performed. In this case the WISN calculations are a sub-routine in the programme for theannual compilation of service statistics.

a) Data entry

For calculating the requirements of each staff category, the data items to be entered from theservice statistics are those specified in the Activity Standards which have been set for each of thestaff categories. For each type of health facility the task force should:

a) List all the staff categories employed in this type of facility;b) List the Activity Standards set for each of these staff categories;c) List the data items required by each of these Activity Standards;

This should already have been done by the groups setting the Activity Standards.

In some cases a data item is used for the calculations of the staff categories in one cadre only e.g.laboratory tests for laboratory staff, X-ray examinations for X-ray staff, physiotherapy patients orsessions for physiotherapy staff, etc. In other cases a single data item is used in the calculationsof the Staffing Requirements for several categories, perhaps in different cadres e.g. the averagenumber of inpatients or bed occupancy for calculating the Staffing Requirements of severalcategories of hospital doctors, several categories of nurses, kitchen staff, laundry staff; the annualnumber of outpatients for the calculations of several categories of doctors, several categories ofnurses, medical records staff, several categories of pharmacy staff, etc. in hospitals and healthcentres. Therefore:

d) Consolidate these lists of data items in order to produce a comprehensive master list of thedata items from each type of health facility required by the WISN calculations.

These are the data items which must be entered into the computer for each health facility.


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It would be possible to set up a separate spreadsheet for the WISN calculations for each cadre i.e.each with its own input format, data entry, calculations and table of results. Perhaps this is howit would be arranged if the task were to be done manually in order to avoid the complexity and thepossibility of errors when dealing with calculations covering several cadres based on the same setof input data. However, the computer is designed to handle this type of complexity with ease. Also separate spreadsheets for each cadre would entail duplication of data entry, which can be aconsiderable workload. The best approach is to have a single consolidated pro forma for the dataentry for each type of health facility which covers all the data items required for the WISNcalculations for all the staff categories employed in these health facilities. The computer itself willselect from this format the appropriate data items for each calculation, and insert the results intothe appropriate place in a comprehensive table of results.

It is usual to provide space in the data entry format for the figures for each month or quarter(depending on the frequency of reporting in the country), so that a correction can be made for thecommon situation in which some of the monthly or quarterly figures are missing for some healthfacilities.

Dataitem

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec No. ofmonthsreports

Estimatedannualfigure

If some individual entries are missing, the spreadsheet is set up to make a pro rata adjustment inorder to calculate best estimates of annual figures which are required by the WISN Method. Theestimated annual figure is given by the formula:

Annual figure =Sum of available entries x 12

Number of available entries

The final column of this spreadsheet, Estimated Annual Figure, is the starting point of the WISNcalculations themselves.

Where only annual figures are available, they are entered directly into the "annual figure" columnof the data entry format, ignoring all the other entry columns. In these circumstances it is notpossible to make any correction for missing monthly figures or other imperfections which theseannual figures may contain.

The current staffing of each facility is also entered into the computer, since this is part of the WISNcalculation. The staff categories employed in the facility are listed below the service statisticsitems in the final column of the spreadsheet as part of the starting point of the WISN calculationfor each facility.

Each type of health facility employs its own set of staff categories with their own ActivityStandards, and therefore each type of health facility has its own set of data items (service statisticsand staff categories) and data entry format. A separate data entry format must be produced for eachtype of health facility covered by the WISN calculations. Thus there will be a health post dataentry format, a health centre data entry format, a district hospital data entry format, etc. Eachhealth post and health centre format is copied several times in one spreadsheet to provide enoughdata entry tableaux for all the health posts and health centres in one district. When the data hasbeen entered and checked, the spreadsheet is saved as a file of the basic data for the WISN


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calculations for one type of health facility in one district. Many such files can be saved on to onediskette, and this provides the basic data for all health facilities in a district, a region or the wholecountry.

When the data entry has been completed for a number of health facilities, the data file in thecomputer memory represents a considerable investment in time and effort in collecting, enteringand checking the data. It is prudent to protect this investment. One way of doing this is to treatthe spreadsheet containing the data on a set of health facilities as an interim product of thecalculation process. When the data entry is completed the file is saved on to a diskette which isthen made "read only". The final column of this spreadsheet is copied to become the first columnof a second spreadsheet, the staffing calculation, which performs the WISN calculations for allthese health facilities and tabulates the results. Thus each type of health facility has a data file anda calculation file stored on separate diskettes. The final column of each data file is copied tobecome the first column of the corresponding calculation file.

b) WISN calculations

The computer is programmed to perform calculations of the type shown in the examples set out inSection C.4 above. The data entry format for one type of health facility e.g. health centres, is usedfor all facilities of that type throughout the country. Also the mathematical formulae for calcul-ating Staffing Requirements for each cadre is the same for all health facilities of the same typethroughout the country. Thus these formulae (which may be complex) need be entered into acalculation file in the computer only once and then copied to provide a separate calculation for eachhealth facility.

c) Tables of results

The result of the WISN calculations for each staff category in each health facility consists of fouritems:

Actual staff: part of the data entry for each facilityRequired staff: according to the WISN calculationsDifference: actual staff - required staffRatio (WISN): actual staff / required staff.

These four items are automatically inserted into preprogrammed tables of results. These tablesnormally show the results for each staff category in a group of facilities e.g. all the health posts inan area, all the health centres in a district, all the MCH clinics in a district, all the district hospitalsin a region, etc., for easy comparison between different facilities and between different staffcategories within a facility. A simple example of such results is shown in Section A.7, Table 2.

Such tables of results (covering one type of health facility) also shows the totals or averages foreach staff category employed in the group of facilities:

Actual staff: total for all facilities listed in the tableRequired staff: total for all facilities listed in the tableDifference: net shortage or excess of staff in the groupRatio (WISN): average ratio throughout the group.

These will be totals or averages for an area, district, etc. Another table must be programmed whichassembles these total/average figures for all the areas in a district in order to produce district totalsand averages, for all the districts in a region to produce the regional totals and averages, etc.


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Annex A - Staffing requirements for time-specified postsIt is instructive to use the calculated available working time per year for different staff categoriesin order to make a few illustrative calculations of the staffing resources required in a number ofspecial situations. In all these situations the Staffing Requirement is not determined by theworkload of a post; rather they are the staffing resources required to man a post for a specified timepattern during the year. Each calculation uses the figures from Section C.1 example 2:

a) Manning a post during normal working hours throughout the year i.e. not on weekends,public holidays, etc.

This is required in many posts e.g. in day clinics, district and provincial offices, MOH.

The total time for which the post is manned during the year is:

52 weeks x 44 hours/week - 10 public holidays x 8 hours/day

= 2,288 - 80 = 2,208 hours/year

One staff in Category A is available 1,776 hours/year, so the post would require

2,208/1,776 = 1.24 staff of Category A

In other words, if this is a Category A post, manning it on normal working days throughout the yearrequires one full time staff in Category A and another 0.24 or 24% of a similar staff member's time,in order to cover for vacation, training, sickness and all other absences. Manning 4 of these postswould require 4 x 1.24 = 4.96 , i.e., 5 staff to be employed.

One staff of Category B is available 1,872 hours/year, so the same type of post would require

2,208/1,872 = 1.18 staff of Category B

In other words, if this is a Category B post, manning it on normal working days throughout the yearrequires one full time staff in Category B and another 0.18 or 18% of a similar staff member's time,in order to cover for vacation, training, sickness and all other absences. Manning five of theseposts would require 5 x 1.18 = 5.90 i.e. 6 staff to be employed.

b) Manning a post 8 hours/day, 7 days/week throughout the year

This is required for some posts in support departments in major hospitals e.g. maintenance staff.


52 weeks x 7 days/week x 8 hours/day = 2,912 hours/year

One staff in Category A, e.g. senior engineer, is available 1,776 hours/year, so the post wouldrequire


In other words, if this is a Category A post, manning it on day shifts throughout the year requiresone full time staff in Category A and another 0.64 of a similar staff member's time, in order tocover not only for vacation, training and sickness as before, but also now for weekends and publicholidays as well. Manning one such post in a facility would require employing two staff, but threeof these posts (in a much larger facility) would require 3 x 1.64 = 4.92, i.e. only five staff to beemployed.

One staff of Category B, e.g. maintenance engineer, is available 1,872 hours/year, so the postwould require



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In other words, if this is a Category B post, manning it on days throughout the year requires onefull time staff in Category B and another 0.56 of a similar staff member's time, in order to covernot only for vacation, training and sickness as before, but also now for weekends and publicholidays as well. Manning two of these posts would require 2 x 1.56 = 3.12, i.e. three staff to beemployed.

c) Manning a post 8 a.m. to 10 p.m. six days a week and 8 a.m. to 6 p.m. on Sundays

These are the dispensary opening hours in the main hospitals in one country.


