Do not exceed more than one page, double spaced, per question.
This knowledge assessment is not timed and you have full access to your book and notes; therefore, it is expected that your answers will be detailed, insightful, of academic merit and with minimal spelling/grammar/format mistakes.
1. Pick two countries, one classified as having a developed economy and another one that is classified as underdeveloped or developing. After reviewing any current information you can find on the healthcare workforce of each, to include physicians and nurses, provide a brief yet detailed summary of key similarities and differences of the two (as applicable).
This assessment can include current or future supply/demands, healthcare education opportunities, cultural barriers, rural vs urban areas, age of workforce, training opportunities, etc. Utilize chapter 2 in your book if you need additional ideas on workforce supply.
2. Review companies listed on Forbes “The World’s Best Employers,” 2021, and pick two to research their websites further. One must be a healthcare organization and one must be a non-healthcare organization.
https://www.forbes.com/lists/worlds-best-employers/#3e1389f91e0c
You will be reviewing these websites as if you are considering working for them. After quickly exploring both, answer the following questions. Be sure to begin your answer by providing the name, country and website of the organizations.
a. Does your healthcare organization provide just as much information for prospective customers/patients as they do for prospective employees? Does the non-health care organization? Explain.
b. Which had more information on it that interested you and why?
c. Which website scored best with you overall? Why?
HEALTHCARE WORKFORCE PLANNING
Thomas C. Ricketts, III, PhD
Learning Objective
s
CHAPTER
2
27
Learning Objectives
After completing this chapter, the reader should be able to
• trace the history of human resources for health and workforce planning;
• learn why and when workforce planning is undertaken;
• briefly describe the five major methods used in workforce planning;
• understand the key concepts of benchmarking, adjusted needs, and
demand as they apply to workforce planning;
• develop a simple estimate of the future supply of a profession for
a
population; and
• interpret the results of workforce planning reports as they relate to
individual healthcare organizations and delivery systems.
Introduction
Most of this book views human resources management (HRM) from the per-
spective of the healthcare organization. Chapters focus on such topics as job
design, recruitment and retention, and evaluation of individual performance.
However, organizations are also affected by the larger external environment
in which they are situated. In HRM, broad workforce policy and labor mar-
ket factors, which are external aspects, affect an organization’s ability to attract
and retain employees. An organization may have a theoretically sound recruit-
ment program for nurses, but if sufficient numbers of nurses are not being trained
in the national healthcare system, the program will likely prove unsuccessful.
This chapter’s focus is unique among the chapters in this book in
that it addresses workforce planning for communities, regions, states,
countries, and other jurisdictions. It devotes attention to the healthcare
workforce needs throughout society rather than the needs of a particular
organization.
Fried_CH02.qxd 6/11/08 4:08 PM Page 27
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EBSCO Publishing : eBook Academic Collection (EBSCOhost) – printed on 2/1/2022 4:14 PM via WESTERN KENTUCKY UNIVERSITY
AN: 237620 ; Fottler, Myron D., Fried, Bruce.; Human Resources in Healthcare : Managing for Success
Account: s8993066.main.ehost
Human resources for health (HRH) workforce planning deals with
questions, including the following:
• How do we determine the number of surgeons needed in a particular
geographic area?
• What factors help us to best anticipate future supply and need for various
types of healthcare workers?
• What methods are used to project future workforce needs? What are the
strengths and weaknesses of different approaches, and how may they be
most effectively applied?
This chapter, therefore, takes a macro-level perspective on the healthcare
workforce and examines concepts and methodologies that are useful in pro-
jecting workforce requirements for communities and larger regions. Much of
the remainder of this book focuses on internal strategies for managing human
resources, which we can view as micro-level approaches, and addresses work-
force concerns from the perspective of a single organization.
Workforce planning is the assessment of needs for human resources. This
process can be very formal and complex or depend on “back-of-the-envelope”
estimates and can be applied to small organizations or practices as well as to
national and international healthcare delivery systems. Workforce planning fits
in with overall health systems planning and human resources development
and management. One conceptualization sees workforce planning as one of
three steps in workforce development (De Geyndt 2000):
1. Planning is the quantity concern.
2. Training is the quality concern.
3. Managing is the performance and output concern.
The Australian Medical Workforce Advisory Committee (2003) de-
scribes workforce planning succinctly: “ensuring that the right practitioners are
in the right place at the right time with the right skills.” However, the consen-
sus remains that workforce planning is “not an exact science” (Fried 1997).
Workforce planning is used to support decision making and policy de-
velopment for a wide range of concerns. For healthcare organizations to meet
their clinical and operating goals and objectives, they must effectively deploy
and support workers of all kinds. Doing so requires that the numbers and
types of workers match the needs of the patients, regulators, and payers who
make up the functional environment of the healthcare organization. For state,
provincial, and regional or national systems, policymakers also require infor-
mation from planning processes that include workforce projections and assess-
ments. Functionally, workforce planning does several things:
• Interprets tasks and roles
• Establishes education and training needs
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• Explains the dynamics of the workforce
• Describes and disseminates information about workforce and workplace
change
• Defines and identifies shortages and surpluses
The History of Healthcare Workforce Planning
HRH planning dates back to the origins of organized medicine and health-
care. Military planners recognized the need to provide adequate numbers of
caregivers for wounded and ill soldiers, and very rough assessments of the
requirements for qualified medical workers were part of the preparation for
military campaigns. The healthcare system in the Soviet Union, and later in
socialized nations, made use of systemwide planning (which includes an es-
timate of the numbers and types of workers) in structuring healthcare. As
European democracies moved toward national healthcare insurance sys-
tems, they recognized the need to balance their policies for training and
preparing healthcare workers with the anticipated needs of the covered pop-
ulations. Given the importance of human resources to healthcare systems
and the examples of planning that were in existence, it was still possible for
an expert group to observe that “only very recently has there been more of
a substantive debate about this issue internationally” (Dubois, McKee, and
Nolte 2006). While HRH planning has a fairly rich history within individ-
ual nations and among international bodies like the United Nations, it has
received little reflection in most other countries. The United States offers
an exception.
Daniel Fox (1996) describes healthcare workforce policy in the
United States as “contentious and uncertain” and characterizes its history as
a process that moved from “piety, to platitudes, to pork.” His observations
apply mostly to the ongoing debate over whether the government should di-
rectly support the education and preparation of physicians, or indirect
ly
through some levy on social insurance, or not at all. Fox tracked the history
of policies that were discussed and applied over time to support medical ed-
ucation. His analysis pertains to the development of policy that depends on
workforce planning, but he did not speak specifically of that development
process.
Fox’s observations provide a useful context for understanding why we
would or would not plan for a healthcare workforce in the United States.
These reasons have implications for whether planning should be supported.
By calling the initial stage of workforce policymaking the result of “pious”
thinking, Fox implies that policymakers knew exactly the “right thing to do”
and needed no or little specific guidance or planning to assist them. The sub-
sequent dependence on “platitudes” about the reality of need and supply of
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physicians and nurses was made by using “accepted wisdom,” which again
meant that there was little need for either planning or research. The culmi-
nation of the policy stream with “pork” meant that resources were distrib-
uted according to political power with little regard for the “facts”—again, a
situation that does not require the development of information and specif
ic
planning.
Healthcare workforce policy has traditionally been driven by a percep-
tion of a shortage of one or more of the healthcare professions. The history
of concern over shortages may have started with physicians, but nurses were
also considered a special part of the healthcare workforce and were subject to
policy attention. The Nurse Training Act of 1941 attempted to expand nurs-
ing schools during wartime to provide nurses for the military. An apparent
shortage of nurses in the late 1950s generated the first federal legislation to
support training of healthcare professionals for the “market,” not for some
specific federal role. Subsidies for nursing education and public health trainee-
ships were included in the Health Amendments Act of 1956, beginning an in-
cremental expansion of federal government support for healthcare workforce
training.
What followed were a series of healthcare professions laws that en-
couraged the creation of training programs, supported faculty, expanded
schools, or provided special aid for programs to redistribute the workforce.
The Health Professions Educational Assistance Act of 1963 (P.L. 88-129)
provided construction money for healthcare professions schools—funds tied
to increased enrollment requirements to assist with the school’s operating
expenses as well as loans and scholarship programs. The Act authorized sup-
port to medical schools for the first time and firmly established the presence
of the federal government in health-related educational institutions. This
was followed by an almost annual succession of laws that added support for
nurses, created loan-repayment plans, and paid for construction. In 1970,
the National Health Service Corps was created, which put the federal gov-
ernment in a role as a direct provider of healthcare professional service for
the general population.
The precedent had been set for federal involvement in workforce pol-
icy in 1956, but early in the twentieth century many states took on health-
care professions education and regulation as an extension of their responsi-
bility for public education and their implied “police powers” to protect the
health, safety, and welfare of their citizens. Assuming a combination of power
over both education and entry into the healthcare professions seems to sug-
gest that the conditions were ripe for some form of planning on the part of
the states that were investing substantial resources in medical and other
health professions schools and that had ready policy levers to control the sup-
ply of practitioners. However, the politics of the healthcare professions were
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clearly dominated by the professions themselves, and the dominant culture
was to support the market for a highly paid elite physician workforce assisted
by less-well-paid nurses and other caregivers (Starr 1982). According to
Weissert and Silberman (1998), not until the 1990s did the states begin to
“send a message that the medical schools have a responsibility to the state
and its citizens.” For some reason, the states were not overly concerned with
healthcare workforce supply and needs until the beginning of the twenty-first
century.
Workforce planning can be considered a subtopic in the general area of
HRH planning, but the two do not necessarily share a common history, and
important differences exist in the way they are approached. Planning is usu-
ally initiated when a perception exists that limited resources are available to
meet all possible needs and that the market will not adequately distribute the
available benefits.
The Rationale for Healthcare Workforce Planning
History tells us that policy and political pressures are generated when either
the market or the public signals a shortage of some type of basic good or serv-
ice. In the case of healthcare workforce, the shortage is of healing practition-
ers and their supporting trades and professions. The case for formal planning,
however, is often made in a more abstract and value-free context. Advocates
for workforce planning sometimes appeal to a need for “rational policymak-
ing,” but often the stimulus for formal action is when people claim that they
cannot get what they want, need, or deserve.
In the United States today, the perception of a nursing shortage and
the concern over a potential physician shortage are stimulating the de-
mand for workforce planning. In Canada and the United Kingdom, both
of which provide national healthcare coverage, queues for certain types of
care are long, drawing attention to the need for workforce planning. The
World Health Organization (2000, 2006) recognizes that HRH planning
has to be able to respond to changes in technology and global patterns of
migration in both population and profession. The drivers of HRH plan-
ning have expanded to include the workforce’s adaptation to technology
as well as the match of needs to supply. Figure 2.1 describes an analytical
framework for HRH planning that considers the emerging concerns over
global markets; migration; and changes in technology, institutions, and
populations. The figure emphasizes that the healthcare system is embed-
ded in a complex web of very strong external forces that shape the inputs
to the system, including the human resources necessary for the system to
function.
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Overview of Workforce Planning Methodologies
Five basic strategies are used in workforce planning: (1) population-based
estimating, (2) benchmarking, (3) needs-based assessment, (4) demand-based
assessment, and (5) training-output estimating. Each approach has its strengths
and weaknesses, depending on the goal of the planning exercise and the con-
text in which it will be applied. These methods may be used separately or in
combination, depending on the system at which the planning is targeted as
well as the specific policy questions posed during planning.
For national health systems, population-based estimating combined with
training-output estimating may be more applicable than the other methods. The
goal of planning in such systems may be to balance investments in training with
the healthcare needs of the overall population. For individual organizations,
benchmarking with peer institutions may provide useful information on how to
staff a hospital or clinic to achieve productivity. Demand-based assessment can al-
low managers to anticipate the effects of changes in requirements for staff after in-
creased marketing efforts or proactive modifications to product mix (Schnelle et
al. 2004). Needs-based assessment may be appropriate as systems and agencies try
to cope with changes in disease prevalence or the availability of new technologies.
32 H u m a n R e s o u r c e s i n H e a l t h c a r e
Demographic
Transition
Technological
Innovation
Organizational Reform
Institutional
Change
Global
Trade
Human Resources
Work Outcomes
Health System
Work Content Workplace
FIGURE 2.1
The Contexts
for Planning in
HRH
Workforce
Planning
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Population-Based Estimating
This method rests on presumed appropriate or normative ratios of personnel
and professionals to population. These ratios are not always generated from
epidemiological analysis or careful study of productivity and utilization, but
they often come from rules of thumb or from the current state of balance of
practitioners to population. In the United States, several proposals for the
most appropriate ratio of physicians to population have been based on obser-
vations of current and past ratios. For example, in the United States, the
Health Professional Shortage Area criterion views a ratio of 1 full-time equiv-
alent primary care physician for every 3,500 people as an indicator of a severe
level of need. A ratio of 1 physician to 3,000 people accompanied by elevated
population-risk indicators, such as high infant mortality and a high proportion
of people older than 65 years in a “rational service” area, also signals high
need, making the area or population eligible for shortage designation.
In a description of the origins of the Health Professional Shortage Area
(formerly Health Manpower Shortage Area) criterion, a federal report sug-
gested that the 1:3,500 ratio was selected because it was 1.5 times the mean
population-to-primary-care-physician ratio by county in 1974 and because it
qualifies a quarter of all counties with the worst ratios (Bureau of Health Man-
power 1977). That report indicated that the ratio of 1:2,500 was selected as
a measure of relative adequacy, being close to the median ratio for all U.S.
counties in 1974.
Many ratios have been suggested as indicative of adequate supply. Fig-
ure 2.2 summarizes 16 such “ideal” or “adequate” ratios. The ratios are drawn
from work by David Kindig (1994) and the Council on Graduate Medical Ed-
ucation (1996, 1999). The wide variation in ratios points to the weaknesses
inherent in population-based approaches. Variability can be the result of dif-
ferences in assumptions concerning the productivity of practitioners, the
needs for services in the population, and even miscalculations caused by poor
data in surveys and practice lists. Nevertheless, analysts and planners persist in
using ratios as standard indicators of desired staffing or as guides to their stud-
ies of professional supply.
Benchmarking
The benchmarking method takes into consideration existing ratios but adds a
test of efficiency to the analysis. The most prominent example focuses on the
physician workforce in the United States, where regional, population-based ra-
tios have been estimated and compared to organizational ratios (Schroeder
1996; Goodman et al. 1996). In this case, regional ratios for hospital-referral
areas generated for the Dartmouth Atlas of Health Care were compared to the
ratio in a large managed care system and selected market-area ratios where
there was intense or little managed care penetration. This approach to setting
national standards is much more controversial than its use for organizations
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(Malone 1997; Wholey, Burns, and Lavizzo-Mourey 1998). The ratios used in
the Goodman analysis included an adjusted HMO (health maintenance organ-
ization) staffing ratio (1:1,908) and the actual generalist ratio for the Wichita
(1:1,527) and Minneapolis (1:1,316) hospital-referral regions (see Figure 2.2).
Across the United States, using the hospital-referral regions to calculate
denominators, 96 percent of the population lived in areas with more general-
ist physicians than the HMO benchmark, 60 percent lived in areas that ex-
ceeded the Wichita standard, and 27 percent lived in areas that exceeded the
Minneapolis standard.
Advocates of benchmarking view these ratios as achievable, optimal ra-
tios and accept the implication that these ratios describe the most efficient
supply of practitioners. Benchmarking has become a part of the workforce-
analysis process, and the influence of the Dartmouth Atlas of Health Care in
guiding policy debate may make this approach more important. However,
there has been little acceptance of specific standards for setting policy targets
or for setting standards for underservice. The development of a revised stan-
dard for underservice for primary medical care has been under discussion by
the federal government since 1998 when a formal proposal was published but
withdrawn (Ricketts et al. 2007).
Needs-Based Assessment
Perhaps the most obvious method of determining how many healthcare pro-
fessionals should be supported in a system or an organization is to match the
consensus healthcare needs of a population or client base with their biologi-
cal need for care. Unfortunately, healthcare need is difficult to determine and
is subject to much variation. The substantial differences in physician opinions
over the indicators and conditions that signal need for various procedures—
such as carotid endarterectomy and coronary bypass graft operations, among
other costly and specialized interventions—have been well documented (Birk-
meyer et al. 1998; Wennberg et al. 1998). That variation has been persistent,
and even concerted efforts to develop consensus on the need for specialist care
have not been altogether successful (Fink et al. 1984). Those consensus meth-
ods, however, can be applied to more localized situations, and useful guidance
can be developed to determine how many individuals in a population are likely
to require selected services.
The consensus process for needs-based assessment is iterative, where
lists of indicators, signs, and conditions are presented in various combina-
tions and where “expert” clinicians are asked to determine if these combi-
nations are high-, medium-, or low-level reasons for hospitalization, for
conducting a specific procedure, for course of therapy, or for prescribing a
specific medication. The expert panel members rate these combinations, dis-
cuss the results, and re-rate them. These steps usually result in a mix of
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35C h a p t e r 2 : H e a l t h c a r e W o r k f o r c e P l a n n i n g
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combinations—strong agreement on a particular care pathway is achieved,
but agreement on other situations is not as high. However, the area of agree-
ment is usually sufficiently large to allow for estimation of the total burden
of care that certain groups of people are likely to require.