52 weeks x 6 days/week x 14 hours/day + 52 days x 10 hours/day

= 4368 hours/year + 520 hours/year = 4,888 hours/year

One staff in Category A e.g. pharmacist, is available 1,776 hours/year, so a Category A post in sucha dispensary would require


In other words, manning a Category A post in this dispensary requires employing 3 full time staffin Category A. These staff would operate a shift rota to keep the post manned.

One staff of Category B is available 1,872 hours/year, so the post would require


In other words, manning each Category B post in this dispensary requires employing two full timestaff in Category B and finding another 0.61 of a similar staff member's time. These staff wouldoperate a shift rota to keep the post manned.

d) Manning a post continuously throughout the year

There are many such posts in hospitals e.g. ward nurses.


52 weeks x 7 days/week x 24 hours/day = 8,736 hours/year

One staff in Category A is available 1,776 hours/year, so the post would require


In other words, manning a Category A post continuously requires employing about five full timestaff in Category A to cover the continuous shift working, weekends and public holidays, and thevacation, training and absence time of all the staff involved.

One staff of Category B is available 1,872 hours/year, so the post would require


In other words, manning a Category B post continuously also requires employing five full timestaff in Category B.

Of course, only a few posts in hospitals are manned continuously for three shifts; some are mannedfor two shifts, and many for the day shift only. Even where there is continuous operation e.g. onthe wards or in the outpatient department (accident and emergency), there is differential manningon the three shifts, with the fewest staff on duty during the night.


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Annex B – Instructions for groups which are setting activity standardsThese are the instructions for a cadre group, i.e. a group of senior and experienced staff in a cadrewho will set the Activity Standards for all the staff categories within the cadre in all of the healthfacilities in which these categories are employed. The instructions also apply with very littleadjustment to a facility group i.e. a group of staff from one type of health facility who will set theActivity Standards for all the staff categories which are employed in this type of facility. Theseadjustments are all noted in the text.

1. List all the types of health facility which are to be covered. [For a facility group the type ofhealth facility is already determined and they list all the departments/units within the facilitywhich are to be covered by the exercise.]

2. Select one type of facility [department/unit]. List all the staff categories which haveestablished posts in this type of facility [department/unit] i.e. all the staff categories whichshould be employed in them. [A cadre group will list only the staff categories within its owncadre employed in each type of facility. A facility group will list all staff categoriesemployed in each department/unit.]

3. For each of these staff categories in turn, list the major activities which these staff undertakein the work of the facility. The major activities are those which together take up all orvirtually all of the working time of the staff category in the health facility [department/unit]. These are called the components of workload for the job. For most staff categories thereare not more than four of these components of workload; some staff categories have onlyone or two. If necessary combine some related activities into one component of workload. [Using job descriptions to identify the components of workload of a staff category is usuallynot helpful; job descriptions are frequently out of date and in any case are too detailed forthis purpose. It is better for those with direct experience of the work in these facilities tosuggest from their own experience the major activities undertaken there by each staffcategory.]

4. Take the first category of staff and identify which of the components of workload arecovered by items in the statistics which are regularly collected and reported in thesefacilities, and also which of the components of workload are not covered by these statistics. If none of the data items in the reported statistics are directly relevant to one of thecomponents of workload, try to find a proxy measure of the workload e.g. number ofoutpatient attendances instead of prescriptions filled, for the workload of hospital dispensers;number of hospital admissions instead of bed occupancy, for ward staff; number ofinpatients instead of items washed, for the workload of launderers.5. For each of thecomponents of workload which are covered by an item in the statistics, specify what theitem is e.g. outpatient visits, antenatal examinations, inspections of premises, etc. and set aunit time for it e.g. 10 mins for an outpatient visit, 20 mins per antenatal examination, or seta rate for the activity e.g. 10 inspections/day.

This is the most critical step in the whole task. These unit times or rates should correspond to thestandard of performance which would be expected of experienced and well motivated staff takinginto account the general situation or circumstances found in these facilities in the country e.g.availability of equipment and supplies.


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6. For the components of workload which are not covered by items in the statistics, set a timeallowance for each activity. This allowance may be in the form of a percentage e.g.administration: 10% of total time. Alternatively it may be in the form of a time allowancee.g. cleaning: one hour per day; clinical meetings: five hours per week; stocktaking andreplenishing two days per month. The allowance may apply to all staff in a category, e.g.all doctors in a hospital attend clinical meetings, or it may apply only to a fixed number ofstaff however many staff are employed e.g. one person in charge carries out the admin-istration in the unit, or two staff perform the stocktaking and replenishment.

7. Now repeat steps 4-6 for each of the remaining staff categories listed in step 2 as beingemployed in these facilities, using the list of components of workload for each of thesecategories from step 3.

8. Is there a staff category with none of its major work activities covered by any item in theannual service statistics e.g. cleaners, drivers? if there is, this category must be given adifferent type of workload standard, which must be one of the following:

ratio on other staff e.g. one medical assistant per four rural medical aides in a health centre,one laboratory assistant per two rural medical aides in a health centre;

fixed number per facility e.g. three watchmen per health centre, one nursing attendant perdispensary;

fixed number per item e.g. one driver per vehicle, two radiographers per X-ray machine;fixed number per administrative unit e.g. one health assistant per electoral ward;staffing according to organizational structure e.g. one district health officer per district, one

regional pharmacist per region.

In these cases no separate allowances (for administration, supervision, etc.) are made; these factorsare already included in the workload standard.

9. Now estimate for each of the staff categories employed in the facility:average number of days per year engaged in off-the-job training;average number of days per year for sickness and other absence.

These figures are used in determining the working time available per year, see Section B.1.

10. Now repeat steps 2 to 9 for all the remaining types of facility [department/unit] listed instep 1.

11. Make a table of the results as follows:


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Facility type 1Staff category 1

Major activity 1 Statistics item Unit time or rateMajor activity 2 Statistics item Unit time or rate………Allowance 1 Number of staff (1, 2 .... all) % or hours per day/ week/month/etc.Allowance 2 Number of staff (1, 2 .... all) % or hours per day/ week/month/etc.………Average off-the-job training time days per yearAverage total absence, sickness etc. days per year

Staff category 2etc.

Facility type 2Staff category 1

etc.


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___________________________________________________ Section D – Examples of WISN activity standards already used for individual staff categories

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Section D:Examples of WISN activity standards already

used for individual staff categoriesThis section lists some of the activity standards which have been used in WISN calculations invarious countries. They are offered for guidance only. Each country must set its own activitystandards.

These activity standards offer two types of information:

� how the jobs of different staff categories have been broken down into their main functions andtasks (components of workload) in order to set activity standards for each;

� what actual times or rates (activity standards) have been set for these functions and tasks.There are no absolutely correct or incorrect activity standards for any of the staff categories. Thesame job title may refer to two very different jobs in different countries. For example, in somecountries the community health nurse has six months training and is one of two staff in the smallesttype of local health facility operated by the government, whereas in other countries the same titlerefers to a three-year trained nurse with a number of years' experience and a further one-year publichealth qualification who is in charge of all public health nursing in a sub-district. The mainactivities (and the corresponding components of workload) are quite different for these twocategories of staff. Even if the two jobs are the same in principle, their tasks may be very differentbecause of different medical practices in the countries. For example, in some countries the three-year trained ward nurse carries out all tasks related to inpatients (clinical procedures, administeringmedication, feeding, personal hygiene, etc.) whereas in other countries the three-year trained wardnurse is a technical worker who only performs clinical procedures and issues medication (but doesnot administer it), with the other patient-related tasks being performed by other categories of wardstaff. While the list of the components of workload may be nearly the same for the two staffcategories, the activity standards will be quite different.

For these reasons the examples which follow, which show what activity standards have been usedin other countries, are offered for guidance only. They show what components of workload havebeen used for a number of staff categories, which may be more directly useful than the associatedunit times, rates, etc.

Country or territoryUnited Republic of Tanzania ...................................................................................................... 76

Papua New Guinea ..................................................................................................................... 89

Kenya.......................................................................................................................................... 94

Hong Kong.................................................................................................................................. 94

Oman .......................................................................................................................................... 95

Sri Lanka..................................................................................................................................... 95


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United Republic of Tanzania Performance standards for staff in dispensaries/health posts

Staff category Component of workload Unit time, allowanceRural medical aide Outpatient care

First visit 15 minsSubsequent visits 5 mins

Administrative duties 20% of working timeCollecting salary 3 days/month

MCH aide Antenatal examinationsFirst visit 30 mins/patientSubsequent visits 15 mins/patient

Under-5 examinationsFirst visit 15 mins/childSubsequent visits 10 mins/child

Family planningFirst visit 30 mins/clientSubsequent visits 10 mins/client

Immunisations 7 mins/immun.Supervised deliveries 5 hours/deliveryHome visits 2 hours/visitHealth education 15 mins/meetingCleaning 1 hr/weekday + 5 hrs on Saturday = 10 hrs/weekSupervision of TBA &VHW 10% of working timeSchool health 2 hrs/weekCollecting salary 3 days/month

Nursing assistant Attending outpatients 30 patients/dayCleaning 1 hr/day: 6 hrs/weekCollecting salary 3 days/month

Health assistant Home inspections 10 homes/dayFood premises 5 premises/dayDisease control 1 day per outbreakHealth education 30 mins/meetingAdministrative tasks 2 hrs/dayCollecting salary 3 days/month

Nursing attendant Cleaning full-time Allow 1 per facilityMedical assistant Outpatients

First visit 15 mins/patientSubsequent visits 5 mins/patient

Ward rounds ) 9 hrs/weekMedical/surgical procedures )Administration, supervision,

public relations4.5 hrs/day

Collection salary 3 days/monthRural medical aide Outpatients

First visit 15 mins/patientSubsequent visits 5 mins/patient

Ward rounds ) 3 hrs/day


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Staff category Component of workload Unit time, allowanceMedical/surgical procedures )Collection salary 3 days/month

Nurse/midwife Outpatients 40 patients/dayInpatients 1n/m per 20 inpatientsAdministration 20% of working timeCollection salary 3 days/month

MCH aide Antenatal examinationsFirst visit 30 mins/patientSubsequent visits 15 mins/patient

Under-5 examinationsFirst visit 15 mins/childSubsequent visits 10 mins/child

Family planningFirst visit 30 mins/clientSubsequent visits 10 mins/client

Immunisations 7 mins/immun.Supervised deliveries 5 hours/deliveryHome visits 2 hours/visitHealth education 15 mins/meetingCleaning 1 hr/weekday + 5 hrs on Saturday = 10 hrs/weekSupervision of TBA &VHW 10% of working timeSchool health 2 hrs/weekCollecting salary 3 days/month

Nursing assistant Inpatients 1 NA per 10 inpatientsCollecting salary 3 days/month

Health assistant Home inspections 10 homes/dayFood premises 5 premises/dayDisease control 1 day per outbreakHealth education 30 mins/meetingAdministrative tasks 2 hrs/dayCollecting salary 3 days/month

Laboratory assistant Haematology 25 mins/specimenBacteriology 30 mins/specimenParasitology 15 mins/specimenCollecting salary 3 days/month

Medical records assistant Registration of outpatients 120 patients/dayMaintaining records ) 1 hr/dayCompiling analyses )Collecting salary 3 days/month

Cooking staff Feeding inpatients 1 staff/12 inpatientsCollecting salary 3 days/month

Laundry attendant Laundering 1 staff/12 inpatientsCollecting salary 3 days/month

Nursing attendant Cleaning 1/10 bedsDriver Allow 1 driver per vehicleWatchman Allow 3 per health centre


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Performance standards for staff in hospitals

Doctors

Medical specialists, medical officers, assistant medical officers and medical assistants areemployed in regional and district hospitals. The components of workload which cover mostmedical staff in most specialties and the measures of workload appropriate for each, were identifiedto be:

Ward rounds, minutes per inpatientOutpatient clinics, minutes per outpatientMedical procedures following the ward rounds, hours per dayPostmortems, hours per pm (including writing the report)Clinical meetings (daily and weekly), total hours per weekAdministration (letters, meetings, etc.), hours per weekOutside service in major emergencies, e.g. epidemics, floods, etc., weeks per yearResearch, person weeks per year.

Specialists are not employed in district hospitals and so no standards for them are shown in thesefacilities. Standards are not shown for medical assistants in regional hospitals in accordance withthe national policy although it was recognized that this policy was not followed. This becameapparent in the results of the WISN exercise, when the calculated staffing requirements accordingto the policy were compared with actual staffing in the hospitals.

The standards are based on one ward round in each ward per day; in regional hospitals thestandards allow for specialists' rounds twice a week in surgery and in obstetrics and gynaecology,and three times a week in all other specialist departments. The clinical meetings nearly all followthe same pattern - half an hour per day and a three-hour meeting once a week, total 5.5 hours/week.

a) General medicine

Regional hospital District hospitalSPEC MO AMO MO AMO MA

Wd rds, mins/pat 10 10 10 10 10 10Procs, hrs/day 0.5 1 1 1 1 1.5Outpts, mins/pat 5 8 8 8 8 6Pstmtms, hrs/pm 2 2 2 2 2 0Cln mtgs, hrs/wk 5.5 5.5 5.5 5.5 5.5 5.5Admin, hrs/wk 3 3 3 3 3 0Emy svce, wks/yr 1 1 1 1 1 0Rsch, mwks/yr (1) 13 13 13 13 13 13

1 All doctors allowed three months research per year.


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b) Surgery


Wd rds, mins/pat 10 5 5 10 10 5Procs, hrs/day major 2 2 2 2 2 0

minor 1/4 1/4 1/4 1/4 1/4 1/4Outpts, mins/pat 10 8 8 10 10 10Pstmtms, hrs/pm(1) 0 2 2 2 2 0Cln mtgs, hrs/wk 5.5 5.5 5.5 5.5 5.5 5.5Admin, hrs/wk 3 2 2 3 2 2Emy svce, wks/yr 1 1 1 2 2 1Rsch, mwks/yr 4 2 1 4 2 1

1 Specialist does very few postmortems per year, no calculation made of this workload.

c) Paediatrics


Wd rds, mins/pat 10 8 8 8 8 8Procs, hrs/day 3/wk 1 1 1 1 1Outpts, mins/pat 10 10 10 10 10 10Stmtms, hrs/pm 2 2 2 2 2 0Cln mtgs, hrs/wk 5.5 5.5 5.5 5.5 5.5 5.5Admin, hrs/wk 3 3 3 3 3 0Emy svce, wks/yr 1 1 1 1 1 0Rsch, mwks/yr (1) 1.3 1.3 1.3 1.3 1.3 1.3

1 Research is undertaken by 10% of staff, each of whom are engaged on it for 13 weeks per year i.e. anaverage of 1.3 weeks for all staff.

d) Obstetrics & gynaecology


Wd rds, spec mns/pt 20 20 20 - - -ordy mns/pt - 15 15 15 15 0

Procs, hrs/day 4/wk 3 3 3 3 0Outpts, mins/pat 15 15 15 15 15 0Ptmtms, hrs/pm(1) 0 2 2 2 2 0Cln mtgs, hrs/wk 5.5 5.5 5.5 5.5 5.5 5.5Admin, hrs/wk 3 3 3 4 4 0Emy svce, wks/yr(2) 0 0 0 0 0 0Rsch, mwks/yr (3) 8 for dept 8 for dept

1 Specialist does very few postmortems per year, no calculation made of this workload.2 These staff not called out for emergency service.3 Research undertaken by one doctor at a time in each hospital for two months per year.


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e) Psychiatry

Regional hospital(1)

SPEC MO AMO MAWd rds, mins/pat 30 20 20 10Procs, hrs/day 0.5 1 1 1Outpts, mins/pat 30 20 20 10Pstmtms, hrs/pm 2 2 2 0Cln mtgs, hrs/wk(2) 8.5 8.5 8.5 8.5Admin, hrs/wk 3 2 2 0Emy svce, wks/yr 1 1 1 1Rsch, mwks/yr (3) ---20 for dept---

1 No psychiatric medical staff in district hospitals.2 Clinical meetings include an extra three-hour meeting per week.3 Research undertaken by two staff at a time in each regional hospital for ten weeks per year.

f) Ophthalmology

Regional hospital(1)

SPEC AMO(2)

Wd rds, mins/pat 8 10Procs, hrs major 0.5 0

minor 1/4 1/4Outpts, mins/pat 15 10Pstmtms, hrs/pm(3) - -Cln mtgs, hrs/wk 5.5 5.5Admin, hrs/wk 3 3Emy svce, wks/yr 1 1Rsch, mwks/yr(4) 4 for deptMobile clinics (5) 1 day travel per clinic

1 No ophthalmology medical staff in district hospitals.2 Only eye specialist and AMOs employed in these departments.3 Ophthalmology staff do not undertake postmortems.4 One member of staff in the department undertakes research for four weeks per year.5 Mobile clinics require one day for travelling; patient contact time already allowed for under other items.

g) Public health

There should be one public health doctor for each district and one for the region, whose annualtime allocation should be:

Dealing with epidemics 6 weeks/yearHealth education 12 weeks/yearEndemic diseases 15%Administration 35%Research 20%


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h) Anaesthesiology

Regional hospital District hospital(1)

SPEC MO MA MO MAWd rds, mins/pat 10 10 10 - -Procs, hrs major(4) 3.75 3.75 0 3.75 3.75

minor(4) 0.5 0.5 0 0.5 0.5Other hrs/wk 2 2 0 - -Outpts, mins/pat(2) - - - - -Pstmtms, hrs/pm(2) - - - - -Cln mtgs, hrs/wk 5.5 5.5 5.5 5.5 5.5Admin, hrs/wk 3 3 2 -Emy svce, wks/yr(2) - - - -Rsch, mwks/yr (3) 5 for dept - -

1 District hospital requires one anaesthetic officer + medical assistants sufficient to cover the workload.2. Anaesthetic staff do not undertake outpatient clinics, post mortems or outside work in major emergencies.3. One member of staff in the department undertakes research for five weeks per year.4. Staff time required on average for operations is as follows:

Major MinorPre-op examination 15 mins )Preparing equipment 10 mins ) 5 minsPre-op medication, induction 5 mins )Operation 2 hours 15 minsPost-op monitoring 30 mins )Cleaning equipment 15 mins ) 10 minsFollow-up, 5 mins every 4hrs 30 mins )

for 24 hours, 6 x 5 mins

Totals 3hr 45 mins 30 mins

Nursing staff

Some Performance Standards for nurses were already covered by a Handbook of Nursing Practice(or Standards). This specified the number of outpatients or clinic attendances per day per nurse,and in general terms the number of occupied beds a nurse can supervise. The PerformanceStandards for ward nurses, set out below, are much more detailed and specific.