For national or other large populations, analysts can combine sepa-
rate classes of diseases and their associated estimates of care to develop pro-
jections of staffing requirements. This was the approach taken by the Grad-
uate Medical Education National Advisory Committee (1980) when it
developed national projections of need and supply of physicians and primary
care practitioners. That process was called “adjusted needs-based approach”
to workforce planning, and it has been used since its development for spe-
cialty-specific estimates of requirements (Elisha, Levinson, and Grinshpoon
2004). For very specific specialties, the task of determining even supply is
very difficult: “The actual number of FTE [full-time equivalent] neurosur-
geons in practice is more difficult to determine, because the number is con-
stantly changing as a result of death, retirement, modification of practice
habits and mix of clinical practice versus other professional activities” (Popp
and Toselli 1996).
The use of needs-based assessment to plan for staffing is supported in
some sectors of the healthcare system by more carefully structured studies. An
example includes the development of appropriate ratios of dental care practi-
tioners (DeFriese and Barker 1982). Practical applications in healthcare or-
ganizations and bounded delivery systems require a focus on a particular type
of need related to a specific type of organizational form—for example, the
need in relation to staffing for outpatient mental health clinics that are man-
aged centrally and that are located in areas where few alternative sources of
this type of care exist (Elisha, Levinson, and Grinshpoon 2004).
Demand-Based Assessment
This workforce planning method is explicitly economic in nature and is based
largely on past patterns of service utilization. Demand is considered to be
somewhat independent of need for care in that some individuals may seek care
when they are not ill, because they either misread their symptoms or desire to
be treated regardless of medical need. In practice, need and demand are con-
sidered very closely tied. In an economic sense, demand is equal to utiliza-
tion—what is consumed is what is demanded; that is, there is a balance in sup-
ply and demand in the market that is regulated by the price of the goods and
services that are consumed. However, often the case is that demand and sup-
ply are not in balance in a sector such as healthcare because prices are not eas-
ily determined by either the purchaser or the supplier. Still, utilization can be
a strong indicator of demand in a system in which the few barriers to care are
caused by access restrictions. An open argument in the United States is
whether or not the government restricts access by market rationing—a system
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that is opposite the explicit budget-rationing system in countries such as the
United Kingdom and Canada.
A good example of the use of demand-based assessment is provided in
studies commissioned by the American Medical Association (Marder et al.
1988). Any mathematical model that projects the supply or demand for
healthcare professionals must include certain assumptions about the future.
For example, knowing that a substantial growth is likely in the outdated num-
ber and population proportion allows the planner to anticipate much higher
levels of utilization. These elevated levels of demand will be reflected in in-
creased supplies of practitioners who are trained to care for the elderly, pro-
vided the training system is able to respond. In an application of this principle
at a very macro level, a study by Cooper and colleagues (2002) demonstrates
that overall economic activity is what determines the future supply of physi-
cians in the United States. The authors’ assumption is that the supply of med-
ical practitioners is determined by the degree to which demand can be ex-
pressed in a relatively open market for care.
Training-Output Estimating
Training-output estimating is perhaps the most common method for antici-
pating supply of practitioners. Essentially, it draws on data from training pro-
grams, such as the number of enrollees, the number of anticipated graduates,
and the trends in applications. This approach has been used to anticipate
trends in the general supply of physicians (Cooper, Stoflet, and Wartman
2003), general surgeons (Jonasson, Kwakwa, and Sheldon 1995), internists
(Andersen et al. 1990), pediatricians (Bazell and Salsberg 1998), and allied
health professionals (DePoy, Wood, and Miller 1997).
Estimations of the supply of nurse practitioners and physician assistants
rely heavily on trends in enrollment in training programs (Hooker and Caw-
ley 2002; Buerhaus, Staiger, and Auerbach 2000). Anticipating the character-
istics of the future workforce in relation to current training patterns is impor-
tant to understand how well today’s practitioners will meet clinical and social
needs in the future. This issue has become critical in the United States, as the
focus of national policy has shifted toward having a workforce that matches
the racial and ethnic structure of the population (Fiscella et al. 2000).
Challenges and Difficulties of Workforce Planning
The fundamental challenge to HRH planning is that any credible analysis
that points to an impending shortage or surplus of practitioners is likely to
result in a policy or an organizational response that precludes that scenario
from occurring. Retrospective analyses of “how well we did” often empha-
size how poorly the projections performed rather than how much reaction
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these projections generated (Cooper et al. 2002). Disappointingly, such ret-
rospective analyses are applied only to national estimates of the state of the
workforce at some unspecified future time. In planning for physician supply,
rarely are organizational or delivery system analyses discussed and critiqued,
except when making them the basis of national estimates (Weiner 2004,
1994, 1987; Hart et al. 1997).
Planning for nursing staffing includes much more organizational em-
phasis because such planning is considered a “staffing” problem subject to
management, rather than a need to anticipate a market response (Seago et al.
2001). Nursing staffing, however, is also subject to broad-scale analyses to an-
ticipate local conditions (Cooper and Aiken 2001).
International Perspectives
National-level HRH workforce planning is practiced more often in other coun-
tries. This is a function of the political economy of these countries’ healthcare
systems, in which central direction and planning is the norm. In other coun-
tries, most ministries or departments of health include a human resources divi-
sion or section that is responsible for the planning function. The planning that
goes on is applicable to the overall system, where decisions are made concern-
ing the number of practitioners and support staff to be trained or allowed into
the country. Planning for specific staffing needs of institutions often takes place
within the same part of the bureaucracy, but sometimes delineation is made be-
tween strategic planning for national needs and strategic planning for policy
and institutional planning for staffing and management decision making.
Canada, for example, developed the Pan-Canadian Health Human
Resources (HHR) Planning Initiative intended to bring more evidence-
based methods to the work of Health Canada. This consortium effort relies
on external research and analysis groups as well as on internal staff. The task
of the Canadian HHR planning group is focused on assessing the future
staffing and contracting needs of Health Canada and the provincial ministries
and departments, as that nation attempts to reform the Canadian healthcare
system in response to the 2003 First Ministers’ Accord on Health Care Re-
newal. The 2003 Canadian federal budget allocated $90 million over five
years to strengthen healthcare human resources planning and coordination.
The national work and interprovincial planning activities are coordinated
through the Advisory Committee on Health Delivery and Human Re-
sources, which has assigned a planning subcommittee to develop evidence-
based recommendations on education strategies, especially interprofessional
education, and on establishing a workforce that can respond to a patient-centered
healthcare system.
38 H u m a n R e s o u r c e s i n H e a l t h c a r e
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In 1995, Australia developed formal structures in its Department of
Health to oversee planning activities for its healthcare workforce. For politi-
cal and practical reasons, the oversight of planning functions was divided be-
tween two committees—one for medical positions (Australian Medical
Workforce Advisory Committee) and one for all other professions and occu-
pations (Australian Health Workforce Advisory Committee). The central
technical task of these committees is to estimate the “required health work-
force to meet future health service requirements and the development of
strategies to meet that need” (Australian Medical Workforce Advisory Com-
mittee 2003).
The World Health Organization supports the Human Resources for
Health program, which has invested heavily in developing skills of personnel
who can do workforce planning for national and regional healthcare systems
(see www.wpro.who.int/sites/whd for an example of work done in the west-
ern Pacific). Australia, for example, has committed substantial resources
and energy in the development of plans for its rural and remote workforce,
and it has developed a national public health workforce program (see
www.nphp.gov.au/workprog/workforce).
Barriers to healthcare workforce development in all countries in-
clude a failure to specify health goals, limited liaison between the health
and education sectors, and resource constraints. Other factors that have
complicated a strategic approach to healthcare workforce development in-
clude the diversity and rapid evolution of health services, the long train-
ing period for most healthcare professions, and the increasing mobility of
the healthcare workforce. Political ideology can also be a major player. In
New Zealand, the market-oriented health reforms of the 1990s created a
competitive rather than a collaborative environment in which workforce
development was not a priority (Hornblow 2002). That has changed to
some extent in recent years, but the Health Workforce Advisory Commit-
tee that was established to direct policy was disbanded in 2006 (see
www.hwac.govt.nz).
One international development that is beginning to have widespread
effects on workforce planning and planning in a management context is the
European Union’s Working Time Directive (WTD) (Roche-Nagle 2004;
Paice and Reid 2004). This rule applies to a wide range of healthcare profes-
sionals and sets limits on the amount of time an individual is allowed to work
in a day and over a work week. The initial implementation of the WTD began
in August 2007. In August 2009, the directive will restrict the hours that
trainees can work from 58 hours to 48 hours per week. The response to the
restrictions has been to increase the intake of trainees in some systems, such
as the National Health Service in the United Kingdom, and to restructure
some training program schedules.
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Workforce Supply Metrics
Measuring the supply of healthcare professionals is not as straightforward as
it seems. A doctor is what a doctor does, but when considering the overall
professional supply needed for a specific area or organization, the distinction
between what a doctor is and what a doctor does is harder to make. For ex-
ample, in counting primary care physicians, most experts and many explicit
policies consider a family physician as dedicated to providing primary care,
which is defined as healthcare that most people need most of the time. Un-
der that description, a primary care practitioner, then, takes care of the most
common complaints and coordinates the care needs of a patient—be it specialty
or inpatient. However, is a psychiatrist or an OB-GYN a primary care physi-
cian? Each may be the patient’s first contact with the medical system, and each
may coordinate the care for many individuals, but the practice of a psychiatrist
and an OB-GYN is limited to certain aspects of human health and illness.
To add more confusion, in many states and under certain federal regula-
tions, these practitioners are considered primary care physicians. In other sys-
tems, the primary care physician’s work is proscribed by certain rules to include
only ambulatory care. These physicians are most often termed “GPs” or general
practitioners. They may, however, have greater autonomy in the system and be
able to control entry into hospitals. This kind of gatekeeping power may, in turn,
influence the resulting demand or expressed need for surgery and, subsequently,
for surgeons. The dynamics of the system, thus, become important to the esti-
mation of the need for specialists and the staff who support them.
The extent of details involved in creating an inventory of primary care
physicians is indicative of the complexity of any process that tries to ascertain
how well the supply of healthcare professionals meets the needs of a popula-
tion or an organization. This challenge often deters managers as well as plan-
ners from attempting to balance their anticipated needs for healthcare profes-
sionals with likely scenarios for supply. Sufficient models are available on how
to approach HRH workforce planning that can make the effort well worth-
while in reducing overall costs of staffing or training and the costs associated
with mismatches of needs and resources.
Summary
HRH workforce planning is the anticipation of how many practitioners and
support workers an organization or a system will require to achieve its mis-
sion. The development of effective workforce plans depends on the use of ac-
curate and reliable data that describe current supply, pattern of entry and exit
from professions and positions, and the number of incoming workers from
training programs and schools. At the national level, HRH planning requires
40 H u m a n R e s o u r c e s i n H e a l t h c a r e
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Discussion Questions
41C h a p t e r 2 : H e a l t h c a r e W o r k f o r c e P l a n n i n g
1. What are the major types of healthcare
workforce planning? Provide examples
of situations where each strategy would
be more appropriate than the others.
2. Healthcare workforce planning is often
done after a shortage in a particular
profession is recognized. How could
planning help avert those shortages?
3. Counting healthcare professionals as
part of healthcare workforce planning
is not always straightforward. For a
specific profession—nursing, dentistry,
or medicine—describe how the prac-
tice patterns of the professionals may
change the effective supply of that
profession.
Experiential
Exercise
In 1999, California became
the first state to pass a law
that requires minimum staffing ratios for nurses
in general acute care hospitals (Coffman,
Seago, and Spetz 2002). California Assembly
Bill 394 (AB 394) mandated the Department
of Health Services to create “minimum, spe-
cific, and numerical nurse-to-patient ratios by
licensed nurse classification and by hospital unit
for the inpatient parts of general hospitals in the
state.” In January 2004, those regulations came
into effect, translating into the following: In the
emergency department, one nurse cannot care
for more than four patients, while in postoper-
ative surgical units, nurses cannot care for more
than six patients.
Using the national nursing supply-
and-demand model, the following table on
page 42 shows the projected supply of regis-
tered nurses (RNs) and a trend for inpatient
days in general acute care hospitals in North
Carolina, from 2007 through 2023.
The North Carolina General Assem-
bly is considering implementing a mandatory
staffing ratio that matches the California
rules for emergency departments and post-op
Case
an understanding of major economic and social trends as well as a keen sense
of the politics involved in labor and professions.
Five basic methods are used in workforce planning: (1) population-
based estimating, (2) benchmarking, (3) needs-based assessment, (4) de-
mand-based assessment, and (5) training-output estimating. Each ap-
proach offers strengths and presents weaknesses, depending on the context
in which it is applied. The institutional planner can use all or a combina-
tion of these approaches in developing staffing plans, preparing for
turnover and transitions, and positioning the organization to compete ef-
fectively for resources.
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If North Carolina imple-
ments a staffing law ex-
actly like the one in California, and that law
is put into effect on January 1, 2009, how
would the numbers in the above table
change? Estimate the change in the number
42 H u m a n R e s o u r c e s i n H e a l t h c a r e
surgical units in general acute care hospitals.
The North Carolina Hospital Association
found that in all of the hospitals in the state
with emergency departments and post-op
surgical units, emergency departments ac-
counted for 8 percent of total inpatient days
in 2007, and the post-op units accounted for
11 percent of inpatient days. Overall, hospi-
tal RNs accounted for 38 percent of all RNs
practicing in North Carolina. Three percent
of these hospital RNs worked in emergency
departments, while 2.2 percent worked in
post-op units. The available supply of RNs in
2007 allowed all hospitals in the state to fully
staff their emergency departments and post-
op units.
of RNs required to staff the emergency de-
partments and post-op units of acute care
hospitals in North Carolina. The use of both
units is expected to rise in direct proportion
to the overall use of hospitals as measured by
inpatient days.
Exercise
Year Number of RNs Trend of Inpatient Days
2007 67,712 4,024,336
2008 68,382 4,090,608
2009 69,049 4,156,880
2010 69,718 4,223,151
2011 74,387 4,289,423
2012 75,050 4,355,695
2013 75,536 4,421,967
2014 75,730 4,488,239
2015 75,890 4,554,511
2016 76,020 4,620,782
2017 76,160 4,687,054
2018 76,210 4,753,326
2019 76,208 4,819,598
2020 76,199 4,885,870
2021 76,165 4,952,141
2022 76,065 5,018,413
2023 75,800 5,084,685
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43C h a p t e r 2 : H e a l t h c a r e W o r k f o r c e P l a n n i n g
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STRATEGIC HUMAN RESOURCES
MANAGEMENT
Myron D. Fottler, PhD
CHAPTER
1
1
Learning Objectives
After completing this chapter, the reader should be able to
• define strategic human resources management,
• outline key human resources functions,
• discuss the significance of human resources management to present and
future healthcare executives, and
• describe the organizational and human resources systems that affect
organizational outcomes.
Introduction
Like most other service industries, the healthcare industry is very labor inten-
sive. One reason for healthcare’s reliance on an extensive workforce is that it
is not possible to produce a “service” and then store it for later consumption.
In healthcare, the production of the service that is purchased and the con-
sumption of that service occur simultaneously. Thus, the interaction between
healthcare consumers and healthcare providers is an integral part of the deliv-
ery of health services. Given the dependence on healthcare professionals to
deliver service, the possibility of heterogeneity of service quality must be rec-
ognized within an employee (as skills and competencies change over time) and
among employees (as different individuals or representatives of various pro-
fessions provide a service).
The intensive use of labor for service delivery and the possibility of vari-
ability in professional practice require that the attention of leaders in the in-
dustry be directed toward managing the performance of the persons involved
in the delivery of services. The effective management of people requires that
healthcare executives understand the factors that influence the performance of
individuals employed in their organizations. These factors include not only the
traditional human resources management (HRM) activities (i.e., recruitment
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and selection, training and development, appraisal, compensation, and em-
ployee relations) but also the environmental and other organizational aspects
that impinge on human resources (HR) activities.
Strategic human resources management (SHRM) refers to the compre-
hensive set of managerial activities and tasks related to developing and main-
taining a qualified workforce. This workforce, in turn, contributes to organi-
zational effectiveness, as defined by the organization’s strategic goals. SHRM
occurs in a complex and dynamic milieu of forces within the organizational
context. A significant trend that started within the last decade is for HR man-
agers to adopt a strategic perspective of their job and to recognize critical link-
ages between organizational strategy and HR strategies (Fottler et al. 1990;
Greer 2001).