The standards for the senior nurses were:

Matron One for each regional or district hospitalAsst. matron One for each regional or district hospitalNursing officer One for up to 30 nursing staff employed in the ward, unit, etc.Asst. nursing officer One for each further 30 nursing staff employed in the ward, unit, etc.

The Performance Standards for nurses, nurse midwives and nurse assistants who work on the wardswere based on inpatient ratios, i.e. the number of inpatients which a member of staff couldreasonably be expected to cover in performing their nursing functions during the shift. Thisinpatient ratio was lower in regional hospitals (i.e. requiring more staff for the same number of


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inpatients) where the more serious cases are treated by specialists. The ratio varied with the shift;fewer nurses were needed on the wards at night. Where a variation between shifts is specified, itis allowed for in the calculation of staff need. This ratio also differed for different types of nursing,e.g. paediatric, psychiatric, etc., and these ratios were estimated because bed occupancy figures foreach ward were available in the service statistics. The workload standards for nurse attendants,whose task is mainly cleaning, were based on the number of beds in the ward (as a proxy for size)not the number of inpatients (occupied beds); they also show variation by type of hospital and byshift.

The mathematical formula for calculating the number of nurses needed to staff a ward with specificinpatient ratios is as follows:

Morning shift: A hours long, ratio 1 nurse to K inpatientsAfternoon shift: B hours long, ratio 1 nurse to L inpatientsNight shift: C hours long, ratio 1 nurse to M inpatients

Nurses required/ 365inpatient (occupied bed) = x (A/K + B/L + C/M)

AWTwhere AWT = Available Working Time in hours per year

Exactly the same formula is used to calculate the number of nurse attendants required. In this caseK, L and M are the number of beds in each ward instead of the average number of inpatients.

The shift rota in the hospitals was 7-2, 2-8 and 8-7 i.e. 7 hours/6 hours/11 hours, and so in theformula:

A = 7 B = 6 C = 11

The values of K, L and M in different situations are given in the tables below.

In the tables ips = inpatients; bds = beds

a) General medical wards

District hospitals : Regional hospitalsCategory / shift 7-2 2-8 8-7 : 7-2 2-8 8-7NM/Trnd Nse 1/10 ips 1/10 ips 1/20 ips : 1/5 ips 1/5 ips 1/10 ipsNse Asst 1/5 ips 1/10 ips 1/20 ips : 1/5 ips 1/10 ips 1/20 ipsNse Attdt 1/10 bds 1/20 bds 1/20 bds : 1/10 bds 1/20 bds 1/20 bds

b) Paediatric wards

District hospitals : Regional hospitalsCategory / shift 7-2 2-8 8-7 : 7-2 2-8 8-7NM/Trnd Nse 1/5 ips 1/10 ips 1/10 ips : 1/5 ips 1/10 ips 1/10 ipsNse Asst 1/5 ips 1/10 ips 1/10 ips : 1/5 ips 1/10 ips 1/10 ipsNse Attdt 3/20 bds 1/20 bds 1/20 bds : 3/20 bds 1/20 bds 1/20 bds


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c) Psychiatric wards

District hospitals : Regional hospitalsCategory / shift 7-2 2-8 8-7 : 7-2 2-8 8-7NO Curative 1/5 ips 1/10 ips 1/20 ips : 1/5 ips 1/10 ips 1/20 ipsNO Community 1/5 ips - - : 1/4 ips - -N0 Occ Therapy 1/10 bds - - : 1/10 bds - -NM/Trnd Nse 1/10 ips 1/10 ips 1/20 ips : 1/8 ips 1/8 ips 1/16 ipsNse Asst 1/5 ips 1/5 ips 1/10 ips : 1/4 ips 1/4 ips 1/8 ipsNse Attd 1/10 bds 1/10 bds 1/20 bds : 1/10 bds 1/10 bds 1/20 bds

d) Maternity unit

District hospitals : Regional hospitalsCategory / shift 7-2 2-8 8-7 : 7-2 2-8 8-7NO ---------------------1 in charge + 1/10 deliveries/day --------------------NM/Trnd Nse ------------------------ 4 hrs/delivery + 2 hrs/shift ------------------------Nse Asst --------------------------------3 hrs/delivery --------------------------------Nse Attd 1/10 bds 1/10 bds 1/20 bds : 1/10 bds 1/10 bds 1/20 bds

Patients admitted for antenatal care before delivery or for postnatal care afterwards are in thegeneral medical wards.

e) Operating theatres

Average duration of surgical operations:

General surgery Obst & gynae OphthalmologyMajor operations 2 hrs 2 hrs 30 minsMinor operations 15 mins 15 mins 15 mins

General surgery and obs & gynae

Major operations: a team of 1 NO + 2 NMs + 4 nurse assistants for 30 minspreparation + duration of operation + 30 mins clearing.

Minor operations: 1 NO or NM for 15 mins preparation + duration of operation + 15mins clearing.

Ophthalmic surgery

All operations: 1 NO or ANO, preparation and clearing times as given above.

Nurse attendants, all types of surgery:

SHIFT7-2 2-8 8-7

Regional hospitals 4 2 1District hospitals 3 1 1


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Nurses also staffed the regular outpatient clinics. These workload standards were set in terms ofthe average number of minutes of nurse time occupied by each patient seen, or by the nursing teamrequired to be on duty throughout the clinic to support the doctor. In some of the older hospitalsthese standards could not be met because of the restricted space available.

f) Ophthalmic clinic

Nursing officer and assistant nursing officer:Screening 4 minsDispensing 4 minsEye investigations 5 minsAdmitting patients 8 mins

(on average 10% of patients are admitted)

Nursing officer: administration 3 hrs/week

Nurse assistant/attendant: 1/clinic

g) General medical clinic

Nurse midwife : 10 mins per patientNurse assistant : 1/clinicNurse attendant : 1/clinic

h) Psychiatric clinic

NO counselling : 2 hrs/patient, new and repeat cases; all others -1 hr/new case, 15 mins/repeat case

Nurse midwife : 1/clinicNurse assistant : 1/clinicNurse attendant : 1/clinic

i) MCH clinic

1 PHN A for each clinic.PHN B/nurse midwife: same workload standards as the MCH aide in health centres.

Nurse attendant: 3/clinic in regional hospitals; 2/clinic in district hospitals.

Hospital technical and support staff

a) Dental staff

Dental officer There should be one dental officer in each regional and districthospital, spending 20% of the working time on preventive activitiesand 10% on administrative activities

Assistant dentalofficer

Owing to the shortage of dental officers, an assistant dental officercould be appointed in the place of a dental officer

Dental technician Because there were so very few of this category in the country, andtheir duties were covered by the dental officer, no workload standardswere proposed.


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Dental assistant School pupil screening and data analysis 1 day/schoolExtractions 15 mins/extractionFillings 30 mins/fillingScaling 1 hr/patientPolishing 10 mins/patientAdmin. (supervision, reporting budgeting,

salary)20%

Dental auxiliary Extractions 15 mins/extractionFillings 30 mins/fillingScaling 1 hr/patientPolishing 10 mins/patientCleaning and sterilisation 2 mins/pat + 1 hr/daySalary collection 2 hrs/month

The dental auxiliary remains in close attendance on the dental assistant during patient treatment,so has the same unit times for extractions, etc. Owing to the severe shortage of instruments, eachset is scrubbed and rinsed after use (two mins) and then sterilised; cleaning and sterilisation at theend of the day takes one hour.

b) Pharmacy staff

Pharmacist There should be two pharmacists per regional hospital and onepharmacist per district hospital. They undertake costing, ordering,procurement, stores management (receipt and issue), compounding,dispensing, clinical consultations, continuing education andadministration (meetings, reports, supervision, budgeting, etc.)

Pharmaceutical Dispensing 5 mins/patientassistant Stores management 1.5 hrs/day

Administration 1 hr/daySalary collection 2 hrs/month

Pharmaceutical Dispensing 5 mins/patientauxiliary Salary collection 2 hrs/month

In addition, one hour's compounding was done each day by one of the above staff; it required onehour of preparation and one hour of clearing, done by the pharmaceutical auxiliary.