This book explains and illustrates the methods and practices for increas-
ing the probability that competent personnel will be available to provide the
services delivered by the organization and that these employees will appropri-
ately perform the necessary tasks. Implementing these methods and practices
means that requirements for positions must be determined, qualified persons
must be recruited and selected, employees must be trained and developed to
meet future organizational needs, and adequate rewards must be provided to
attract and retain top performers. All of these functions must be managed
within the legal constraints imposed by society (i.e., legislation, regulation,
and court decisions). This chapter emphasizes that HR functions are per-
formed within the context of the overall activities of the organization. These
functions are influenced or constrained by the environment, the organiza-
tional mission and strategies that are being pursued, and the systems indige-
nous to the institution.
Why study SHRM? How does this topic relate to the career interests
or aspirations of present or future healthcare executives? Staffing the organ-
ization, designing jobs, building teams, developing employee skills, identi-
fying approaches to improve performance and customer service, and re-
warding employee success are as relevant to line managers as they are to HR
managers. A successful healthcare executive needs to understand human be-
havior, work with employees effectively, and be knowledgeable about nu-
merous systems and practices available to put together a skilled and moti-
vated workforce. The executive also has to be aware of economic,
technological, social, and legal issues that facilitate or constrain efforts to at-
tain strategic objectives.
Healthcare executives do not want to hire the wrong person, to expe-
rience high turnover, to manage unmotivated employees, to be taken to court
for discrimination actions, to be cited for unsafe practices, to have poorly
trained staff undermine patient satisfaction, or to commit unfair labor prac-
tices. Despite their best efforts, executives often fail at HRM because they hire
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the wrong people or they do not motivate or develop their staff. The material
in this book can help executives avoid mistakes and achieve great results with
their workforce.
Healthcare organizations can gain a competitive advantage over com-
petitors by effectively managing their human resources. This competitive ad-
vantage may include cost leadership (i.e., being a low-cost provider) and prod-
uct differentiation (i.e., having high levels of service quality). A 1994 study
examined the HRM practices and productivity levels of 968 organizations
across 35 industries (Huselid 1994). The effectiveness of each organization’s
HRM practices was rated based on the presence of such benefits as incentive
plans, employee grievance systems, formal performance appraisal systems, and
employee participation in decision making. The study found that organiza-
tions with high HRM effectiveness ratings clearly outperformed those with
low HRM rankings. A similar study of 293 publicly held companies reported
that productivity was highly correlated with effective HRM practices (Huselid,
Jackson, and Schuler 1997).
Based on “extensive reading of both popular and academic literature,
talking with numerous executives in a variety of industries, and an application
of common sense,” Jeffrey Pfeffer (1998) identifies in his book, The Human
Equation, the seven HRM practices that enhance an organization’s competi-
tive advantage. These practices seem to be present in organizations that are ef-
fective in managing their human resources, and they occur repeatedly in studies
of high performing organizations. In addition, these themes are interrelated
and mutually reinforcing; it is difficult to achieve positive results by imple-
menting just one practice on its own. See Figure 1.1 for a list of the seven
HRM themes relevant to healthcare. While these HR practices generally have
a positive impact on organizational performance, their relative effectiveness
may also vary depending on their alignment (or lack thereof) with each other
and with the organizational mission, values, culture, strategies, goals, and ob-
jectives (Ford et al. 2006).
The bad news about achieving competitive advantage through the
workforce is that it inevitably takes time to accomplish (Pfeffer 1998). The
good news is that, once achieved, this type of competitive advantage is likely
to be more enduring and more difficult for competitors to duplicate. Mea-
surement is a crucial component for implementing the seven HR practices
listed in Figure 1.1. Failure to evaluate the impact of HR practices dooms
these practices to second-class status, neglect, and potential breakdown. Feed-
back from such measurement is essential in further development of or changes
to practices as well as in monitoring how each practice is achieving its intended
purpose.
Most of these HR practices are described in more detail throughout the
book. Although the evidence presented in the literature shows that effective
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HRM practices can strongly enhance an organization’s competitive advan-
tage, it fails to indicate why these practices have such an influence. In this
chapter, we describe a model—the SHRM—that attempts to explain this phe-
nomenon. First, however, a discussion of environmental trends is in order.
Environmental Trends
Among the major environmental trends that affect healthcare institutions are
changing financing arrangements, emergence of new competitors, advent of new
technology, low or declining inpatient occupancy rates, changes in physician–
organization relationships, transformation of the demography and increase in
4 H u m a n R e s o u r c e s i n H e a l t h c a r e
FIGURE 1.1
Seven HRM
Practices for
Effective
Healthcare
Organizations
1. Provide employment security. Employees can be fired if they do not perform,
but they should not be put on the street quickly because of economic down-
turns or strategic errors by senior management over which employees have no
control. An example that Pfeffer frequently cites is Southwest Airlines, which
sees job security as a vital tool for building employee partnership and argues
that short-term layoffs would “put our best assets, our people, in the arms of
the competition.”
2. Use different criteria to select personnel. Companies should screen for cultural fit
and attitude, among other things, rather than just for skills that new
employees
can easily acquire through training.
3. Use self-managed teams and decentralization as basic elements of organizational de-
sign. Pfeffer is particularly keen on the way teams can substitute peer-based con-
trol of work for hierarchical control, thereby allowing for the elimination of man-
agement layers.
4. Offer high compensation contingent on organizational performance. High pay can
produce economic success, as illustrated by the story of Pathmark. This large gro-
cery store chain in the eastern United States had three months to turn the com-
pany around or go bust. The new boss increased the salaries of his store managers
by 40 percent to 50 percent, enabling managers to concentrate on improving per-
formance rather than complain about their pay.
5. Train extensively. Pfeffer notes that this activity “begs for some sort of return-on-
investment calculations” but concludes that such analyses are difficult, if not im-
possible, to carry out. Successful companies that emphasize training do so almost
as a matter of faith.
6. Reduce status distinctions and barriers. These include dress, language, office arrange-
ments, parking, and wage differentials.
7. Share financial and performance information. The chief executive officer of Whole
Foods Market has said that a high-trust organization “can’t have secrets.” His com-
pany shares salary information with every employee who is interested.
SOURCE: Pfeffer (1998)
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diversity of the workforce, shortage of capital, increasing market penetration
by managed care, heightened pressures to contain costs, and greater expecta-
tions of patients. The results of these trends have been increased competition,
the need for higher levels of performance, and concern for institutional sur-
vival. Many healthcare organizations are closing facilities; undergoing corpo-
rate reorganization; instituting staffing freezes and/or reductions in work-
force; allowing greater flexibility in work scheduling; providing services
despite fewer resources; restructuring and/or redesigning jobs; outsourcing
many functions; and developing leaner management structures, with fewer
levels and wider spans of control.
Organizations are pursuing various major competitive strategies to re-
spond to the current turbulent healthcare environment, including offering
low-cost health services, providing superior patient service through high-
quality technical capability and customer service, specializing in key clinical ar-
eas (e.g., becoming centers of excellence), and diversifying within or outside
healthcare (Coddington and Moore 1987). In addition, organizations are en-
tering into strategic alliances (Kaluzny, Zuckerman, and Ricketts 1995) and
restructuring their organizations in various ways. Regardless of which strate-
gies are being pursued, all healthcare organizations are experiencing a de-
crease in staffing levels in many traditional service areas and an increase in
staffing in new ventures, specialized clinical areas, and related support services
(Wilson 1986).
Staffing profiles in healthcare today are characterized by a limited num-
ber of highly skilled and well-compensated professionals. Healthcare organi-
zations are no longer “employers of last resort” for the unskilled. At the same
time, however, most organizations are experiencing shortages of various nurs-
ing and allied health personnel.
The development of appropriate responses to the ever-changing
healthcare environment has received so much attention that HRM planning
is now well accepted in healthcare organizations. However, implementation
of such plans has often been problematic. The process often ends with the
development of goals and objectives and does not include strategies or meth-
ods of implementation and ways to monitor results. Implementation appears
to be the major difficulty in the overall management process (Porter 1980).
A major reason for this lack of implementation has been failure of
healthcare executives to assess and manage the various external, interface, and
internal stakeholders whose cooperation and support are necessary to success-
fully implement any business strategy (i.e., corporate, business, or functional)
(Blair and Fottler 1990). A stakeholder is any individual or group with a
“stake” in the organization. External stakeholders include patients and their
families, public and private regulatory agencies, and third-party payers. Inter-
face stakeholders are those who operate on the “interface” of the organization
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in both the internal and external environments; these stakeholders may in-
clude members of the medical staff who have admitting privileges or who are
board members at several institutions. Internal stakeholders are those who op-
erate within the organization, such as managers, professionals, and nonprofes-
sional employees.
Involving supportive stakeholders, such as employees and HR man-
agers, is crucial to the success of any HRM plan. If HR executives are not ac-
tively involved, then employee planning, recruitment, selection, development,
appraisal, and compensation necessary for successful plan implementation are
not likely to occur. McManis (1987, 19) notes that “[w]hile many hospitals
have elegant and elaborate strategic plans, they often do not have support-
ing human resource strategies to ensure that the overall corporate plan can
be implemented. But strategies don’t fail, people do.” Despite this fact, the
healthcare industry as a whole spends less than one-half the amount that
other industries are spending on human resources management (Hospitals
1989).
The SHRM Model
A strategic approach to human resources management includes the following
(Fottler et al. 1990):
• Assessing the organization’s environment and mission
• Formulating the organization’s business strategy
• Identifying HR requirements based on the business strategy
• Comparing the current HR inventory—in terms of numbers,
characteristics, and practices—with future strategic requirements
• Developing an HR strategy based on the differences between the current
inventory and future requirements
• Implementing the appropriate HR practices to reinforce the business
strategy and to attain competitive advantage
Figure 1.2 provides some examples of possible linkages between strate-
gic decisions and HRM practices.
SHRM has not been given as high a priority in healthcare as it has re-
ceived in many other industries. This neglect is particularly surprising in a la-
bor-intensive industry that requires the right people in the right jobs at the
right times and that often undergoes shortages in various occupations (Cerne
1988). In addition, the literature in the field offers fairly strong evidence that
organizations that use more progressive HR approaches achieve significantly
better financial results than comparable, although less progressive, organiza-
tions do (Gomez-Mejia 1988; Huselid 1994; Huselid, Jackson, and Schuler
1997; Kravetz 1988).
6 H u m a n R e s o u r c e s i n H e a l t h c a r e
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Figure 1.3 illustrates some strategic HR trends that affect job analysis
and planning, staffing, training and development, performance appraisal,
compensation, employee rights and discipline, and employee and labor rela-
tions. These trends are discussed in more detail in later chapters in this book.
The bottom line of Figure 1.3 is that organizations are moving to higher lev-
els of flexibility, collaboration, decentralization, and team orientation. This
transformation is driven by the environmental changes and the organizational
responses to those changes discussed earlier.
C h a p t e r 1 : S t r a t e g i c H u m a n R e s o u r c e s M a n a g e m e n t 7
Strategic Decision Implications on HR Practices
Pursue low-cost competitive Provide lower compensation
strategy Negotiate give-backs in labor
relations
Provide training to
improve efficiency
Pursue service-quality Provide high compensation
differentiation competitive Recruit top-quality candidates
strategy Evaluate performance on the
basis of patient satisfaction
Provide training in guest
relations
Pursue growth through Adjust compensation
acquisition Select candidates from
acquired organization
Outplace redundant
workers
Provide training to new
employees
Pursue growth through Promote existing employees
development of new markets on the basis of an objective
performance-appraisal
system
Purchase new technology Provide training in using and
maintaining the technology
Offer new service/product line Recruit and select physicians
and other personnel
Increase productivity and cost Encourage work teams to be
effectiveness through process innovative
improvement Take risks
Assume a long-term perspective
FIGURE 1.2
Implications
of Strategic
Decisions on
HR Practices
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8 H u m a n R e s o u r c e s i n H e a l t h c a r e
FIGURE 1.3
Strategic
Human
Resources
Trends
Old HR Practices Current HR Practices
Job Analysis/Planning
Explicit job descriptions Broad job classes
Detailed HR planning Loose work planning
Detailed controls Flexibility
Efficiency Innovation
Staffing
Supervisors make hiring decisions Team makes hiring decisions
Emphasis on candidate’s technical Emphasis on “fit” of applicant
qualifications within the culture
Layoffs Voluntary incentives to retire
Letting laid-off workers fend for Providing continued support
themselves to terminated employees
Training and Development
Individual training Team-based training
Job-specific training Generic training emphasizing
flexibility
“Buy” skills by hiring experienced “Make” skills by training
workers less-skilled workers
Organization responsible for Employee responsible for
career development career development
Performance Appraisal
Uniform appraisal procedures Customized appraisals
Control-oriented appraisals Developmental appraisals
Supervisor inputs only Appraisals with multiple inputs
Compensation
Seniority Performance-based pay
Centralized pay decisions Decentralized pay decisions
Fixed fringe benefits Flexible fringe benefits
(i.e., cafeteria approach)
Employee Rights and Discipline
Emphasis on employer protection Emphasis on employee
protection
Informal ethical standards Explicit ethical codes and
enforcement procedures
Emphasis on discipline to reduce Emphasis on prevention to
mistakes reduce mistakes
Employee and Labor Relations
Top-down communication Bottom-up communication
and feedback
Adversarial approach Collaboration approach
Preventive labor relations Employee freedom of choice
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The SHRM Process
As illustrated in Figure 1.4, a healthcare organization is made up of systems
that require constant interaction within the environment. To remain viable,
an organization must adapt its strategic planning and thinking to extend to
external changes. The internal components of the organization are affected by
these changes, so the organization’s plans may necessitate modifications in
terms of the internal systems and HR process systems. There must be har-
mony among these systems.
The characteristics, performance levels, and amount of coherence in
operating practices among these systems influence the outcomes achieved in
terms of organizational and employee-level measures of performance. HR
goals, objectives, process systems, culture, technology, and workforce must be
aligned with each other (i.e., internal alignment) and with various levels of or-
ganizational strategies (i.e., external alignment) (Ford et al. 2006).
Internal and External Environmental Assessment
Environmental assessment is a crucial element of SHRM. As a result of changes
in the legal/regulatory climate, economic conditions, and labor-market real-
ities, healthcare organizations face constantly changing opportunities and
threats. These opportunities and threats make particular services or markets
more or less attractive in the organization’s perspective.
Among the trends currently affecting the healthcare environment are
increasing diversity of the workforce, aging of the workforce, labor shortages,
changing worker values and attitudes, and advances in technology. Healthcare
executives have responded to these external environmental pressures through
various internal, structural changes, including developing network structures,
joining healthcare systems, participating in mergers and acquisitions, forming
work teams, implementing continuous quality improvement, allowing telecom-
muting, employee leasing, outsourcing, using more temporary or contingent
workers, and globalization.
Healthcare executives need to assess not only their organizational
strengths and weaknesses but also their internal systems; human resources’
skills, knowledge, and abilities; and portfolio of service markets. Management
of human resources involves paying attention to the effect of environmental
and internal components on the HR process. Because of the critical role of
healthcare professionals in delivering services, managers should develop HR
policies and practices that are closely related to, influenced by, and supportive
of the strategic goals and plans of their organization.
Organizations, either explicitly or implicitly, pursue a strategy in their
operations. Deciding on a strategy means determining the products or serv-
ices that will be created and the markets to which the chosen services will be
offered. Once the selection is made, the methods to be used to compete in the
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10 H u m a n R e s o u r c e s i n H e a l t h c a r e
Organizational
Mission
• Purpose
• Mission
• Business unit
Organizational
Strategy
Formulation
• Corporate
• Business
• Functional
HR Outcomes
• High levels of competence
• High levels of motivation
• Positive work-related attitudes
• Low employee turnover
• Organizational commitment
• High levels of satisfaction
Organizational Outcomes
• Competitive advantage
• Financial performance
• Legal compliance
• Attainment of strategic goals
• Satisfaction of key stakeholders
HR Strategy
Implementation
• Management
of external and
interface
stakeholders
• Management
of external
stakeholders
• HR practices/
tactics to
implement
(i.e., adequate
staffing)
Environmental
Assessment
• Opportunities
• Threats
• Services/markets
• Technological trends
• Legal/regulatory
climate
• Economic conditions
• Labor markets
HR Strategy
Formulation
• HR goals and
objectives
• HR process systems
— HR planning
— Job analysis and
job design
— Recruitment/
retention
— Selection/placement
— Training/
development
— Performance appraisal
— Compensation
— Labor relations
• Organizational
design/culture
• Technology/
information systems
• Workforce
Formulation of
Other Functional
Strategies
• Accounting/finance
• Marketing
• Operations
management
Implementation
of other functional
strategies
Internal Assessments
• Strengths
• Weaknesses
• Portfolio of service
markets
• Human resources’
skills, knowledge,
and abilities
• Internal systems
FIGURE 1.4
SHRM
Model
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chosen market must be identified. The methods adopted are based on inter-
nal resources available, or potentially available, for use by managers. As shown
in Figure 1.4, strategies should consider environmental conditions and orga-
nizational capabilities. To be in a position to take advantage of opportunities
that are anticipated to occur, as well as to parry potential threats from changed
conditions or competitor initiatives, managers must have detailed knowledge
of the current and future operating environment. Cognizance of internal
strengths and weaknesses allows managers to develop plans based on an accu-
rate assessment of the organization’s ability to perform in the marketplace at
the desired level.
SHRM does not occur in a vacuum; rather, it occurs in a complex and
dynamic constellation of forces in the organizational context. One significant
trend has been for HR managers to adopt a strategic perspective and to rec-
ognize the critical links between human resources and organizational goals.
As seen in Figure 1.4, the SHRM process starts with the identification of the
organization’s purpose, mission, and business unit, as defined by the board of
directors and the senior management team. The process ends with the HR
function serving as a strategic partner to the operating departments. Under
this new view of human resources management, the HR manager’s job is to
help operating managers achieve their strategic goals by serving as the expert
in all employment-related activities and issues.
When HR is viewed as a strategic partner, talking about the single best
way to do anything makes no sense. Instead, the organization must adopt HR
practices that are consistent with its strategic mission, goals, and objectives. In
addition, all healthcare executives are HR managers. Proper management of
employees entails having effective supervisors and line managers throughout
the organization.
Organizational Mission and Corporate Strategy
An organization’s purpose is its basic reason for existence. The purpose of a
hospital may be to deliver high-quality clinical care to the population in a
given service area. An organization’s mission, created by its board and senior
managers, specifies how the organization intends to manage itself to most ef-
fectively fulfill its purpose. The mission statement often provides subtle clues
on the importance the organization places on its human resources. The pur-
pose and mission affect HR practices in obvious ways. A nursing home, for ex-
ample, must employ nursing personnel, nurse aides, and food service workers
to meet the needs of its patients.
The first step in formulating a corporate and business strategy is do-
ing a SWOT (strengths, weaknesses, opportunities, and threats) analysis. The
managers then attempt to use the organization’s strengths to capitalize on
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environmental opportunities and to cope with environmental threats. Hu-
man resources play a fundamental role in SWOT analysis because the nature
and type of people who work within an organization and the organization’s
ability to attract new talent represent significant strengths and weaknesses.
Most organizations formulate strategy at three basic levels: the corpo-
rate level, the business level, and various functional levels. Corporate strategy
is a set of strategic alternatives that an organization chooses from as it man-
ages its operations simultaneously across several industries and markets. Busi-
ness strategy is a set of strategic alternatives that an organization chooses from
to most effectively compete in a particular industry or market. Functional
strategies consider how the organization will manage each of its major func-
tions (i.e., marketing, finance, and human resources).
A key challenge for HR managers when the organization is using a cor-
porate growth strategy is recruiting and training large numbers of qualified
employees, who are needed to provide services in added operations. New-hire
training programs may also be needed to orient and update the skills of in-
coming employees. In Figure 1.4, the two-way arrows connecting “Organi-
zational Strategy Formulation” and “HR Strategy Formulation” indicate that
the impact of the HR function should be considered in the initial development
of organizational strategy. When HR is a true strategic partner, all organiza-
tional parties consult with and support one another.
HR Strategy Formulation and Implementation
Once the organization’s corporate and business strategies have been deter-
mined, managers can then develop an HR strategy. This strategy commonly
includes a staffing strategy (planning, recruitment, selection, placement), a
developmental strategy (performance management, training, development,
career planning), and a compensation strategy (salary structure, employee in-
centives).
A staffing strategy refers to a set of activities used by the organization
to determine its future HR needs, recruit qualified applicants with an interest
in the organization, and select the best of those applicants as new employees.
This strategy should be undertaken only after a careful and systematic devel-
opment of the corporate and business strategies so that staffing activities mesh
with other strategic elements of the organization. For example, if retrench-
ment is part of the business strategy, the staffing strategy will focus on deter-
mining which employees to retain and what process to use in termination.
A developmental strategy helps the organization enhance the quality of
its human resources. This strategy must also be consistent with the corporate
and business strategies. For example, if the organization wishes to follow a
strategy of differentiating itself from competitors through customer focus and
service quality, then it will need to invest heavily in training its employees to
provide the highest-quality service and to ensure that performance manage-
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ment focuses on measuring, recognizing, and rewarding performance—all of
which lead to high levels of service quality. Alternatively, if the business strat-
egy is to be a leader in providing low-cost services, the developmental strat-
egy may focus on training to enhance productivity to keep overall costs low.
A compensation strategy must also complement the organization’s other
strategies. For example, if the organization is pursuing a strategy of related di-
versification, its compensation strategy must be geared toward rewarding em-
ployees whose skills allow them to move from the original business to related
businesses (e.g., inpatient care to home health care). The organization may
choose to pay a premium to highly talented individuals who have skills that
are relevant to one of its new businesses. When formulating and implement-
ing an HR strategy and the basic HR components discussed earlier, managers
must account for other key parts of the organization, such as organizational
design, corporate culture, technology, and the workforce (Bamberger and
Fiegelbaum 1996).
Organizational design refers to the framework of jobs, positions, groups
of positions, and reporting relationships among positions. Most healthcare or-
ganizations use a functional design whereby members of a specific occupation
or role are grouped into functional departments such as OB-GYN, surgery, and
emergency services. Management roles are also divided into functional areas
such as marketing, finance, and human resources. The top of the organizational
chart is likely to reflect positions such as chief executive officer (CEO) and vice
presidents of marketing, finance, and human resources. To operate efficiently,
and allow for seamless service, an organization with a functional design re-
quires considerable coordination across its various departments.
Many healthcare organizations have been moving toward a flat organi-
zational structure or horizontal corporation. Such an organization is created by
eliminating levels of management, reducing bureaucracy, using wide spans of
control, and relying heavily on teamwork and coordination to get work ac-
complished. These horizontal corporations are designed to be highly flexible,
adaptable, streamlined, and empowered. The HR function in such organiza-
tions is typically diffused throughout the system so that operating managers
take on more of the responsibility for HR activities and the HR staff play a
consultative role.
Corporate culture refers to the set of values that help members of that
culture understand what they stand for, how they do things, and what they
consider important. Because culture is the foundation of the organization’s
internal environment, it plays a major role in shaping the management of hu-
man resources, determining how well organizational members will function
together and how well the organization will be able to achieve its goals. There
is no ideal culture for all organizations, but a strong and well-articulated cul-
ture enables employees to know what the organization stands for, what it val-
ues, and how to behave. A number of forces shape an organization’s culture,
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including the founder or founders, institutional affiliations, shared experi-
ences, symbols, stories, slogans, heroes, and ceremonies.
Managers must recognize the importance of culture and take appropri-
ate care to transmit that culture to others in the organization. Culture can be
transmitted through orientation, training, consistent behavior (i.e., walking
the talk), corporate history, and telling and retelling of stories. Culture may
facilitate the work of either HR managers or line managers. If the organiza-
tion has a strong, well-understood, and attractive culture, recruiting and re-
taining qualified employees become easier. If the culture is perceived as weak
or unattractive, recruitment and retention become problematic. Likewise, the
HR function can reinforce an existing culture by selecting new employees who
have values that are consistent with that culture.
Technology also plays a role in the formulation and implementation of
an HR strategy. The HR activities of healthcare organizations are quite differ-
ent from those in the manufacturing industry. In healthcare, different criteria
for hiring and methods of training are used. In addition, healthcare organiza-
tions typically emphasize educational credentials. Many aspects of technology
play a role in HR in all healthcare settings. For example, automation of cer-
tain routine functions may reduce demand for certain HR activities but may
increase it for others. Computers and robotics are important technological el-
ements that affect HRM, and rapid changes in technology affect employee se-
lection, training, compensation, and other areas.
Appropriately designed management information systems provide
data to support planning and management decision making. HR information
is a crucial element of such a system, as such information can be used for both
planning and operational purposes. For example, strategic planning efforts
may require data on the number of professionals in various positions who will
be available to fill future needs. Internal planning may require HR data in
categories such as productivity trends, employee skills, work demands, and
employee turnover rates. The use of an intranet (an internal internet that is
available to all members of an organization) can improve service to all em-
ployees, help the HR department, and reduce many routine administrative
costs (Gray 1997).
Finally, workforce composition and trends also affect HR strategy formu-
lation and implementation. The American workforce has become increasingly
diverse in numerous ways. It has seen growth in the number of older employ-
ees, women, Latinos, Asians, African Americans, foreign born, the disabled,
single parents, gays, lesbians, and people with special dietary preferences. Pre-
viously, most employers observed a fairly predictable employee pattern: Peo-
ple entered the workforce at a young age, maintained stable employment for
many years, and retired at the usual age—on or around age 65. This pattern
has changed and continues to evolve as a result of demographic factors, im-
proved health, and the abolition of mandatory retirement.
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As mentioned earlier, the successful implementation of an HR strategy
generally requires identifying and managing key stakeholders (Blair and Fot-
tler 1990, 1998). The HR strategy, as all other strategies, can only be imple-
mented through people; therefore, such implementation requires motiva-
tional and communication processes, goal setting, and leadership. Specific
practices or tactics are also necessary to implement the HR strategy. For ex-
ample, if a healthcare organization’s business strategy is to differentiate itself
from competitors through its high-level focus on meeting customer (patient)
needs, then the organization may formulate an HR strategy to provide all em-
ployees with training in guest relations.
However, that training strategy alone will not accomplish the business
objective. Methods for implementation also need to be decided; for example,
should the training be provided in-house or externally through programs such
as those run by the Disney Institute? How will each employee’s success in ap-
plying the principles learned be measured and rewarded? The answers to such
questions provide the specific tactics needed to implement the HR strategy as-
sociated with the business goal of differentiation through customer service.
Obviously, the organization will also develop and implement other functional
strategies in accounting/finance, marketing, operations management, and other
areas. Positive or negative organizational outcomes are determined by how well
all of these functional strategies are formulated, aligned, and implemented.
HR Outcomes and Performance
The outcomes achieved by a healthcare organization depend on its environ-
ment, its mission, its strategies, its HR process systems, its internal systems and
the consistency with which the operating practices are followed across these
systems, and its capability to execute all of the above factors. The appropriate
methods for organizing and relating these factors are determined by the out-
comes desired by managers and other major stakeholders, and numerous
methods exist for conceptualizing organizational performance and outcomes
(Cameron and Whetten 1983; Goodman and Pennings and Associates 1977).
For this discussion, the specific outcomes are HR outcomes and organiza-
tional outcomes (see the two bottom boxes in Figure 1.4).
Numerous HR outcomes are associated with HR practices. An organ-
ization should provide its workforce with job security, meaningful work, safe
conditions of employment, equitable financial compensation, and a satisfac-
tory quality of work life. Organizations will not be able to attract and retain
the number, type, and quality of professionals required to deliver quality
health services if the internal work environment is unsuitable. In addition, em-
ployees are a valuable stakeholder group whose concerns are important be-
cause of the complexity of the service they provide. Job satisfaction (Stark-
weather and Steinbacher 1998), commitment to the organization (Porter et
al. 1974), motivation (Fottler et al. 2006), levels of job stress (DeFrank and
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Ivancevich 1998), and other constructs can be used as measures of employee
attitude and psychological condition.
HR metrics are measures of HR outcomes and performance. Part of HR’s role
as a strategic business partner is to measure the effectiveness of the HR func-
tion as a whole as well as the various HR tasks. Today, HR is under some
scrutiny, as management and other areas of the organization inquire how var-
ious HR activities contribute to performance outcomes (HR Focus 2005a).
Specifically, the questions often focus on the return on investment (ROI) of
HR activities.
Human capital metrics have been developed to determine how HR ac-
tivities contribute to the organization’s bottom line (HR Focus 2005b). Some
employers now gather data on the ROI of various recruitment sources, such
as print advertising, Internet advertising, college recruitment, internal trans-
fers, and career fairs (Garvey 2005). Other employers track productivity using
cost metrics, such as the time to fill positions, the percentage of diverse can-
didates hired, interview-to-offer ratios, offer-to-acceptance ratios, hiring man-
ager satisfaction, new-hire satisfaction, cost per hire, headcount ratios,
turnover costs, financial benefits of employee retention, and the ROI of train-
ing (Garvey 2005; Schneider 2006).
Such metrics relate to specific HR activities, but there is also a need to
measure the overall contribution of the HR function to organizational per-
formance and outcomes (Lawler, Levenson, and Boudreau 2004).
The HR Scorecard is one method to measure this contribution. This
tool is basically a modified version of the balanced scorecard (BSC), which is
a measurement and control system that looks at a mix of quantitative and
qualitative factors to evaluate organizational performance (Kaplan and Norton
1996). The “balance” reflects the need for short-term and long-term objec-
tives, financial and nonfinancial metrics, lagging and leading indicators, and
internal and external performance perspectives. A book entitled The Work-
force Scorecard extends research on the BSC to maximize workforce poten-
tial (Huselid, Becker, and Beatty 2005). The authors show that traditional fi-
nancial performance measures are “lagging” performance indicators, which
can be predicted by the way organizations manage their human resources.
HR practices are the “leading” indicators, predicting subsequent financial
performance.
The Mayo Clinic has developed its own HR balanced scorecard that al-
lows the HR function to become more involved in the organization’s strate-
gic planning (Fottler, Erickson, and Rivers 2006). Based on the assumption
“what gets measured gets managed,” Mayo’s HR balanced scorecard meas-
ures and monitors a large number of input and output HR indicators that are
aligned with the organization’s mission and strategic goals. This HR score-
card measures financial (i.e., staff retention savings), customer (i.e., employee
16 H u m a n R e s o u r c e s i n H e a l t h c a r e
Measuring the
HR Function
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retention, patient satisfaction), internal (i.e., time to fill positions), and learn-
ing (i.e., staff satisfaction, perceived training participation) areas.
Organizational Outcomes and Performance
For long-term survival, a healthcare organization must have a balanced, ex-
change relationship with the environment. This equitable relationship must
exist because it is mutually beneficial to the organization and to the environ-
ment with which it interacts. A number of outcome measures can be used to
determine how well the organization is performing in the marketplace and is
producing a service that will be valued by consumers, such as growth, prof-
itability, ROI, competitive advantage, legal compliance, strategic objectives
attainment, and key stakeholder satisfaction. The latter may include such in-
dexes as patient satisfaction, cost per patient day, and community perception.
The mission and objectives of the organization are reflected in the out-
comes that are stressed by management and in the strategies, general tactics,
and HR practices that are chosen. Management makes decisions that, com-
bined with the level of fit achieved among the internal systems, determine the
outcomes the institution can achieve. For example, almost all healthcare or-
ganizations need to earn some profit for continued viability. However, some
organizations refrain from initiating new ventures that may be highly prof-
itable if the ventures do not fit their overall mission of providing quality serv-
ices needed by a defined population group. Conversely, some organizations
may start some services that are acknowledged to be break-even propositions
at best because those services are viewed as critical to their mission and the
needs of their target market.
The concerns of such an organization are reflected not only in the
choice of services it offers but also in the HR approaches it uses and the out-
come measures it views as important. This organization likely places more em-
phasis on assessment criteria for employee performance and nursing unit op-
erations that stress the provision of quality care than on criteria concerned
with efficient use of supplies and the maintenance of staffing ratios. This se-
lection of priorities does not mean that the organization is ignoring efficiency
of operations; it just signals that the organization places greater weight on the
former criteria. The outcome measures used to judge the institution should
reflect its priorities.
Another institution may place greater emphasis on economic return,
profitability, and efficiency of operations. Quality of care is also important to
that organization, but the driving force for becoming a low-cost provider
causes the organization to make decisions that reflect its business strategy;
therefore, it stresses maintenance or reduction of staffing levels and strictly
prohibits overtime. Its recruitment and selection criteria stress identification
and selection of employees who will meet minimum job requirements and ex-
pectations and, possibly, will accept lower pay levels. In an organization that
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strives to be efficient, less energy may be spent on “social maintenance” activ-
ities designed to meet employee needs and to keep them from leaving or
unionizing. The outcomes in this situation will reflect, at least in the short
run, higher economic return and lower measures of quality of work life.
Regardless of their specific outcome objectives, most healthcare or-
ganizations seek competitive advantage over similar institutions. The ultimate
goal of the HR function should be to develop a distinctive brand so that em-
ployees, potential employees, and the general public view that particular or-
ganization as the “choice” rather than as the “last resort.”
In HR, branding refers to the organization’s corporate image or culture
(Johnson and Roberts 2006). Because organizations are constantly compet-
ing for the best talent, developing an attractive HR brand is extremely impor-
tant. A brand embodies the values and standards that guide employee behav-
ior. It indicates the purpose of the organization, the types of people it hires,
and the results it recognizes and rewards (Barker 2005). If an organization can
convey that it is a great place to work for, it can attract the “right” people (HR
Focus 2005c). Being acknowledged by an external source is a good way to cre-
ate a recognized HR brand. Inclusion on national, published “best” lists, such
as the following, helps an organization build a base of followers and enhances
its recruitment and retention programs:
• Fortune’s 100 Best Companies to Work For
• Working Mothers’s 100 Best Companies for Working Mothers
• Computerworld’s Best Places to Work in IT
• Robert Levering and Milton Moskowitz’s 100 Best Companies to Work
for in America
Being selected for Fortune’s 100 Best Companies list is so desirable that
some organizations try to change their culture, philosophy, and brand just to
be included (Phillips 2005).