Pharmaceuticalattendant

Cleaning the rooms and equipment, loading and unloadingpharmaceutical supplies and messenger duties require onepharmaceutical attendant per four pharmaceutical assistants andauxiliaries

c) Laboratory staff

Laboratory technologist Most advanced clinical chemistry:SGOT/SGPT, acid phosphates,alkali phosphates, G6PD

30 mins/test

Microbiology 45 mins/testImmuno-serology: Elisa 1 hr/testTrace transfusion reaction 2 hrs/testL.E.test 30 mins/test


88_________________________________________________________________________________________

Bone marrow 30 mins/testAdministration (supervision, QA,meetings, supplies, etc.)

30%

Laboratory technician Advanced clinical chemistry: uricacid, choloresterol, total protein,albumen, bilirubin, amelase,electrolytes

20 mins/test

Histopathology: seminal fluidanalysis, wet preparation, counts,pap smear

5 mins/test

Record keeping 1 hr/daySalary collection 2 hrs/month

Laboratory assistant Specimen collection 5 mins/ specimen

Haematology: sickling test,haemoglobin test, ESR, PCV, WBC(total and differential), bleedingtime, clotting time

7 mins/test

Bacteriology: sputum - AFB, skin -AFB, gram stain

30 mins/test

Parasitology: stool, urine, malariaparasites, skin snip.

10 mins/test

Simple clinical chemistry:Urine (sugar, protein) 5 mins/testBlood (urea, sugar, createnim) 40 mins/test

Immunoserology: VDRL, HIV,pregnancy test, widal.

7.5 mins/test

Blood donation: 42 mins/specimenCross matching, Coombs test.

Record keeping 1 hr/daySalary collection 2 hrs/month

Laboratory attendant General cleaning and support, needs one laboratory attendantper 3 laboratory assistants


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d) Radiography staff

Radiographer Preparation, positioning, operatingmachine, evaluating, patient care.

20 mins/patient

Administration (management,stock, budgets, supervision,meetings, etc.)

40%

Radiographic assistant Skeletal examinations 20 mins/patientProcessing film 10 mins/filmAdministration (registering, etc.) 25%

Radiographic attendant Cleaning the radiographic accommodation, allow one perfacility

e) Medical records staff

The unit times for the major activities were the same for both medical records officers and medicalrecords assistants:

Outpatient registration 3 mins/patientInpatient admission 10 mins/admissionInpatient discharge 5 mins/dischargeShelving files and register books 1 hr/daySorting files 3 mins/fileCompiling patient data 2 days/monthAdministration 20%

f) Catering staff

Trained cook (head cook) Management, supervision, meetings, etc. requires one trained cook per four cooks

Cook Cooking duties 1 cook/20 inpatientsCleaning 2 hrs/day

g) Laundry staff

There were no staff categories in this cadre. The standard workloads were:

Regional hospital 1 laundryman/16 inpatientsDistrict hospital 1 laundryman/30 inpatients

In addition, the person in charge at each facility spends 10% of time on administrative duties.

h) Hospital secretaries

The duties of a hospital secretary cover a very wide range of different types of activity, for mostof which statistics were not available. The factor which determined this workload was the numberof staff employed in the hospital and the standard workload was set at 250 staff, i.e. in a hospitalwith more than 250 staff the hospital secretary should have an assistant hospital secretary for eachextra 250 staff employed by the hospital.


90_________________________________________________________________________________________

Outpatient department

Separate from the scheduled outpatient clinics, the outpatient department provided a service ondemand in dealing with casual illnesses and unspecified referrals. The person in charge should bean MO in a regional hospital and an AMO in a district hospital. The workload standards for otherstaff in the department were the same for both types of hospital. For a unit receiving 200patients/day, the staffing required was:

SHIFTMorning Afternoon Night

Medical assistant 4 2 2Nursing officer 1 - -Nurse midwives 4 2 1Nursing assistants 8 4 2Nurse attendants 2 2 1Medical recorders 2 2 1

Staffing standards for other sizes of outpatient department are calculated pro rata.


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Papua New GuineaStaff category Component of workload Activity standardConsultant paediatricians Inpatientsin a teaching hospital Teaching rounds 3 hrs/round, 6 days/week

Business rounds 8 pats/hr, 365 days/yrPatient care 1 hr/admissionOperative delivs. 30 mins/deliveryPostnatal ward 2.5 mins/delivery

OutpatientsGeneral outpatients 5 attends./hourObservation room 20/hr seen twice, 365 days/yrConsultations 6 attends./hrUltrasound 2 staff do 2 in 12 hoursOutside visits 1 day/visit

Other activitiesTeaching prep. 780 contact hrs/yrAdministration half day/weekResearch half day/week

Consultant physicians in a teaching hospital

Staff category Component of workload Activity standard

Consultant physicians Inpatients 3 hrs/round, 2 rounds/ week/unitin a teaching hospital Teaching rounds

The specified teaching schedule requires one consultant, one registrar and oneresident on each teaching round.

Patient care roundsGeneral med. units 8 patients/hr, 6 days/wk

52 weeks/yr registrar + resident

TB unit 33 patients/hr, 6 days/wk52 weeks/yr registrar + resident

Medical admissions Consultant 0.25 hr/adm.Registrar 1 hr/adm.Resident 2 hrs/adm.

Procedures in Gen. med. units 15 patients/hr, 6 days/week,52 wks/yr registrar + resident


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OutpatientsGen. med. clinics 3/hour for all staff consultant,

registrar, resident

Specialty clinics:Asthma, diabetes, cardiology 6/hr, each staff takes half the patients

consultant and registrar

Ultrasound 3/hr, each staff takes half the patientsconsultant and registrar

Intermediate clinics 2/hr, consultants only

Outside visitsHospitals Days spent consultants onlyHealth centres Days spent registrars only

Other activitiesTeaching Consultant 780 hrs/yr

Administration Consultant half day/weekRegistrar 1 hr/week

Research consultant half day/weekRegistrar half day/week

Doctors in non-teaching hospitalsThese workload standards cover both general medical officers and resident medical officers in non-teaching hospitals.

Staff category Component of workload Activity standardDoctors in non-teaching Inpatientshospitals Daily ward rounds 15 patients/hr i.e. admin. assistance from

nurses during rounds

Admissions 1 hr/MO admission20 mins/HEO admissionproportion 50:50.

ProceduresRadiology 30 mins/patientLumbar puncture 15 mins/patientTraction, plaster casts 30 mins/patient


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Staff category Component of workload Activity standardOperations All scheduled theatre time filled,

2 doctors for each operation

OutpatientsGeneral 20 mins/patient

ClinicsSurgery 8 mins/patientMedicine FV: 40 mins/patient

SV:15-20 mins/patientAntenatal FV: 30 mins/patient

SV: 10 mins/patientGynae FV: 30 mins/patient

SV: 10 mins/patient(FV = first visit, SV = subsequent visit)

Consultations, incl. interm'te 40 mins/patient

Other activitiesOutside visits, supervision Days/yr spent on outside visits

by all doctors

Urban clinics Hrs/week for clinics throughout the year

Clinical meetings hours/week for meetings attendedby all doctors

Research 2 hrs/week/doctorAdministration 12.5%

Health centres and sub-centres

Staff category Component of workload Activity standardNursing officers Admissions 0.5hr/patient/day

Outpatients 50/dayClinic attds. 670/monthMobile attds. 500/month +travellingSupervised births 12.5/month

Community health workers Admissions 1 hr/patient/dayOutpatients 30/dayClinic attds. 2 CHWS to 3 nosMobile attds. 500/month +travelling


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Aid posts

Staff category Component of workload Activity standardCommunity health workers Outpatients 22/half day + activities outside

the aid post

Urban clinics

Staff category Component of workload Activity standardNursing officers Outpatients 50/day

Clinic attds. 670/month

Community health workers Outpatients 30/day

Hospitals

Staff category Component of workload Activity standardNursing officers + Inpatients 2 hrs/patient/daynursing auxs. Deliveries 9 hrs/delivery

Outpatients 44/dayThe calculated total nurse staffing for hospitals is divided between nursing officers and nursingauxiliaries after the WISN calculation.

Pharmacy staff

Staff category Component of workload Activity standardPharmacists Advising specialists employed 0-1 speclsts: 0

in hospitals 2-7 speclsts: 18-20 speclsts: 221+ speclsts: 3

Dispensers Filling prescriptions 15/hr

Checking and replenishing Wards without imprest ward orders replenishedRegular replenishment 3 times/week, 30 mins/order

Resetting imprest each imprest cleared annually,1 week each

Regular stock check checked once a week30 mins/check

Orders filled for other facils. 20 mins/aid post order15 mins/hlth cntr order

Monthly stocktaking 20 mins/yr for each item stocked


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Staff category Component of workload Activity standardReplenishing first aid kits 10 mins/replenishmentin schools and govt. depts.