Cardinal Health in Dublin, Ohio, ranks 19th on Fortune’s list and is a
major provider of healthcare products, services, and technologies (Schoeff
2006). Corporate leaders at Cardinal recently decided that the organization’s
competitive advantage lies with its people. As a result, the organization is con-
centrating its HR efforts on more strategic issues and outsourcing more admin-
istrative functions. Among its strategic activities are identifying and developing
talent and more closely linking HR activities to strategic objectives. Cardinal’s
management believes that these changes will enable HR to become a strategic
player and will greatly increase the organization’s global HR capability.
The immediate goal of building a strong HR brand is to attract and re-
tain the best employees. However, the ultimate goal is to enhance the organiza-
tion’s outcomes and performance—that is, to achieve competitive advantage.
18 H u m a n R e s o u r c e s i n H e a l t h c a r e
The HR Brand
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Human Resources and the Joint Commission
The Joint Commission initiated a pilot project to assess the relationship be-
tween adequate staffing and clinical outcomes (Lovern 2001). The project was
led by a 20-member national task force composed of hospital leaders, clinicians,
and technical experts, among others (Joint Commission 2002). The task force
submitted its recommendations, which became a standard—Standard HR
1.30—that was implemented in January 2004. This standard requires health-
care organizations to assess their staffing effectiveness by continually screening
for issues that can potentially arise as a result of inadequate staffing. Staffing ef-
fectiveness is defined as the number, competency, and skill mix of staff related
to the provision of needed care, treatment, and services. The Joint Commis-
sion’s focus is on the link between HR strategy implementation (i.e., adequate
staffing) and organizational outcomes (i.e., clinical outcomes)—see these two
boxes in Figure 1.4.
Under Standard HR 1.30, a healthcare facility selects a minimum of
four screening indicators—two for clinical/service and two for human re-
sources. The idea behind using two sets of indicators is to understand their
relationship with one another; it also emphasizes that no indicator, in and of
itself, can directly demonstrate staffing effectiveness. An example of a clinical/
service screening indicator is an adverse drug event, and examples of HR
screening indicators are overtime and staff vacancy rates. Staffing inefficien-
cies may be revealed by examining multiple screening indicators related to pa-
tient outcomes.
A facility has to choose at least one indicator for each clinical/service
and HR category from the Joint Commission’s list, and additional screening
indicators can be selected based on the facility’s unique characteristics, special-
ties, and services. This selection also defines the expected impact that the ab-
sence of direct and indirect caregivers may have on patient outcomes. The
data collected on these indicators are analyzed to identify potential staffing-
effectiveness issues when performance varies from expected targets—that is,
ranges of performance are evaluated, external comparisons are made, and im-
provement goals are assessed. The data are analyzed over time against the
screening indicators to identify trends, patterns, or the stability of a process.
At least once a year, managers report to the senior management team regard-
ing the aggregation and analysis of data related to staffing effectiveness and
regarding any actions taken to improve staffing.
HR screening indicators include the following:
• Overtime
• Staff vacancy rates
• Staff turnover rates
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• Understaffing, as compared to the facility’s staffing plan
• Nursing hours per patient day
• Staff injuries on the job
• On-call per diem use
• Sick time
Clinical/service screening indicators include the following:
• Patient readmission rates
• Patient infection rates
• Patient clinical outcomes by diagnostic category
The healthcare organization is expected to drill down to determine the
causes of variation when data vary from expectation. The organization then
undertakes steps leading to appropriate actions that are likely to remedy iden-
tified problems. For example, analysis of the data may indicate the need for
evaluation of the organization’s staffing practices. If so, the organization takes
specific actions to improve its performance. Examples of strategies that may
be used to address identified staffing issues include the following:
• Staff recruitment
• Education/training
• Service curtailment
• Increased technology support
• Reorganization of work flow
• Provision of additional ancillary or support staff
• Adjustment of skill base
A Strategic Perspective on Human Resources
Managers at all levels are becoming increasingly aware that critical sources of
competitive advantage include appropriate systems for attracting, motivating,
and managing the organization’s human resources. Adopting a strategic view
of human resources involves considering employees as human “assets” and de-
veloping appropriate policies and programs to increase the value of these as-
sets to the organization and the marketplace. Effective organizations realize
that their employees have value, much as the organization’s physical and cap-
ital assets have value.
Viewing human resources from an investment perspective, rather than
as variable costs of production, allows the organization to determine how to
best invest in its people. This leads to a dilemma. An organization that does
not invest in its employees may be less attractive to both current and prospec-
tive employees, which causes inefficiency and weakens the organization’s
competitive position. However, an organization that does invest in its people
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needs to ensure that these investments are not lost. Consequently, an organi-
zation needs to develop strategies to ensure that its employees stay on long
enough so that it can realize an acceptable return on its investment in em-
ployee skills and knowledge.
Not all organizations realize that human assets can be strategically
managed from an investment perspective. Management may or may not have
an appreciation of the value of its human assets relative to its other assets such
as brand names, distribution channels, real estate, and facilities and equip-
ment. Organizations may be characterized as human-resources oriented or
not based on their answers to the following:
• Does the organization see its people as central to its mission and
strategy?
• Do the organization’s mission statement and strategy objectives mention
or espouse the value of human assets?
• Does the organization’s management philosophy encourage the
development of any strategy that prevents the depreciation of its human
assets, or does the organization view its human assets as a cost to be
minimized?
Often, an HR investment perspective is not adopted because it involves
making a longer-term commitment to employees. Because employees can leave
and most organizations are infused with short-term measures of performance,
investments in human assets are often ignored. Organizations that are perform-
ing well may feel no need to change their HR strategies. Those that are not do-
ing as well usually need a quick fix to turn things around and therefore ignore
longer-term investments in people. However, although investment in human
resources does not yield immediate results, it yields positive outcomes that are
likely to last longer and are more difficult to duplicate by competitors.
Who Performs HR Tasks?
The person or unit that performs HR tasks has changed drastically in recent
years. Today, the typical HR department does not exist, and no particular unit
or individual is charged with performing HR tasks (HR Focus 2005b). Inter-
nal restructuring has often resulted in a shift as to who carries out HR tasks,
but it has not eliminated those functions identified in Figure 1.4. In fact, in
some healthcare organizations, the HR department continues to perform the
majority of HR functions. However, questions are now being raised such as,
Can some HR tasks be performed more efficiently by line managers or by out-
side vendors? Can some HR tasks be centralized or eliminated altogether? Can
technology perform HR tasks that were once previously done by HR staff?
(Rison and Tower 2005).
Over time, the number of HR staff has declined, and continues to de-
cline, as others have begun to assume responsibility for certain HR functions
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(HR Magazine 2005). Outsourcing, shared service centers, and line managers
now assist in performing many HR functions and activities. While most organ-
izations are expected to outsource more HR tasks in the future, the strategic
components of HR will likely remain within the organization itself (Pomeroy
2005; HR Focus 2006a). HR managers will continue to be involved with
strategic HR matters and other key functions, including performance manage-
ment and compensation management (Davolt 2006; Pomeroy 2005).
The shift toward strategic HR is beginning to permit the HR function to
shed its administrative image and to focus on more mission-oriented activities,
as noted earlier (HR Focus 2006b). This shift also means that all healthcare
executives need to become skilled managers of their human resources. More
HR professionals are assuming a strategic perspective when it comes to manag-
ing HR-related issues (HR Focus 2005d; Meisinger 2005). As they do so, they
are continually upgrading and enhancing their professional capabilities (Khatri
2006). This means that they must be given a seat at the board of director’s table
to help the chief officers, senior management, and board members make appro-
priate decisions concerning HR matters (HR Focus 2004; Fottler et al. 2006).
The three critical HR issues to which an HR professional can lend ex-
pertise and therefore help organizational governance include selecting the in-
coming CEO, tying the CEO’s compensation to performance, and identify-
ing and developing optimum business and HR strategies (Kenney 2005). In
addition, the HR professional can also contribute to leveraging HR’s role in
major change strategies (e.g., mergers and acquisitions), developing and im-
plementing HR metrics that are aligned with business strategies, and helping
line managers achieve their unit goals (Pinola 2002).
In a study of HR leaders in more than 1,000 organizations, 67 percent
of the respondents reported that they belonged to the executive team in their
organization (HR Focus 2003). Similarly, a 2006 survey of 427 HR profes-
sionals revealed that of the respondents who oversaw the HR department, 63
percent directly reported to the CEO or president (HR Focus 2006c). More-
over, the same survey found that more than half of the respondents worked
for an organization that had an established strategic HR plan, and most of the
respondents worked directly with senior management in developing organi-
zational strategies. Of course, these data are not necessarily representative of
the healthcare industry. If such data were available for the healthcare industry,
the results may indicate somewhat lower levels of HR function influence.
Summary
In healthcare, the intensive reliance on professionals to deliver high-quality
services requires organizations and their leaders to focus attention on the
strategic management of their human resources and to be aware of the factors
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that influence the performance of all their employees. To assist healthcare ex-
ecutives in understanding this dynamic, this chapter presents a model that ex-
plains the interrelationship among corporate strategy, selected organizational-
design features, HRM activities, employee outcomes, and organizational
outcomes.
The outcomes achieved by the organization are influenced by numer-
ous HR and non-HR factors. The mission determines the direction that is be-
ing taken by the organization and the goals it desires to achieve. The amount
of integration or alignment of mission, strategy, HR functions, behavioral
components, and non-HR strategies defines the level of achievement that is
possible.
Healthcare organizations are increasingly striving to impress a distinc-
tive HR brand image upon employees, potential employees, and the general
public. They are doing this by modifying their cultures and working hard to
be included on various national lists of “best companies.” Successful branding
results in competitive advantage in both labor and service markets. Organiza-
tions are also increasing the volume and quality of HR metrics they collect and
use in an effort to better align their HR strategies with their business strate-
gies. Finally, the locus of HRM is shifting, as strategic functions are retained
by HR professionals within the organization while administrative tasks are
outsourced elsewhere or delegated to line managers.
Discussion Questions
C h a p t e r 1 : S t r a t e g i c H u m a n R e s o u r c e s M a n a g e m e n t 23
1. Distinguish among corporate, business,
and functional strategies. How does
each strategy relate to human resources
management? Why?
2. How may an organization’s human
resources be viewed as either a strength
or a weakness when doing a SWOT
analysis? What could be done to
strengthen human resources in the event
that it is seen as a weakness?
3. List factors under the control of
healthcare managers that contribute to
the decrease in the number of people
applying to health professions schools.
Describe the steps that healthcare
organizations can take to improve this
situation.
4. What are the organizational advantages
of integrating strategic management and
human resources management? What
are the steps involved in such an
integration?
5. One healthcare organization is pursuing
a business strategy of differentiating its
service product through providing
excellent customer service. What HR
metrics do you recommend to reinforce
this business strategy? Why?
6. In what sense are all healthcare
executives human resources managers?
How can executives best prepare to
perform well in this HR function?
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Each year, Fortune maga-
zine publishes a list of
“The Best Companies to Work For in Amer-
ica.” Editors of the magazine base their selec-
tion on an extensive review of the HR prac-
tices of many organizations as well as on
surveys of those organizations’ current and
former employees.
Use the Internet to identify three
healthcare organizations on the latest For-
tune “best companies” list. Next, visit the
websites of these organizations, and review
the posted information from the perspective
of a prospective job applicant. Then, as a po-
tential employee, answer the following:
• What information on the websites most
interested you, and why?
• Which organization’s website scored
best with you, and why?
Based on the information posted on
these websites, what are the implications for
you as a future healthcare executive who will
be planning and implementing HRM prac-
tices? What information will you include on
your organization’s website that will attract
and retain employees?
Experiential Exercises
24 H u m a n R e s o u r c e s i n H e a l t h c a r e
Before class, obtain the an-
nual report of any health-
care organization of your choice. Review the
material presented and the language used.
Write a one-page memo that assesses that or-
ganization’s philosophy regarding its human
resources. In class, form a group of four or five
students. As a group, compare the similarities
and differences among the organizations that
each group member investigated. Discuss the
following:
• How can you differentiate those
organizations that merely “talk the talk”
from those that also “walk the walk”?
• What factors influence how an
organization perceives its human
resources?
• How do “better” organizations perceive
their human resources?
• What did you learn from this exercise?
Exercise 1
Before class, review the
seven HR practices de-
veloped by Jeffrey Pfeffer and shown in Fig-
ure 1.1. Consider how your current/most
recent employer follows any three of these
seven practices. Write a 1–2 page summary
that lists the three practices you selected
and their compatibilities (or incompatibili-
ties) with your employer’s HRM practices.
In class, form a group of four or five stu-
dents and share your perceptions. Discuss
the following:
• What similarities and differences arise
among the practices in your
organization and those in your group
members’ employers?
• Which of the seven practices seem to be
least followed by these organizations,
and why?
Exercise 2
Exercise 3
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References
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9/9/201
3
1
John White
Dept. of Public Health
CHALLENGES AND OPPORTUNITIESCHALLENGES AND OPPORTUNITIESCHALLENGES AND OPPORTUNITIESCHALLENGES AND OPPORTUNITIES
Human Resource Management
Drucker:
Problems are
opportunities
to excel.
Challenges
• Workforce
– Expanding
– Shrinking
– Changing
• Technology
– Pace of change
– Delivery of care
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2
Challenges: con’t
• Authority v. Responsibility
– Greater responsibility
– Authority for change rests elsewhere
• Effectiveness
– Still important but…
• COST
Organizations are Flatter/Fatter
Importance of HRM
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3
Human Capital #1 Global Challenge
Focus on Basic HRM
Expanding Work Week
1660
1680
1700
1720
1740
1760
1780
1800
1820
1840
1860
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20
12
US
Global
data extracted on 09 Sep 2013 20:09 UTC (GMT) from OECD.Stat
9/9/2013
4
Manage Everyone!
• Manage Employees
• Manage your Boss
• Manage other supervisors
• Manage patients/clients
Stakeholder Model
“Core Process”
• Job analysis
• Recruitment/retention
• Selection/placement
• Payroll
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Job Analysis
• What is it people do?
• Employee focused
• Consultants
• Theory based
• Basis for all other
functions
Recruitment & Retention
• Focus of federal legislation
• Costs of replacing workers
• Retention efforts
Selection and Placement
• Civil Rights Act
• ADA
• Mechanistic model
• Matrix organizations
• Job Ladders
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Diversity Efforts
Traditionalists (1925-45)
• See boomers as disrespectful, overly
blunt, too “warm and fuzzy”
• See busters as very young, impatient,
unethical
Boomers: (1946-1964)
• See traditionalists as by-the-book, overly
cautious, conservative, inflexible
• See busters as selfish, manipulative, aloof
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Busters: (1965-75)
• See traditionalists as old, outdated, rigid
• See boomers as workaholic, unrealistic,
disgustingly “new age”
Millennials
• Work/life balance important
• Technology is good
• Faster career progression expected
• PWC
– 38% saying that older senior management do not
relate to younger workers
– 34% saying that their personal drive was
intimidating to other generations.
– half felt that their managers did not always
understand the way they use technology at work.
Training and Development
• CEU and licensure
• New equipment
• Methods
• Standards
• New managers?
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8
Performance Appraisal
• Nobody enjoys this
• Supposed to be about improving
performance
• Mostly about distributing rewards
• Focus on negatives
• Bias
Compensation
• Compensation is more than just pay
• “Perks”
• Retirement
• Health Insurance
• Changing Expectations
Labor Relations
• Increased union activity
• Cost always increases
• Management doesn’t always listen
• Avoidance
• Negotiation
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Outcomes
• Employee:
– Retention
– Satisfaction
• Organizational
– Effectiveness
– Efficiency
Future Directions?
• Outsourcing
• Matrix for real?