Making bulk supplies in Allow 0.25 staffbase hospitals only

Storemen Ward replenishment wards and clinics replenished 3times/week, 2 hrs/ward or clinic

Receive supplies 40 mins/yr for each item stocked

Deliver medical gases 1.5 hours/delivery

Clerk/typist Type orders, maintain records 300 outpatient prescriptions/day

Pathology staff in base and Haematology 7 mins/testprovincial hospitals Biochemistry 9 mins/test

Microbiology 15 mins/testVDRL 12 mins/testBlood bank 21 mins/testSupervision visits 1 day/visit

Research) 25%Cleaning)

Clerical/ typing 12%

Management 7%

X-Ray staff in base and provincial hospitals

Staff category Component of workload Activity standardRadiographers Taking X-rays 15 mins/patient

Developing film manual: 200/daymachine:300/day

Scanning 3/hourECG 40 mins each

Clerical/typing 15 mins/patient

Nursing staff Specialist examinations 1 hour each


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KenyaMedical laboratory staff

The activity standard was set at 24 specimens per day for all types of tests. This standard allowsfor the necessary time to be spent on cleaning, setting out, replenishing supplies, management,recording and reporting, and all the other essential activities in a hospital laboratory which are notrecorded in the annual statistics but which must be done if the laboratory is to function effectively.

X-ray staff

The activity standard was set at 25 minutes per X-ray, 15 minutes for taking the X-ray and 10minutes for developing.

Pharmacy staff

Province hospitals: one pharmaceutical technologist per five wards.

District and sub-district hospitals: one pharmaceutical technologist per 10 wards

Hong Kong

PHC and Public Health: direct service delivery activities

Staff category Component of workload Activity standardRegistered nurse General outpatient 7 mins/attendance

Family health servicesChild health 15 mins/attendanceMaternal health 15 mins/attendanceFamily planning 5 mins/attendanceComprehensive observation 23 mins/attendance

Clinical genetics 7.5 mins/attendance

Child assessment 1 hr 10 mins/assessmt.

TB & chest 17.5 mins/attendance

Social hygiene & special skin 45 mins/attendance


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OmanStaff category Component of workload Activity standardLaboratory technician Haematology 2 mins/sample

Blood grouping 3 mins/sampleBiochemistry 3 mins/sampleBacteriologyCulture 30 mins/sampleOther 10 mins/sample

Administration 15%

Sri Lanka

Consultants and supporting medical staff in teaching, province, base and district hospitals

Staff category Component of workload Activity standardConslt SHO/MO/HO

Cancer surgery InpatientsAdmissionsTime per admission _ 15 mins% seen _ 100%Ward roundsTime per inpatient 7 mins 8 minsProcedures per round 60 mins 90 mins

OperationsMajor operationsTime per operation 180 mins 180 mins% performed 100%100%Minor operationsTime per operation 30 mins 30 mins% performed 40% 60%

ClinicsFirst visitsTime per FV 15 mins -% seen 100% -Subsequent visitsTime per SV - 7 mins% seen - 100%

TeachingStudents, time per year 300 hrsPostgraduates, time per year -


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Cardiology InpatientsAdmissionsTime per admission 15 mins 20 mins% seen 20% 80%Ward roundsTime per inpatient 4.5 mins 5 minsProcedures per round - 45 mins

OperationsMajor operationsTime per operation% performedMinor operationsTime per operation% performed

ClinicsFirst visitsTime per FV 10 mins –% seen 100% –Subsequent visitsTime per SV 4 mins 5 mins% seen 20% 80%

TeachingStudents, time per year 300 hrsPostgraduates, time per year –

Dermatology InpatientsAdmissionsTime per admission – 10 mins% seen – 100%Ward roundsTime per inpatient 4 mins 5 minsProcedures per round – 120 mins



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ClinicsFirst visitsTime per FV 7 mins –% seen 100% –Subsequent visitsTime per SV 5 mins% seen 20% 80%


General surgery InpatientsAdmissionsTime per admission – 10 mins% seen – 100%Ward roundsTime per inpatient 3 mins 4 minsProcedures per round 20 mins 90 mins

OperationsMajor operationsTime per operation 120 mins 120 mins% performed 100% 100%Minor operationsTime per operation 20 mins 15 mins% performed 20% 80%

ClinicsFirst visitsTime per FV 7.5 mins –% seen 100% –Subsequent visitsTime per SV 4 mins 5 mins% seen 20% 80%

TeachingStudents, time per year 300 hrsPost graduates, time per year 75 hrs

Genito-urinary surgery InpatientsAdmissionsTime per admission – 10 mins% seen – 100%Ward rounds


100________________________________________________________________________________________


Time per inpatient 3 mins 4 minsProcedures per round 20 mins 90 mins



TeachingStudents, time per year 300 hrsPostgraduates, time per year 75 hrs

Gynaecology InpatientsTime per admission 7 mins 10 mins% seen 20% 80%Ward roundsTime per inpatient 3 mins 3 minsProcedures per round 15 mins 60 mins

OperationsMajor operationsTime per operation 60 mins 60 mins% performed 100% 100%Minor operationsTime per operation 20 mins 20 mins% performed 20% 80%ClinicsFirst visitsTime per FV 10 mins –% seen 100% –Subsequent visitsTime per SV 7 mins 7 mins% seen 20% 80%


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General medicine InpatientsAdmissionsTime per admission 10 mins 12 mins% seen 10% 90%Ward roundsTime per inpatient 4 mins 5 minsProcedures per round – 90 mins




Neurology InpatientsAdmissionsTime per admission 20 mins 30 mins% seen 20% 80%Ward roundsTime per inpatient 4 mins 5 minsProcedures per round – 90 mins

OperationsMajor operationsTime per operation% performedMinor operations


102________________________________________________________________________________________


Time per operation% performed



Neurosurgery InpatientsAdmissionsTime per admission 20 mins 30 mins% seen 10% 90%Ward roundsTime per inpatient 4 mins 5 minsProcedures per round 20 mins 90 mins





_________________________________________________________________________________________ 103


Obstetrics InpatientsAdmissionsTime per admission – 10 mins% seen – 100%Ward roundsTime per inpatient 3 mins 4 minsProcedures per round – 60 mins

OperationsCaesarianTime per operation 30 mins 45 mins% performed 80% 20%Forceps deliveryTime per operation 10 mins 15 mins% performed 40% 60%



Oncology InpatientsAdmissionsTime per admission – 15 mins% seen – 100%Ward roundsTime per inpatient 7 mins 8 minsProcedures per round 60 mins 90 mins



104________________________________________________________________________________________


ClinicsFirst visitsTime per FV 15 mins –% seen 100% –Subsequent visitsTime per SV – 7 mins% seen – 100%


Ophthalmology InpatientsAdmissionsTime per admission 10 mins 10 mins% seen 10% 90%Ward roundsTime per inpatient 4 mins 6 minsProcedures per round – –


ClinicsFirst visitsTime per FV 10 mins –% seen 100% –Subsequent visits 6 minsTime per SV 6 mins% seen 20% 80%


Orthopaedic surgery InpatientsAdmissionsTime per admission – 12.5 mins% seen – 100%Ward rounds


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Time per inpatient 4 mins 5 minsProcedures per round 10 mins 60 mins




Otolaryngology InpatientsAdmissionsTime per admission – 10 mins% seen – 100%Ward roundsTime per inpatient 3 mins 4 minsProcedures per round 20 mins 90 mins


ClinicsFirst visitsTime per FV 7.5 mins –% seen 100% –Subsequent visitsTime per SV 4 mins 5 mins


106________________________________________________________________________________________


% seen 20% 80%


Paediatric surgery InpatientsAdmissionsTime per admission – 10 mins% seen – 100%Ward roundsTime per inpatient 3 mins 4 minsProcedures per round 20 mins 90 mins




Paediatrics InpatientsAdmissionsTime per admission – 10 mins% seen – 100%Ward roundsTime per inpatient 4 mins 5 minsProcedures per round 20 mins 60 mins

OperationsMajor operationsTime per operation


_________________________________________________________________________________________ 107


% performedMinor operationsTime per operation% performed



Plastic surgery InpatientsAdmissionsTime per admission 8 mins 10 mins% seen 80% 20%Ward roundsTime per inpatient 4 mins 5 minsProcedures per round 20 mins 60 mins





108________________________________________________________________________________________


Psychiatry InpatientsAdmissionsTime per admission 30 mins 40 mins% seen 30% 70%Ward roundsTime per inpatient 2 mins 2 minsProcedures per round 90 mins 120 mins


ClinicsFirst visitsTime per FV 30 mins 30 mins% seen 60% 40%Subsequent visitsTime per SV 15 mins 20 mins% seen 20% 80%


InpatientsAdmissions

Rheumatology & rehabilitation

Time per admission 30 mins 40 mins% seen 80% 20%Ward roundsTime per inpatient 4 mins 4 minsProcedures per round – 120 mins