John White
Dept. of Public Health
STRATEGIC HUMAN RESOURCES STRATEGIC HUMAN RESOURCES STRATEGIC HUMAN RESOURCES STRATEGIC HUMAN RESOURCES
MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENT
Chapter 01
Copyright 2011 Health Administration
Press
9/9/2013
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Strategy:
• Built without HRM input
• Left to implement
• Personnel impression
Topics in this Lecture
• Strategic HR Management
• HR Best Practices
•
The SHRM Model
• Organizational Mission and Corporate
Strategy
• Measuring the HR Function
•
The HR Brand
• A Strategic Perspective on HR
Copyright 2011 Health Administration
Press
Strategic Human Resources Management
(SHRM)
• SHRM: the comprehensive set of managerial
activities and tasks related to developing and
maintaining a qualified workforce needed to
achieve organizational effectiveness
• HR strategies support business/corporate strategies
• Managing people strategically is crucial in enhancing
organizational performance
• All healthcare executives are human resources
managers
Copyright 2011 Health Administration
Press
9/9/2013
11
Significance of SHRM
• Having human resources with the right skills at the
right time does not happen by accident (see opening vignette)
– Some may not always be available on the market
– Those available may be lacking in the requisite skills, training, or service
orientation
• To maintain or enhance organizational performance, healthcare
organizations should always consider:
– employee recruitment
– selection
– retention
– training
– performance appraisal
– compensation
• Organizations should also consider legal issues and environmental
factors that affect the management of human resources
Copyright 2011 Health Administration
Press
Benefits of SHRM
• Competitive advantage over other
healthcare organizations
• As a result of SHRM, enhanced employee
satisfaction can:
– Improve clinical outcomes
– Enhance service quality
– Increase market share
– Improve financial returns
Copyright 2011 Health Administration
Press
Seven HR Best Practices
• Pheffer (1998)—Practice for effective
organizations:
– Provide employment security
– Use different criteria to select employees
– Use self-managed teams and decentralization
– Offer high compensation contingent on performance
– Train extensively
– Reduce status distinctions and barriers
– Share financial performance information
• Do these practices make sense? Why or why not?
Copyright 2011 Health Administration
Press
9/9/2013
12
“Old” vs “New”
Copyright 2011 Health Administration
PressEx. 1.2
Performance Appraisal
Uniform appraisals Customized appraisals
Control-oriented appraisals Developmental appraisals
Supervisor input only Appraisals with multiple sources
Planning Cycle
• Situational assessment
• Strategic choice
• Implementation
• Control
Model of HRM (fig. 1-2)
• Notice sequential flow
• Organization into separate tasks
• Outcomes
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HRM fits in…
• Implementation?
• All four phases
– SWOT of workforce and environment
– Best use of Human Capital
– Assignment of employees to tasks
– Design of reporting relationships/organization
The Model: Situation Assessment
Copyright 2011 Health Administration
Press
Internal
Assessment
• Strengths
• Weakness
• Portfolio of Service
Markets
• HR KSAs
• Internal Systems
Organizational
Mission
• Purpose
• Mission
• Business Unit
Environmental
Assessment
• Opportunities
• Threats
• Service/Markets
• Technological Trends
• Legal/Regulatory Climate
• Economic Conditions
• Labor market
Organizational
Strategy
Formulation
• Corporation
• Business
• Functional
HR Formulation
(Tactical/Operational)
Copyright 2011 Health Administration
Press
HR Strategy
Formulation
• HR Goals/Objectives
• HR Process Systems
� HR Planning
� Job Analysis/Job Design
� Recruitment/Retention
� Selection/Placement
� Training/Development
� Performance Appraisal
� Compensation
� Labor Relations
• Organizational
Design/Culture
• Technology/Information
Systems
• Workforce
Formulation of
Other Functional
Strategies
• Accounting and Finance
• Marketing
• Operations Management
Implementation of
other functional
Strategies
HR Strategy
Implementation
• Management of
Internal and External
Stakeholders
• HR practices and
tactics to implement,
such as adequate
staffing
9/9/2013
14
Outcomes/Metrics
Copyright 2011 Health Administration
Press
HR Outcomes
• High Competence
• High Motivation
• Positive work-related attitudes
• Low employee turnover
• Organizational commitment
• High Satisfaction
Organizational Outcomes
• Competitive advantage
• Financial performance
• Legal compliance
• Attainment of strategic goals
• Satisfaction of key stakeholders
The SHRM Model
What HR problems might occur if any of
the above steps were not implemented
by a healthcare organization?
Copyright 2011 Health Administration
Press
The HR Brand
• A brand refers to the organization’s image or
culture from the perspective of the general public
or potential customers or employees. The brand
reflects the organization’s:
– Corporate image and culture
– Purpose
– Type of people hired
– Results it recognizes and rewards
• The purpose of the HR brand is to attract and
retain the best employees and ultimately achieve
competitive advantage.
Copyright 2011 Health Administration
Press
9/9/2013
15
Who Performs HR Tasks
• Human resource managers
• Line managers
– Recently assuming more responsibility in HR
functions
• HR departments more concerned with
financial performance and strategic issues
while delegating more routine HR functions to
line managers.
– HR executives are more likely to be members of
the executive team
Copyright 2011 Health Administration
Press
Strategic Perspective of HR
• What are the potential advantages of any of
the current HR practices as opposed to the
old HR practices for a typical healthcare
organization (see Exhibit 1.2)?
• Name one organizational outcome (i.e.,
competitive advantage), and indicate how
and why one or more human resource
practices might positively affect that particular
organizational outcome (see Exhibit 1.3)?
Copyright 2011 Health Administration
Press
Amorim Lopes et al. Human Resources for Health (2015) 13:38
DOI 10.1186/s12960-015-0028-0
REVIEW Open Access
Handling healthcare workforce planning
with care: where do we stand?
Mário Amorim Lopes1*, Álvaro Santos Almeida2 and Bernardo Almada-Lobo1
: Planning the health-care workforce required to meet the health needs of the population, while
providing service levels that maximize the outcome and minimize the financial costs, is a complex task. The problem
can be described as assessing the right number of people with the right skills in the right place at the right time, to
provide the right services to the right people. The literature available on the subject is vast but sparse, with no
consensus established on a definite methodology and technique, making it difficult for the analyst or policy maker to
adopt the recent developments or for the academic researcher to improve such a critical field.
Methods: We revisited more than 60 years of documented research to better understand the chronological and
historical evolution of the area and the methodologies that have stood the test of time. The literature review was
conducted in electronic publication databases and focuses on conceptual methodologies rather than techniques.
Results: Four different and widely used approaches were found within the scope of supply and three within
demand. We elaborated a map systematizing advantages, limitations and assumptions. Moreover, we provide a list of
the data requirements necessary to implement each of the methodologies. We have also identified past and current
trends in the field and elaborated a proposal on how to integrate the different methodologies.
: Methodologies abound, but there is still no definite approach to address HHR planning. Recent
literature suggests that an integrated approach is the way to solve such a complex problem, as it combines elements
both from supply and demand, and more effort should be put in improving that proposal.
Keywords: Review, Health-care workforce planning, Supply, Demand, Needs, Health policy
Health-care human resources (HHR) planning has been
identified as the most critical constraint in achieving the
well-being targets set forth in the United Nations’ Mil-
lennium Development Goals [1]. Moreover, the effective
use and deployment of personnel is paramount to ensure
an efficient service delivery in terms of cost, quality and
quantity [2]. Failure to do so may result in an oversupply
or shortage of clinical staff. While the former may lead to
economic inefficiencies and misallocated resources under
the guise of unemployment [3] or inflated costs through
supplier-induced demand [4], the latter is linked to a more
extensive list of negative effects, including but not limited
to the following: lower quantity and quality of medi-
cal care as few resources exist to provide the necessary
*Correspondence: mario.lopes@fe.up.pt
1INESC TEC, Faculdade de Engenharia, Universidade do Porto, Porto, Portugal
Full list of author information is available at the end of the article
services and the visits are shorter [5]; work overload of
the available physicians and nurses, resulting in sleep-
deprivation, ultimately compromising patient safety [6];
and queues and waiting lists resulting from insufficient
medical staff, causing avoidable patient deaths [7].
Another argument supporting HHR planning is the
recent rise in health-care expenditure, both in per capita
spending on health and as a proportion of per capita
domestic product in real terms [8]. The average annual
growth rate of health-care expenditure in a selection of
18 countries that are part of the Organisation for Eco-
nomic Co-operation and Development (OECD) was 3.0 %
between 1980 and 1990 and 3.3 % in the decade after
[8]. Recent studies confirm the rising trend, with health
spending growing at an average of 3.8 % in 2008 and
3.5 % in 2009 [9], well above the growth rate of the
gross domestic product. Health worker wages account for
© 2015 Amorim Lopes et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
http://crossmark.crossref.org/dialog/?doi=10.1186/s12960-015-0028-0-x&domain=pdf
mailto: mario.lopes@fe.up.pt
http://creativecommons.org/licenses/by/4.0
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Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 2 of 1
9
about 50 % of total public and private health expenditure
across several countries [5], meaning that cost contain-
ment and efficiency improvements will necessarily require
the involvement of the workforce.
In sharp contrast to other scientific areas where a set
of well-defined methodologies and techniques is gener-
ally adopted and refined to solve a given problem, in
HHR planning, methodologies (the conceptual scope of
analysis) and approaches (the techniques applied upon a
particular method) abound, and there is still no commonly
accepted or favoured procedure to accurately forecast
physician requirements [3, 10]. The methodologies fol-
lowed by countries vary significantly, in some cases with
no long-term strategic HHR planning at all, but a wide
array of options does not seem to be a determining factor
in improving the accuracy of forecasting [11]. Despite the
lack of focus, the accuracy of the projections appears to be
making progress in some cases, as a review reporting the
case of The Netherlands shows [12], an encouraging sign
to the ongoing research.
A definite approach to the problem, or at least a sta-
ble starting block, will require a comprehensive overview
of how the problem has been tackled since its inception.
For this purpose, we provide a thorough analysis of the
field, to lay down the foundations for future research, cou-
pled with a historical perspective on the development of
the HHR literature, analysing how the field has evolved
and what methodologies have emerged and continue to be
employed. Secondly, we analyse the strengths and pitfalls
of each of the methodologies and provide a data require-
ment framework containing all the variables and data that
need to be taken into account in order to address the
problem thoroughly. The review is selective as it focuses
primarily on articles that seem to have had a clear impact
on the evolution of the field, although broad in scope
as it attempts to extensively describe all known meth-
ods. Finally, it describes where we stand and the road
ahead, providing a brief overview of new and emerging
approaches to the HHR planning problem.
To the best of our knowledge, the last comprehensive
academic paper on the subject dates back to 1978 [13].
Literature reviews exist but tend to either focus on a par-
ticular period or on a subset of the methodologies or
techniques [11, 14] or to be framed as technical reports
aimed at a wider readership, such as the OECD’s extensive
review of 26 projection models used in 18 countries [9]
or WHO’s policy recommendations to the EU [15]. The
literature reviews can also consist of a technical report tar-
geting a country in particular [16]. In fact, some authors
point out that more systematic reviews, assessments of
potential interventions and further research to aid policy
makers are highly needed [17]. This paper aims to narrow
this gap by being a starting point both for academics and
policy makers.
Literature search method
We carried out an extensive literature review, includ-
ing academic research papers and technical reports from
institutions such as the OECD or WHO. Selected papers
date between 1951 and 2013, and the results were
reported in a chronological and evolutionary way so as
to clearly identify methodologies that are still in use to
this day. The search methodology can be summarized as
follows: after selecting a set of search terms and gener-
ating reliable combinations, we used electronic research
databases to search for related articles. We then selected
a maximum of 20 papers for each combination of search
terms, including the 10 most cited, the 5 most recent and
5 that were randomly chosen. A backward/forward search
was conducted, and the abstract was analysed to ensure
that the papers met the search criteria. Papers that failed
to meet any of the search criteria were excluded.
To identify search terms, we consulted the available
literature reviews and technical reports [5, 10, 11, 13]
so as to a obtain a list of key terms frequently used in
this research field. Table 1 displays the search terms more
frequently employed in the literature. Multiple combi-
nations were selected using these key search terms. For
instance, all possible combinations of health and health-
care with (AND) workforce, manpower, physicians, nurses
and (AND) forecast, projection, planning. Related subor-
dinate queries such as physicians supply forecast, nurses
supply forecast, healthcare supply forecast, healthcare
demand forecast were also employed. These terms were
then used on the online databases PubMed, MEDLINE,
Embase, ProQuest, Healthstar, ABI/Inform, INSPEC,
Google Scholar and Scopus to obtain a base set of the 10
most cited, 5 most recent and 5 randomly chosen papers.
Of this initial selection, an abstract matching and back-
ward/forward search was conducted to assess whether the
topic covered was relevant. Publications that failed to ver-
ify these criteria were excluded. A total of 308 publications
were retrieved, with 75 meeting at least 1 of the inclusion
criteria using the combination of search terms and were
thus included in this review. Table 2 describes our search
methodology.
Scope
HHR planning is a comprehensive field far extending
the number of physicians and nurses. Other health-care
workers such as hygienists, therapists, managers, admin-
istrative assistants and other support staff also play a
critical role, relieving the clinical staff of bureaucratic
and time-consuming tasks. In fact, skill-mix studies show
that proper task delegation is critical to ensure proper
health-care delivery. Furthermore, a complete assessment
may also require the analysis of the impact of other indi-
rect stakeholders, such as workforce educators, regula-
tors, funders and employers. Assessing how the training
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 3 of 19
Table 1 Key terms used to conduct the search
Keywords Search queries
Health Workforce planning
Healthcare Healthcare forecasting
Workforce Health human resources
Manpower Health manpower
Physicians Health planning
Nurses Healthcare planning
Forecast Health services
Projection Health supply
Planning Health demand
. . . Healthcare needs
Healthcare providers
Physician forecasting
Nurse forecasting
Nursing staff
Manpower
Manpower planning
Workforce forecasting
Workforce projections
Workforce management
Staff levels
Health staffing levels
Shortage healthcare workers
is conducted (i.e. could the training time be reduced?; do
medical schools have the capacity to train a given num-
ber of trainees?; are more medical schools necessary?),
the impact of regulatory requirements (i.e. is the entry
to medical school limited by government-fixed numerus
clausus?) or financial and service constraints (i.e. can the
Table 2 The search method applied in this review
Step Search method
1 Identify common search terms from reviews, books and
technical papers
2 Generate plausible combinations of terms to be used for
search using the key search terms identified
4 Search for these terms on PubMed, MEDLINE, Embase,
ProQuest, Healthstar, ABI/Inform, INSPEC, Google Scholar and
Scopus
5 Select a base set for the results consisting of the 20 papers (10
most cited, 5 most recent and 5 randomly chosen)
6 Match the abstract and perform a forward and backward
search to verify the relevance of the paper for the selected base
set
7 Exclude papers that address none of the topics covered, that
only make a brief reference to the subject at hand or that are
not written in English
existing hospitals and health-care units absorb a planned
increase in the number of health-care professionals?) is a
critical requirement for a well-guided policy.
Without disregarding the importance of these other
professions, in this paper, we will focus solely on review-
ing the planning of the clinical staff that directly pro-
vide health-care services and, more specifically, on the
physicians and nurses, along with references to related
fields like dentistry. Obtaining reliable projections for the
available and necessary human resources is an obligatory
starting point. Moreover, the prominence will be in the
spectrum of different methodologies that may be used to
obtain forecasts for the number of physicians and nurses,
with short references to the approaches or technical appa-
ratus, commonly used to apply a given methodology a.
Also, our concern is HHR planning only at the national
and regional level. HHR planning at a local level (hospi-
tal or medical centre) is conceptually different, involving
other methodologies and tools, and therefore, it is not
inserted in this paper.
The remainder of this paper is organized as follows:
in the “Background” section, we introduce the general
and governing principles that characterize the health-care
market. The background information provided is critical
to equip the reader with the necessary concepts. In the
“
” section, we proceed with an evolu-
tionary and chronological description of the field, expos-
ing the work and methodologies that have been shaping
the research field. In the “
” section, we discuss
the current trends in this research area and the road ahead
regarding future research directions. We also present a
summary of all the findings, including a table with an
overview of the methodologies and a data-requirement
framework to understand which methodologies can be
used based on the data available, as well as a proposal sug-
gesting a way to develop an integrated approach. Finally,
we finish with a brief summary and conclusion.
Background
HHR planning as a scientific area and topic of theo-
retical and applied research evolved significantly from
non-existence into a remarkable and serious effort of pri-
vate and governmental institutions, which tried to antic-
ipate how many human resources, primarily physicians
and nurses, will be necessary in order to maintain or
even improve the quantity, quality, availability and effec-
tiveness of the medical services provided. Improved life
expectancy and changing demographics, epidemiological
trends, improved socio-economic conditions and an ever-
increasing world population may result in a rise in the
expected demand for health-care services [18] and, there-
fore, further additions to the list of patients of an ageing
medical workforce [19]. It then comes as no surprise that
health workers are recognized as a critical resource for
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 4 of 19
achieving population health goals [1], working at the front
gate of the health-care sector.
The health-care sector is an intricate, albeit funda-
mental, part of ancient and modern societies, and it
comprises a long list of agents, from the individual seek-
ing health-care services to the medical staff providing
them, all operating within a legal framework involving
providers, consumers, insurance companies, government,
medical schools and regulatory institutions. Regardless
of the statutory system in place, either a Bismarckian-
based or a Beveridgean-based organization, at its core,
the health-care market is always composed of both sup-
pliers of health services and patients demanding their
services. On the one side is the workforce of physi-
cians, nurses and remaining clinical staff trained and
ready to assist those in need. On the other side stand
the forces that drive the demand for medical services,
strongly related to demographic, socioeconomic and epi-
demiological factors. Analysing these two market forces
is a critical step in assessing whether the available health-
care human resources are enough in quantity and skills
to meet the current and future demand in due time and
may lay solid foundations for further research, considering
perhaps changes to the existing health policy framework.
Despite the similarities, the health-care market diverges
from a traditional market of goods and services for sev-
eral reasons [20]. A high degree and extent of uncertainty
affects both supply and demand; asymmetric information
between physicians and patients, restrictions on competi-
tion, strong government interference and supply-induced
demand are some of the most glaring differences that can
be pinpointed. These may be relevant when assessing the
impact of any policy involving HHR planning.
Supply
Supplying human capital with the appropriate expertise so
as to enable workers to perform and satisfy the demand for
health care is no simple task. The time and effort required
to equip HHR, especially physicians and advanced nurse
practitioners, exceeds that of most other professions. In
some particular health-care professions, the set of nec-
essary skills to qualify for medical practice is acquired
through extensive academic learning which involves the
enrolment in long courses that may take up decades to
complete due to a strict licencing process.
A considerable amount of HHR studies focus solely on
this approach, basing their research on the estimation of
the expected supply of physicians by accounting for the
intakes, exits, migrations and population growth in order
to maintain the present ratio of practitioners, using “stock-
and-flow” models for that purpose [3]. The analysis of the
medical training process is relevant but may be insuffi-
cient, as several other factors may affect the efficiency and
effectiveness of the care services delivered.
Despite the limitations, some measures to overcome
imbalances in the quantity (number) of physicians and
nurses have already been identified in the health policy
literature [17, 21], namely the following: increasing the
number of domestic- and foreign-trained medical grad-
uates or increasing the number of medical schools and
classroom sizes; increasing the enrolment limits (numerus
clausus); reducing the requirements for entry to medical
schools; raising the wages of the medical staff, as well as
the perspectives for their future career path; or reducing
the costs of attending medical school, which may encour-
age potential students to enrol. In Table 3, we provide a
more extensive list of policies to cope with a shortage in
the number of health workers. These proposals are short-
term measures to alleviate the immediate stress put on
the health-care system triggered by an undersupply of per-
sonnel and may not be suitable for tackling long-term
imbalances due to huge shortages or surpluses of medical
staff.
Still within the scope of supply, other approaches for
handling the problem of insufficient human resources
have also been suggested, addressing the problem from
Table 3 Health policy options for targeting health workforce
imbalances and alter health-care outcomes (adapted from [17]
and [86])
Field Policy option
Education Increase numbers of new students
Recruit foreign graduates
Recognize previous learning
Improve curriculum content
Regulatory Recognize overseas qualifications
Introduce temporary employment
regulations
Subsidized education for return of
service
Enhanced scope of practice
Different types of health workers
Financial incentives Increase trainee salaries
Raise wages
Provide non-wage benefits
Introduce incentives for return of
skilled migrants
Establish retirement policies
Employ lay health workers
Professional and personal support Better living conditions
Safe and supportive working
environment
Career development programmes
Public recognition measures
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 5 of 19
an angle besides medical training. For instance, the com-
position of the core competences and activities of the
physicians, the skill mix, may be reorganized to enhance
the roles performed by the clinical staff, relieving them
from tasks that could be safely assigned to other health-
care professionals [22]. This strategy does not require a
change in the number of physicians but the restructuring
of the available human resources and medical compe-
tences. Complementarily, supporting policies and reforms
that enhance the productivity, that is, the ratio of out-
put per unit of input given a certain level of technology
and methodology, of the medical staff may result in an
increased outcome that also does not require a change
in the quantity of labour workforce [23]. Assessing the
productivity of the clinical staff is now quite common
[24], and operations research applied to the improvement
of patient flows, queueing, master surgery scheduling,
ambulance fleet management and staff rostering may play
a very important role in increasing current levels of pro-
ductivity. In summary, the initial focus of supply-based
methodologies was on the training process. As of late,
more focus has been given to the productivity and to the
skill mix of the labour workforce as well.
Methodologies for modelling supply
Training (entries and losses) The purpose is to model the
training process so as to predict the number of entrants
in each year. This way, and in combination with migra-
tory flows, mortality, exit and drop out rates, it becomes
possible to estimate the number of physicians and nurses
available for each year, with everything else held constant.
Productivity The productivity of the medical workforce is
not constant, as some professionals work harder or better
than others or simply because there is an excess of bureau-
cracy to comply with. Without touching on the quantity
of professionals, it is possible to reorganize services and
incentives so as to promote increased productivity or
implement lean and operations research recommenda-
tions to significantly improve the output and outcome of
the workforce.
Skill mix Since a degree of interdisciplinarity exists
between medical professionals, it is possible to reassess
the tasks performed by each professional, relieving physi-
cians from day-to-day bureaucratic routines or review-
ing the competences of the nursing profession so as to
broaden their scope of action. Horizontal substitution
(between different medical specialties) and vertical substi-
tution (between different working classes) can be used to
improve the amount of health-care services provided.
Worker-to-population ratios This method establishes a
desired ratio for the number of physicians and nurses per
unit of population and compares it to the actual ratios.
Policies to increase or decrease these ratios may then be
pushed forward. Although simple and easy to apply as
long as data is available, the method lacks the fine detail
of such a complex system, ignoring other factors such as
needs, demand or institutional frameworks that may have
an influence on the productivity of countries or regions
with similar worker-to-population ratios. Moreover, it
abstains from exposing the causes for such asymmetries or
from evaluating the efficiency of the available workforce.
Demand
Demand for health care is a derived demand [25], which
means that people do not seek health care services as a
final good for consumption but as an intermediate service
allowing them to be healthy and to improve their stock
of health capital (well-being). They want to improve their
health, and to do so, they seek health-care services. As
in other markets, the determinants of aggregate demand
for health-care services are population size, income and
preferences. Moreover, for countries where medical care is
mostly an out-of-pocket expenditure, demand is restricted
by the patients’ ability to pay. If a patient requires medical
attention and is unable to finance it, this need for health
care will not translate into effective demand, despite its
existence. Accounting for these cases is especially impor-
tant in countries where health care is not publicly subsi-
dized or where there are obstacles to entry other than the
availability of resources.
The concept of needs in health care is not consensual
in the health literature, with a semantic confusion arising
from its use in health economics [13, 26]. While the eco-
nomic or effective demand translates the actual, observed
demand, usually measured in terms of service utilization
ratios (such as bed occupancy rates, number of inpa-
tients), the needs component tries to fully encompass the
epidemiological conditions that characterize a given pop-
ulation, measured through morbidity and mortality rates
or by the opinion of a panel of experts, and how that
may translate into a given quantity of required health-care
services. Therefore, we see that the classical concept of
economic demand may not reflect the biological needs of
the population, as it may leave out the necessities of the
population regardless of their ability to pay. In the needs
component, the emphasis is on the medical conditions
that may lead to demand for health care, deriving from the
evolution of chronic diseases, prevalence rates and over-
all morbidity patterns. This distinction is better illustrated
in Fig. 1, where we present the case when all demand is
met, at a given price, and equilibrium is attained. The-
oretical demand, projected strictly in terms of biological
needs without a budget constraint (either households’
income or public budget), may not always correspond to
the demand effectively observed. The reason being that
the quantity sought is limited by the disposable income
directed towards out-of-pocket health expenditure or by
limits to the government budget that is allocated to health
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 6 of 19
Fig. 1 Law of supply and demand applied to health services. The
health-care market depicted in terms of supply and demand, with a
tentative distinction between potential and effective demand
care. We draw the distinction by plotting both the curve of
needs (potential demand), corresponding to a no gap sce-
nario, and the economic (effective) demand that is actually
observed.
Although needs is a fundamental concept, it should not
be decoupled from economic demand, as it should not
ignore the budget constraints of the economy. In fact, the
country may not have the ability to provide all the health-
care services presumed to fully satisfy needs. If the area
delimited by B (cf. Fig. 1) is larger than the domestic prod-
uct of the economy, it will be impossible to meet all the
perceived health-care needs of the population. Like any
other problem involving scarce resources, a serious anal-
ysis should not abstain from recognizing the existence of
financial impediments. Conversely, it should try to quan-
tify needs, serving as a theoretical benchmark for the
future.
This has not always been the case. Some studies esti-
mate demand solely based on the current level of service
in relation to future projections of demographic profiles
[27, 28], thereby leaving out an important determinant of
demand, the epidemiological needs [29, 30]. When and
how disease trends evolve is critical to properly anticipate
the needs of the population, a proxy to the expected future
demand. For instance, chronic diseases have been increas-
ing globally [31]. China, a country usually not associated
with overweight and obesity problems, has experienced
an upsurge in type two diabetes. According to the data
reported, in 1980, less than 1 % of Chinese adults had
diabetes, but by 2008, the prevalence of the disease had
already reached 10 % of the population [32]. As a result, it
is expected that more endocrinologists will be necessary
to assist with the treatments. The raw definition of needs
is not subject to any boundaries other than those set by
epidemiological constraints and medical advances.
A substantial part of the studies targeting supply hold
current demand constant, thereby leaving out a proper
analysis of what drives demand for health care. In fact,
a change in the factors that influence demand or the
emergence of new health conditions in a population may
require a reorganization in the quantity, composition and
skill mix of the medical workforce to ensure that all sup-
ply meets demand. This suggests that targeting the right
number of people and the right skills depends as much on
the health conditions and epidemiological characteristics
of a given population as on the supply of physicians and
nurses [33].
In summary, three methods are commonly used to anal-
yse HHR planning from a demand-based perspective [13].
Most of the methods build upon the definitions of needs
and effective demand, and some overlap in their scope of
application. Contrarily to the approaches found in supply-
based methodologies, where the object of study remains
the same and alternative analytical methods are employed,
in demand, opting for a different method may change the
scope of the analysis.
Methodologies for modelling demand
Needs (or potential demand) This method determines the
effect of health diseases, epidemiological patterns and
overall mortality and morbidity rates in the demand for
health services and obtains an approximate number of
personnel hours required to cover those needs. Needs are
usually assessed by a panel of experts in epidemiology and
may not match the services that the public wants.
Economic (or effective demand) In this method, we look at
the services actually contracted by the population, subject
to the usual economic constraints that may put an upper
bound on the quantity solicited. In sharp contrast to the
first method, effective demand may not imply a healthy
population, especially for poor countries without a sub-
sidized health-care service since the general citizen lacks
the means to obtain health-care services. The method
ignores needs or wants and assumes that all the remain-
ing variables remain constant, although that requirement
may be relaxed by complementing the results with other
methods.
Service targets Service targets extend a needs-based
approach by incorporating other measures, such as con-
sumer needs, in order to establish service-target ratios
to be accomplished. Service-target approaches decouple
the multiple areas of health-care services and proceed
with an independent analysis of each subsystem, with
the main advantage being a more detailed proposition of
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 7 of 19
the changes required, with separate recommendations for
distinct areas.
Evolution of the field
Although the health workforce has long been a concern
to policy makers, including those of ancient Rome [34],
the first academic research articles discussing manpower
planning in general, and health-care workforce planning
in particular, date back to the 1950s. This was a natu-
ral response to both the creation of national health-care
systems and universal insurance schemes.
A universal health-care system with no exclusion based
on preconditions and with no restrictions on access, an
idea put forward by Bismarck in the compulsory social
insurance form, and promoted by Beveridge as a national
health service [35], requires a well-prepared and readily
available team of physicians, nurses and administrative
staff. To ensure that services are in fact provided, public
medical universities were created along with subsidized
access to medical training. These reforms resulted in the
emergence of a national ecosystem of health-care suppli-
ers and a pool of patients, a significant change from the
decentralized network of health-care providers. The ubiq-
uity of access required providers to be distributed evenly
so as to satisfy the needs of the population.
After this period of sustained and prolific economic
growth, a period of crisis followed. Expectably, the eco-
nomic slowdown put the focus on efficiency, towards a
better use of the available resources. During this period,
many developed and developing countries experienced
shortages of health-care providers, mostly nurses [36],
justifying the growing interest in this newborn academic
research field.
This was the period when the first articles on health-
care workforce planning emerged. We separate the analy-
sis of the unfolding of HHR planning into three separate
stages, corresponding to the evolution of how the health-
care worker is perceived as an object of study [37]: (a)
the health worker as a production factor, (b) the health
worker as an economic factor and (c) the health worker as
a necessary resource. This structure is helpful in the sense
that it exposes the role given to the workforce, once stud-
ied as an inorganic fixed-input factor and more presently
viewed as a complex and necessary resource with its own
idiosyncrasies like any other economic agent.
First phase: factor of production
The first articles published on the subject date back to
1950, with HHR planning being perceived as a production
function, where the labour workforce is an input factor.
The research, triggered by general health worker short-
ages in developed countries [38, 39], led a growing and
diversified body of research that diverged into different
approaches. Not surprisingly, some of these articles are
the result of initiatives promoted by governments and
international organizations to address their own domes-
tic shortages of physicians and nurses, while others are ad
hoc contributions of attentive researchers keen on provid-
ing an insightful contribution. The techniques employed
vary from descriptive to predictive or merely comparative
techniques and usually involve econometric regressions,
static tables, linear programming or benchmarking. These
techniques are then applied to the areas of analysis previ-
ously described, either supply, economic demand, needs
and service-target or worker-to-population ratios, which
we will identify next.
A significant part of the research papers produced
at that time are well-documented, with comprehensive
lists and reviews of the models developed still available
[40, 41]. Of these, we highlight those that are still cited in
the literature and available online.
Supply-based methodologies
The very initial concern of those conducting HHR plan-
ning was estimating the necessary number (head count)
of medical professionals to either maintain the current
worker-to-population ratios or reduce/increase it if an
imbalance was found. One of the first insights into the
evolution of the supply of physicians was done by crossing
the observed physician-to-population ratios along with
the posited population growth in the United States of
America, by that time impulsed by the “baby boom” and
by an expected increase in the use of medical services.
The people in charge of HHR planning evaluate the num-
ber of physicians required to maintain the ratios given
those demographic and economic changes [42, 43]. In
the report, the same criterion is used to estimate future
manpower requirements for all the available medical spe-
cialties, nurses and miscellaneous professions necessary
for due operation.
One way of doing so is to look at the current stock of
professionals and factoring in negative and positive flows
that affect the stock. Factors such as mortality, migra-
tion or retirement generate losses to the current work-
force stock. Likewise, entries from medical schools and
immigration increase the current level of professionals.
Models that map this structure are commonly known as
“stock-and-flow”. Despite not using this specific terminol-
ogy, models created at the time already incorporated the
idea of increases and decreases in the current stock due
to exogenous factors and then used that information to
obtain projections [44–46].
Focusing particularly on the supply of nurses in the
United States of America, other papers proceed with an
analysis of the economic factors, namely the hourly wage
and the wage of the nurse’s spouse and the effect on the
supply of nursing professionals [45, 47]. Evidence sug-
gested that hospitals exercise monopsony power, which
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 8 of 19
has an impact on how a supply gap may be tackled.
Moreover, results also suggest that the cost of paying
wage incentives to increase working hours is considerably
smaller than the cost of training additional profession-
als, something to take into consideration when evaluating
HHR reforms.
The product of this novel research was tested in the
field. For instance, in the analysis of the health-care work-
force in Taiwan, estimates for the supply were generated
on the basis of retirement, migration and death rates
applied to graduations. They incorporate the training pro-
cess and its effect on the supply of physicians [48].
Methodologies: Training (entries and losses) [42–46, 48],
Productivity [45, 47], and Worker-to-population ratios
[42, 43].
Demand-based methodologies
One of the first publications in the field of HHR planning
starts by differentiating the aforementioned dimensions
of workforce planning [49]. Klarman et al. argue that,
although medical needs could form the basis for determin-
ing workforce requirements, it cannot be decoupled from
economic costs, an active constraint to the extent, scope
and applicability of reformist policies. A forecast of the
necessary supply of physicians is not provided, but it is
suggested that the shortages in the specialty areas may be
a sign of an overall supply shortage.
Another way of predicting the necessary future hospital
beds is by extrapolating from a set of factors assumed to
drive the demand for health care, namely socio-economic
factors and biologic needs, measured through morbidity
rates [50]. This approach was also used to estimate hospi-
tal bed requirements, providing both empirical works on
real data for the United States [51] and theoretical frame-
works with hypothetical parameters [52]. In some cases,
the approach of forecasting bed requirements would be
extended to other health-care units such as primary med-
ical care, nursing home care, consultant medical care
(medical care provided by a physician with specialized
training), hospital care or domiciliary care [52].
Methods for estimating the number of professionals
required (head counts) from a demand perspective also
started emerging at around this time. For instance, in one
case, estimating the number of necessary physicians for
the future was done by calculating the number of profes-
sionals necessary to close the gap between observed and
unattended demand, where demand is measured in terms
of utilization. In this case, using service-level indicators
again for the United States [53].