_________________________________________________________________________________________ 109




Thoracic surgery InpatientsAdmissionsTime per admission – 20 mins% seen – 100%Ward roundsTime per inpatient 4 mins 5 minsProcedures per round 20 mins 90 mins


ClinicsFirst visitsTime per FV 12 mins –% seen 100% –Subsequent visitsTime per SV 5 mins 7.5 mins% seen 20% 80%


Venereology InpatientsAdmissionsTime per admission% seenWard rounds


110________________________________________________________________________________________


Time per inpatientProcedures per round



TeachingStudents, time per year ) 300 hrsPostgraduates, time per year )

Medical staff in district hospitals with no consultants

Staff category Component of workload Activity standardMedical officers Inpatients 10 mins

AdmissionsTime per admission 10 mins% seen 100%Ward roundsTime per inpatient 6.25 minsProcedures per round 20 mins

ClinicsFirst visitsTime per FV 10 mins% seen 100%Subsequent visitsTime per SV 5 mins% seen 100%

OutpatientsTime per outpatient 5 mins


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Medical staff in peripheral units and rural hospitals

Staff category Component of workload Activity standardMedical officers Inpatient

AdmissionsTime per admission 10 mins% seen 100%Ward roundsTime per inpatient 4 minsProcedures per round 20 mins

ClinicsFirst visitsTime per FV 10 mins% seen 100%Subsequent visitsTime per SV 6 mins% seen 100%

OutpatientsTime per outpatient 5 mins

Teaching hospitals

Staff category Component of workload Activity standardNursing staff Ward dutyWard nurses Surgical 3 occ beds/nse

Medical 3 occ beds/nsePaediatric 3 occ beds/nseGYN/OBS 3 occ beds/nseNeurosurgery 2 occ beds/nseOrthopaedic 2 occ beds/nsePsychiatric 4 occ beds/nseBurns 2 occ beds/nsePlastic surgery 2 occ beds/nseEye 5 occ beds/nseENT 5 occ beds/nseRheumy. & rehab. 6 occ beds/nseDermatology 6 occ beds/nseAccident 6 occ beds/nse

ICU nurses ICU duty 5 nses/bed

Premature baby unit Prem. baby duty 5 nses/cot


112________________________________________________________________________________________


Labour room Deliveries 4 nses/available bedClinic nurses Clinic duty

Medical 2 nses/clinPsychiatric 2 nses/clinEye 3 nses/clinENT 3 nses/clinSurgical 3 nses/clinSkin 3 nses/clinOrthopaedic 15 nses/clinFP 2 nses/clinAll others 2 nses/clin

OT nurses Theatre dutyFull lists 13 nses/listPart lists 10 nses/listCasualty 2 nses/list

OPD nurses OPD duty 75 outpatients/day

CSSD 24 hours 10 nurses

Laboratory staff Performing testsMLT Haematology 25 tests/day

Biochemistry 25 tests/dayHistology 15 tests/dayBacteriology 25 tests/dayClin pathology 25 tests/dayParasitology 25 tests/day

Receiving samples 1.2 mins/test

Log, send results 2.4 mins/test

AllowancesStocks and reordering 1 MLT continuouslyCompiling statistics 1 MLT for 3 hrs/monthNight laboratory 1 MLT on duty every night

Labourer Number of MLTS required 1 labr/2 MLTs

Pharmacy staff / Pharmacist OPD 80 outpatients/day

Clinics 80 outpatients/day


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Inpatients 9,000 admissions/yrX-ray staff / Radiographer Plain X-rays 40/day

Special techniques 30 mins/patient

Female labourer At least 1

Physiotherapy staff Treating patients 12 half-hour units/dayPhysiotherapist

ECG staff / ECG recordist Ambulant patients 15 mins/patient

Ward patients 25 mins/patient

Allowance administration 1 recordist 4 hrs/week

Province hospitals

Staff category Component of workload Activity standardNursing staff Ward dutyWard nurses Surgical 3 occ. beds/nse

Medical 4 occ. beds/nsePaediatric 3 occ. beds/nseGYN/OBS 3 occ. beds/nseOrthopaedic 2 occ. beds/nsePsychiatric 3 occ. beds/nseENT 5 occ. beds/nseDermatology 8 occ. beds/nseAntenatal 5 occ. beds/nseAccident service 6 occ. beds/nse

ICU nurses ICU duty 5 nses/bed

Premature baby unit Prem baby duty 5 nses/cot

Labour room Deliveries 3 nses/available bed

Clinic nurses Clinic duty 1 nse/clinic, all types




114________________________________________________________________________________________

Staff category Component of workload Activity standardCSSD 8 hours 8 nurses


Biochemistry 25 tests/dayHistology 15 tests/dayBacteriology 25 tests/dayClin pathology 25 tests/day



AllowancesStocks and reordering 1 MLT continuouslyCompiling statistics 1 MLT for 3 hrs/monthNight laboratory 1 MLT on duty every night

Labourer Number of MLTs required 3 Labrs/7 MLTs

Pharmacy staff / Pharmacist OPD 40,000 outpatients/yr

Clinics 40,000 attendances/yr

Inpatients 13,750 admissions/yr

AllowancesMain store 2 pharms.Surgical store 1 pharmRelief 2 pharms

X-ray staff / Radiographer Plain X-rays 40/day




ECG staff

ECG recordist Ambulant patients 15 mins/patient


Allowance administration 1 recordist 4 hrs/week


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Base hospitals

Staff category Component of workload Activity standardNursing staff Ward dutyWard nurses Surgical 3 occ. beds/nse

Medical 5 occ. beds/nsePaediatric 3 occ. beds/nseGYN/OBS 3 occ. beds/nse


Labour room/maternity Deliveries 2 nses/available bednurses

Clinic nurses Clinic duty 1 nse/clinic all types

OT nurses Theatre duty2 wingsFull lists 13 nses/listPart lists 10 nses/listCasualty 2 nses/list

1 wing 2 tablesFull lists 9 nses/listPart lists 6 nses/list

Casualty 2 nses/list

OPD nurses OPD duty 75/day

CSSD (8 hours) 8 nurses


Biochemistry 25 tests/dayHistology 15 tests/dayBacteriology 25 tests/dayClin pathology 40 tests/day



AllowancesStocks and reordering 1 MLT 1 hour/dayCompiling statistics 1 MLT 3 hrs/month

Labourer No. MLTS required 1 Lbr/2 MLT


116________________________________________________________________________________________




Inpatients 1/50 occ. beds

AllowanceRelief 2 pharms.

X-Ray staff / Radiographer Plain X-rays 40/day



Physiotherapy staffPhysiotherapist Treating patients 12 half-hour units/day

ECG staffECG recordist Ambulant patients 15 mins/patient


AllowanceAdministration 1 recordist 4 hrs/week

District hospitals

Staff category Component of workload Activity standardNursing staff Ward duties 5 beds/nseWard nurses


Labour room/maternity Deliveries 2 nses/available bednurses

Clinic nurses Clinics duty 1 nse/clinic, all types



Laboratory staff / MLT Performing tests 40 tests/day


_________________________________________________________________________________________ 117

Staff category Component of workload Activity standardReceiving samples 1.2 mins/test


AllowancesStocks and reordering 1 MLT 1 hour/dayCompiling statistics 1 MLT 3 hrs/month

Labourer 1 labourer/2 MLTs



Inpatients 1/50 occ. beds

Allowance: relief 2 pharms

X-ray staff / Radiographer Plain X-rays 40/day




ECG staffECG recordist Ambulant patients 15 mins/patient


AllowanceAdministration 1 recordist 4 hrs/week

Consultant dental surgeons and associated staff in general hospitals,provincial hospitals, base hospitals, dental institute

Staff category Component of workload Activity standardConsultant Trauma (dental, maxillo-facial)Dental surgeons Conservative management 15 mins

Closed reduction 30-45 minsOpen reduction 30-45 minsManagement of residual deformities 30-45 mins

Infections (dental, oro-facial)Conservative management 10 minsIncision and drainage 10 mins


118________________________________________________________________________________________

Staff category Component of workload Activity standardDecortication/sequestrotomy 30 minsSegmental resections of jaw 3 hrs

Dento-alveolar surgerySurgical removal of impactedTeeth and retained roots 30 minsSurgical endodontics 30 minsPeriodontal surgery 30 minsPre-prosthetic surgery 30 mins

Facial deformitiesCleft-lip and palate repair 1 hrJaw deformities 2 hrsAnkylosis of TMJ 2 hrsSyndromes 3 hrs

CystEnucleation and packing 30 minsMarsupialization and packing 30 mins

NeoplasmIncisional biopsy 10 minsExcision biopsy 45 minsFlap procedure 2 hrsBone grafting 2 hrs

Salivary glandsMajor 1.5 hrsMinor 30 minsSpecial investigations 15 mins

Malignant disease and reconstructionExcision of jaw 5 hrsGlossectomy 5 hrsExcision of cheek/lips 5 hrs

TracheostomyElective 30 minsEmergency 10 mins

Extractions under general anaesthesia 30 minsNon-surgical managementOral mucosal diseases 15 minsBite raising applications 20 minsShort wave diathermy 15 minsRoot canal therapy 20 minsSplints 20 minsObturators/prosthesis 20 mins


_________________________________________________________________________________________ 119


Ward activitiesWard rounds 2 mins/occ. bedClinical procedures 1 hr/day

AllowancesClinical meetings 1.5 hrs/monthUnit management 2 hrs/monthPostgraduate training (dental institute only) 2 hrs/month

Senior house officers All consultant procedures are performed with assistance of one senior house officer exceptallowances, so SHO Activity Standards are as given above.

House officers All consultant procedures are performed with assistance of one house officer except allowances,so HO Activity Standards are as given above with the addition of:Taking history 20 mins/admissionPreparing patients for surgery 20 mins/operationDiagnosis card, medical certificate 15 mins/discharge

Dental surgeons and associated staff inA * Teaching hospitals, general hospitals, provincial hospitals, base hospitals

B * District hospitals, peripheral units, central dispensaries, health centres, adolescent clinics,prison hospitals, chest hospital

C * Dental institute

Staff category standard Component of workload Activity standard *Dental surgeon Emergency

ExtractionsDeciduous A,B 10 minsPermanent

Caries A,B 10/hourPeriodontal A,B 10/hourOther A,B 10/hour

D.A.A. treated A,B 5 minsFractures treated A,B 10 minsMedico-legal A,B 15 mins

Post op.Haemorrhage A,B 15 minsInfections A,B 5 mins

Oral medicinePre-malignant

Leucoplakia A,B 5 mins


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Staff category standard Component of workload Activity standard *Others A,B 5 mins

Oral carcinoma A,B 5 minsCandida albicans A,B 5 mins

RoutineRestorations

Temporary A,B 10 minsPermanent

Amalgam A 15 mins B 20 mins

Composite A 20 minsB 25 mins

Advanced conservation A,B 20 mins

PeriodontalScaling

Manual A,B 30 minsMachine A 15 mins

Surgery A,B 30 mins

SurgeryIncisions & drainage A,B 15 minsImpacted A,B 30 minsApicectomy A,B 30 minsFractures A,B 1 hourBiopsies A,B 20 minsOther A,B 30 mins

Referrals A,B 10 mins

All activities above C add 20% to B figures

AllowancesHealth edn. talks to the community A,B,C 0.5 day/monthMOH monthly conference A,B,C 0.5 day/monthRecording & reporting A,B,C 10 mins/day +

30 mins/monthMaintaining stocks (1 person only) A,B,C 30 mins/monthSupervising, preventive maintenance

and cleaning A,B,C 1 hr/month

Nurses A 1/clinic

Trained attendants A,B,C 1/chair


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School dental clinics

Staff category Component of workload Activity standardDental therapists Fillings

Deciduous 20 minsPermanent 20 mins

DressingsDeciduous 15 minsPermanent 15 mins

Extractions 15 minsComplete scaling 10-15 mins

InitialExamination 10 minsComplete 5 mins

RevisionExamination 5 minsComplete 5 mins

Referral 5 mins

Health education session 20 mins

Outreach 2-3 days

AllowanceSupervisory visit 1 hour/monthMonthly MOH meeting 1 day/monthRecording & reporting 15 mins/day + 1 hour/monthCollecting salary 0.5 days/monthInventory (1 person only) 1 hour/month

Labourer 1/clinic

Dental institute and all hospitals

Staff category Component of workload Activity standardDental technicians Orthodontic plate 1 hour

DentureFull 2 hoursPartial 1 hourObturator 1 hourCrown 45 minsGunning splint 1 hourRepairs 30 minsRebasing 30 minsRelining 1 hour

Labourer 1/6 dental technicians


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Activity standards (service standards and allowance standards) for MCH staff

Staff category Component of workload Unit time, allowancePublic health InspectionsNursing sister PHMS 2.5 hours

SPHMS 2.5 hours

MCH clinicsConducted 5.5 hoursSupervised 2.5 hours

School healthMedical inspections 11 minsFollow up visits 5 mins

InvestigationsMaternal deaths 2.5 hoursInfant deaths 25 mins

Senior public health midwife InspectionsPHMS 2.5 hoursReports submitted 45 mins

MCH clinicsAssisted 3.5 hoursSupervised 3.5 hours

Homes visitedSupervision 25 minsInvestigation 22.5 mins

Public health midwife RegistrationEligible families 17.5 minsPregnant mothers 17.5 mins

Home visits to pregnant mothersFVS - at risk 17.5mins- normal 30 minsSubseqVs - normal 20 mins- at risk 25 mins

Natal careHome deliveries - normal 6 hours- at risk 9 hours- abnormal 9 hours

InvestigationsStill births 45 minsMaternal deaths 3.5 hoursInfant deaths 1 hour


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Staff category Component of workload Unit time, allowance

Postnatal care: home visitsFVs 30 minsSubseqVs 25 mins

Infant care: home visitsFVs 17.5 minsSubseqVs 12.5 mins

Pre-school child care: home visitsFVs 12.5 minsSubseqVs 10 mins

Family planning acceptorsOral pill 12.5 minsIUCD 12.5 minsInjectable 12.5 minsLRT 12.5 minsVasectomy 12.5 mins

Clinic activitiesPregnant - FVs 15 mins

- SubseqVs 12 minsInfant - FVs 10 mins

- SubseqVs 10 minsPre-school - FVs 10 mins

- SubseqVs 10 mins

Time allowances for regular activitiesThe time allowances to be made for regular activities which are not directly covered by the servicestatistics are of two types: standard allowances which are the same in all MOH areas (forconferences, maintaining registers, etc.); and an allowance for travelling time between the base andwork locations during field activities. The amount of such time spent on travel depends on the sizeand population density of the MOH area. Four types of area were identified, and the correspondingtime allowances for travel by each staff category are:

Type of area code PHNS SPHM PHM

Urban good UG 0.5 hr/day 0.5 hr/day 1 hr/day

Urban bad UB 1 hr/day 1 hr/day 1.75 hr/day

Rural good RG 1.5 hrs/day .5 hrs/day 2 hrs/day

Rural bad RB 2 hrs/day 2 hrs/day 3 hrs/day

Field activities are undertaken 14 days per month (averaged throughout the year).


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The total time allowances, standard + travelling, for each staff category in each type of MOH area,and the corresponding percentage allowances to be used in the WISN calculations are as follows:

Public health nursing sisterStaff conference: 1 day/monthLocal conferences: 1 day/monthMaintain register of infant death )Consolidate and forward area data ): 3 days/monthFile and maintain records )Educational programmes: 1 day/monthTravelling base to location of homes: UG/UB/RG/RB as aboveTravelling between homes: 30 minutes/day

Allowances:6 days/month = 6/19.7 = 30.5%UB/UG/RG/RB = 0.5 to 2.0 x14x12/1,785 = 5.5%/11.0%/16.5%/22.0%30 mins/day = 0.5x14x12/1,785 = 5.5%

Total allowance: UG 30.5%+5.5%+5.5% = 41.5%, say 42%UB 30.5%+11%+5.5% = 47.0%RG 30.5%+16.5%+5.5% = 52.5%, say 52%RB 30.5%+22%+5.5% = 58.0%

Senior public health midwifeOrdering supplies: 1 day/monthData returns: 7 days/qrStaff conferences: 1 day/monthOther activities: 2 days/monthTravelling base to location of homes: UG/UB/RG/RB as aboveTravelling between homes: 30 minutes/day

Allowances:4 days/month + 7 days/qr = 76 days/year = 76/238 = 31.9%UB/UG/RG/RB = 0.5 to 2.0 x14x12/1,785 = 5.5%/11.0%/16.5%/22.0%0.5x14x12/1,785 = 5.5%

Total allowance: UG 31.9%+5.5%+5.5% = 42.9%, say 43%UB 31.9%+11%+5.5% = 48.4%, say 48%RG 31.9%+16.5%+5.5% = 53.9%, say 54%RB 31.9%+22%+5.5% = 59.4%, say 59%

Public health midwifeAttending staff conference: 1.5 days/monthCollecting salary: 0.5 days/monthAssisting school health activities: 1 day/yearRecording and reporting )Planning ) 1 hour/day +Administration ) 0.5 day/monthUpdating records and charts )Travelling: UG/UB/RG/RB as above


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Allowances:2.5 days/month = 2.5/20 = 12.5%1 day/year = 1/240 = 0.4%1 hour/day = 6/45 = 13.3%UB/UG/RG/RB = 1 to 3 x14x12/1,785 = 9.3%/16.3%/18.7%/28.0%

Total allowance: UG 12.5%+0.4%+13.3%+9.3% = 35.5%, say 36%UB 12.5%+0.4%+13.3%+16.3% = 42.5%, say 42%RG 12.5%+0.4%+13.3%+18.7% = 44.9%, say 45%RB 12.5%+0.4%+13.3%+28.0% = 54.2%, say 54%

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