In other studies targeting the U.S.’s health system, the
influence of exogenous variables such as age, income and
urbanization is used to extrapolate the effect of dependent
variables on health policy and HHR planning, includ-
ing the number of persons with health insurance, the
number of general practitioners, medical specialists, avail-
able short-term general hospital beds, admissions and
mean duration of stay per case [54]. This approach is
also similar to the one used in two other models, the
first using data aggregates to facilitate HHR planning at
national, state and substate levels and the second going
to the level of detail of the individual and his interactions
with professionals and institutions [46].
More comprehensive approaches to estimate economic
(effective) demand were also addressed. Some papers sug-
gested incorporating indicators such as an increase in
population, economic development, improved education,
a change of supply, age distribution and other unpre-
dictable factors. Simple calculations, such as the ones used
in the former Soviet Union, could be performed by extrap-
olating based on observed norms of practice regarding the
number of patients attended and then complemented with
basic biological needs by incorporating data about mor-
bidity and mortality rates [44]. Methods like this were then
applied to countries such as Taiwan, characterizing cur-
rent public and private sector demands for health services
[48].
Another option for measuring demand also elaborated
during this time consisted of using other indirect indica-
tors, namely short-stay services, services of nervous and
mental hospitals, physicians’ services outside hospitals,
dental services and other health services. The data is then
fed into a model that tries to minimize the gap between
the number of individuals employed in medical services
that attend to the demand for personnel in that occupation
[53]. Estimates were generated for the United States.
Finally, it should be noted that attention was constantly
being drawn to the importance of prevailing morbidity, a
basic indicator for assessing medical manpower based on
a needs-based approach. Some authors stress that it is the
hospitals and their internal need for residencies that actu-
ally determine the number of specialties [55]. This may
not reflect with accuracy the actual needs of the popula-
tion since patients could potentially remain unattended or
in long waiting lists, but it is an insightful indicator if wait-
ing lists are also factored in. Finally, they also consider the
specialty of the physicians’ role, warning that general prac-
titioners fulfil key medical functions and should not be
relegated to second place. The concept of skill mix, despite
not formally and explicitly defined, is here put in evidence.
Methodologies: Needs (potential demand) [44, 46, 48–
50, 55], Economic (effective demand) [44, 46, 49–54], and
Service targets [46, 53].
Second phase: economic agent
The first phase of HHR planning was characterized mainly
by an aggregate analysis of the health-care market, with
independent and/or cross-analysis of supply and demand.
Reviews produced at that time refer essentially to needs-
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 9 of 19
and demand-based approaches, as well as simple worker-
to-population ratio benchmarks [56]. The phase that
starts in the late 1970s and goes onward through the 1980s
and 1990s redefines the role of the HHR, previously seen
as an homogeneous input factor, into a complex economic
agent [37]. The adoption of such perspective broadens the
scope of analysis, namely by assuming that health-care
workers react to economic incentives.
The deepening of the analysis is done through the appli-
cation of microeconomic theory to the study of health
labour workforce, thereby exposing dimensions that had
gone unnoticed when looking only at the aggregates,
although a macroeconomic analysis continued to take
place [57]. It was triggered by two macroeconomic obser-
vations occurring at this time [37]: a perceived oversup-
ply of physicians and nurses [58–60] and an upsurge in
health-care expenditures [8]. During this phase, atten-
tion was given to topics such as health worker licen-
sure [37, 61], information asymmetry distortions [62] and
its potential repercussion as an unnecessary increment
in demand induced by health suppliers [63] and health
worker performance and productivity [64]. Furthermore,
HHR planning became a major concern in related fields,
such as dentistry [65].
Supply-based methodologies
Although the previously mentioned topics are of notable
relevance, some have no direct utility in the elaboration
of projections and forecasts of future health-care needs,
serving only for policy guidance. For that reason, we
will concentrate our efforts on the performance and pro-
ductivity of health workers, a method fully within the
umbrella of supply. In terms of policy, it is less demanding
to put in practice as it does not require structural changes
to the training process or to medical schools. In theory,
more people can be served with the exact same amount
of human resources if only their productivity increases.
Improving the efficiency of the available pool of resources
is therefore an attractive methodology.
This is the line of research followed in a paper where
a microanalysis of the factors that may influence the out-
put (and therefore productivity) of the health workers is
conducted, in particular nurses in the United States [47].
Sloan et al. found that there is a strong supply response
to the hourly wage. Raising the hourly wage is, in fact,
their proposal to respond to a short-run supply shortage,
arguably a quicker response than changing the number of
intakes to nursing schools. Taking another route to reach
the same goal, one study tries to undercover job satisfac-
tion indicators and perceived productivity in 24 hospitals
for a staff nurse population [66]. The purpose is to under-
stand the factors that may raise productivity but also to
find a connection between job satisfaction and the quality
of care provided. Similarly, waiting and distance times can
also be used to assess the physicians’ productivity, a study
conducted using data from the United States [67].
In the same line of research, some authors conducted an
observational study of 56 physicians in order to uncover
the factors that may influence productivity, measured as
the ratio between the number of patients seen per physi-
cian and the time spent with the patient [24]. The main
research question was understanding which factor con-
tributed the most to the variance in productivity: the
patient or the physician. Results suggest, according to the
study conducted in a Veteran Affairs’ medical centre in
the United States, that the individual physician explains
the variations in productivity observed, with the actual
patient playing a minor role. Similarly, in another study
also conducted in the United States, the productivity of
physician assistants and nurse practitioners and their role
in the health-care workforce is analysed [68]. Scheffler
et al. find that these two categories of health workers
could have a significant influence on the future health-
care workforce if some vertical and horizontal substitu-
tion occurs and tasks are delegated. Note that the change
of setup hereby suggested tackles productivity from a dif-
ferent angle: instead of raising the output, the inputs are
altered.
Methodologies: Productivity [14, 24, 47, 64, 66–68] and
Skill mix [68].
Demand-based methodologies
Studies focusing solely on the demand side produced dur-
ing this phase are considerably less common than in the
first phase. The ones that do so are more concerned with
the lack of attention given to the importance of biologi-
cal needs. It is interesting to note that, at the turn of the
decade and in subsequent years, a lot of emphasis is again
put on the needs of the population. Some authors sug-
gest a needs-based evaluation as a requirement to produce
accurate forecasts [29, 56]. This option contrasts with that
of other authors, which propose using benchmark as a
viable alternative to potential or effective demand projec-
tions [69]. The work developed consisted of comparing
the number of active physicians per capita in the United
States, adjusted for population differences between simi-
lar locations, without uncovering the causes for the given
asymmetries.
Assessing the needs of the population was also the
method of choice in the dentistry field to calculate oral
health workforce requirements. In particular, needs were
projected by the amount of oral care, including preven-
tive, special group care, surgical, orthodontic, periodon-
tal, restorative and prosthetic, that different age cohorts
would require [70]. Then, the time necessary to treat each
of these conditions is estimated, and the number of den-
tists to perform those tasks is derived. Also applied to
dentistry but with a focus on the skill-mix distribution,
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 10 of 19
productivity changes are estimated by examining role sub-
stitution in dentistry [71], helping to conduct evidence-
based scenario analyses in The Netherlands.
Methodologies: Needs [29, 70], Skill mix [71] and
Worker-to-population benchmarking [69].
Integrated methodologies
A new strand of the literature also emerged during this
phase covering supply while at the same time consider-
ing projected changes to demand. In a review of supply
projections conducted both in Canada and in the United
States [14], the authors argue that the traditional supply
projection methodology that characterizes the licensure
cycle and productivity metrics is incomplete if unmet
needs of the population are not defined and included as
a clear research goal, as well as economic, financial or
infrastructure resource constraints.
The integrated approach is also present, for instance,
in the implementation of the “System for Health Area
Resource Planning” (SHARP) [72]. This analytical frame-
work combines all the major methodologies: it includes
the socio-economic factors that drive economic demand,
morbidity and the remaining epidemiological factors that
drive needs, the formation process of the health-care
supply of workforce and utilization rates in order to incor-
porate the current use of health-care services. The frame-
work was successfully used to support HHR planning in
Canada, especially in the province of Ontario, reinforcing
the idea that an integrated or systems approach, combin-
ing the multiple facets of the problem, is the way to go in
the future.
Methodologies: Integrated [14, 72].
Third phase: fundamental resource
In this phase, the notion of health labour workforce is
reformulated, this time viewing it as a necessary resource.
From the 1990s onto the 2000s, the emphasis is on the
regional asymmetries in the placement of the workforce
and in the migration flows from developing to developed
countries [37]. All models proposed include both supply-
and demand-based methodologies to tackle the problem.
Integrated methodologies
Methodology-wise, the trend observed is a continuation
of the second phase, with the call for a holistic approach
to the problem. HHR planning must be addressed from
an integrated perspective, including when analysing all
the blocks of the functioning system so as to calcu-
late the current and future gap between supply and
demand [73]. The authors’ proposal is in line with the
SHARP framework: modelling key demand (economic
and epidemiological) and supply inputs. Furthermore, it is
continuously stressed that the epidemiological drivers of
the need for health-care services should always be part of
HHR planning [30, 74].
When looking at the research literature produced at the
turn of the century, this trend becomes clear. Summing
up the results achieved so far, we can see that health-
care workforce planning is a complex endeavour, and it
becomes necessary to identify all the relevant variables to
accurately forecast the necessary resources for the future
[75]. Again, these variables relate to supply and needs
methodologies. A practical work conducted in Lithua-
nia to forecast family physicians for a 10-year timespan
employs this approach [76]. Firstly, this approach calcu-
lates the supply of physicians through the usual process of
modelling the training of physicians. Moreover, it crosses
the supply forecasts with three different projections for
demand: firstly, the requirements established by a panel of
experts using a Delphi technique; secondly, the resources
necessary to increase the number of visits; and thirdly,
an upper bound placed on the worker-to-population ratio
so that one family physician serves no more than 3 000
inhabitants. The conclusions reached suggest that the
well-informed panel of experts elaborated the most accu-
rate projection of demand for family practitioners and that
none of the supply projections was right on target. Simi-
larly, in a forecast analogous to the nursing profession in
Germany, the analysis is extended from the usual supply
and demand to include the effects of occupational flexibil-
ity and employment structure. Adding these two elements
to the analysis has a relevant influence on the projections
[77]. Notably, this pensiveness with the organizational
role, where the HHR is more than an aggregate number
but rather a dynamic and complex sum of individuals, is
clearly gaining traction.
In the same line, some researchers suggest a needs-
based analytical framework that incorporates input from
four separate elements: demography, epidemiology, stan-
dards of care and provider productivity [30], again falling
in the realm of integrated approaches. Alternatively, needs
can be decoupled in a functional form so that service
targets can be defined and deployed [1]. Dreesch et al.
claim that methods focusing strictly on the supply, on the
demand or on both fail to address or recognize the effects
of the skill mix (the potential of substitution) between
health professions. The importance of a more integrated
approach to HHR planning is also restated. With more or
less variables, the trend is clear: recent models use infor-
mation from both demand- and supply-based method-
ologies, including inputs as varied as demography, the
training process, workers’ productivity or biological needs
in order to generate their forecasts [18, 78, 79].
Although the emphasis is fundamentally put on address-
ing the problem from an integrated perspective, new
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 11 of 19
strands of literature were also developed during this
phase. For instance, it is suggested that instead of
addressing the problem from a quantitative perspective,
either by adding to or subtracting from the stock of health
workers, it should rather be addressed with internal reor-
ganizations, redefining which tasks can be performed by
whom [80]. Such internal substitution and activity dele-
gation could be executed by transferring skills from the
medical specialist and the general medical practitioner
to other health professional roles, namely nurses with
higher education (midwives) or by creating new roles.
This methodology involves, therefore, playing with the
skill mix of the health-care professionals. This was put in
practice in Ireland by employing a model that targets both
supply and demand, reflecting the concerns for including
all parts of the system [28, 81]. Moreover, it tests four pol-
icy interventions, three of which related to supply and the
last related to the skill mix: increasing vocational training
places, recruiting professionals from abroad, incentivizing
later retirement and increasing nurse substitution so that
nurses can deliver more services. Similar studies, encom-
passing the workforce supply, demand and the skill mix,
were also conducted in the dentistry field during this
phase [82]. In this case, workforce supply and demand for
oral health needs are projected to study the impact of skill-
mix reorganizations. To forecast future dentist numbers,
a simple percentage increase based on previous yearly
increases is considered. To estimate demand, demogra-
phy evolution, rates of edentulousness, patterns of dental
attendance and treatment rates of older people, as well
as general dental service treatment times, are considered.
The effect of the skill mix is then studied considering sev-
eral scenarios of varying skill-mix use. Gallagher et al. find
that widening the skill mix can be extremely helpful to
build capacity for dental care.
Another concern that is raised during this phase is that
of measuring the outcome as an important indicator for
assessing the quality of the health-care services. The out-
come is a fundamental indicator for HHR planning. In
particular, equitable and timely access to health care are a
precondition to a good outcome, which is the variable to
be maximized [83].
In summary, it can be said that this stage was a phase
of settling with methodologies, namely supply-, demand-
and needs-based approaches, and of urging for a more
integrated approach while paying attention to the roles
of each health professional and the degree of substitution
between professions. Furthermore, a concern about the
outcome of health-care services was raised, where effec-
tiveness and quality of the treatment is considered on par
with the number of patients seen (productivity).
Methodologies: Integrated [18, 18, 28, 30, 73–79, 81, 82],
Skill mix [1, 28, 77–82], Needs [30, 77], Service targets [1]
and Productivity [77–79]
Discussion
Five decades of work in HHR planning fuelled by eminent
global shortages of health professionals have contributed
to establishing this research field as an important scien-
tific area, decisive for achieving worldwide health-care
targets [1]. Significant results have been attained. In par-
ticular, new methods and techniques were developed, and
the accuracy of projections improved remarkably [23], and
HHR planning became an area of prominent interest, with
the number of publications in the field increasing over
the years. Moreover, the literature evolved, replacing some
approaches with others, paying more attention to the
health-care workers and their productivity and to the del-
egation and distribution of skills. It prioritized integrated
approaches and the role of epidemiology in addressing the
problem. In fact, when we look through all the methodolo-
gies reviewed (Fig. 2), the emerging trend clearly supports
this claim. Integrated approaches are gaining ground after
decades of partial analyses turning to either a supply- or
a demand-based approach and in its simplest form only
resorting to worker-to-population ratio benchmarks.
In Table 4, we summarize the methodologies and
describe the necessary assumptions for using each of
the approaches, along with their advantages, limitations,
how these limitations are overcome, requirements and the
countries in which their usage was documented (accord-
ing to [9]). In the past, this overview would probably help
in choosing the methodology to adopt. With the call for
more integration, it assists in showing how a methodology
may fill in the gap towards a cohesive framework. Also,
it serves to show that there is no perfect methodology
capable of providing accurate forecasts without consider-
able pitfalls and that there is a trade-off between simplicity
and completeness, where going for a simpler methodology
may implicate leaving out important parts of the problem.
An integrated approach
The importance of a comprehensive, integrated approach
is continuously emphasized throughout the period in
review [3]. Although the need for an integrated approach
had already been stressed in several past publications, it
keeps on reappearing, suggesting that it might not have
been fully addressed as of yet. This approach faces many
challenges. A dynamic, system-level perspective covering
key drivers of supply and demand that includes both man-
power planning and workforce development is critical to
overcome such challenges [81]. The importance of paying
attention to needs is also continuously stressed, as changes
in the health patterns of the populations take place [84].
In summary, integrated approach refers to a method that
incorporates in its process projections of the workforce
supply and the impact of microeconomic and organiza-
tional changes in productivity and in the skill mix, of the
evolution of demand for health-care services and also of
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 12 of 19
Fig. 2 Identification of the conceptual methodologies found in some of the literature for the period of 1950–2013
the evolution of health diseases and its potential impact
on the health system.
Notwithstanding, integrating all the pieces may be a
puzzling task. To assist with the task, in Fig. 3, we pro-
vide a high-level functional diagram with a proposal for
how methodologies could be coupled so as to turn it into
a seamlessly integrated system. On the supply side, we
have the current stock of workers along with the training
process so as to obtain an initial snapshot of the cur-
rent workforce. The current stock, which may or may not
be enough to tackle current demand, in which case an
imbalance exists, is subject to positive and negative flows
that may alter its number and composition. This given
quantity of workers may provide more or less health-care
services depending on their productivity and skill mix,
and that influences the conversion from head counts to
A
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Table 4 The methodological approaches established during the first phase of research
Methodology Description Assumptions Advantages Limitations Overcoming
limitations
Requirements Documented
usagea
Supply
Training Projects the availability of
health-care professionals
based on the current stock
of clinicians, the training
process (entries and
dropouts), migration flows,
attritions and retirement
rates
Demand for medical
services is assumed to
remain constant and
the projections are
used to reduce the
supply gap
Predictions for the
future supply can
be obtained in a
fairly simple and
immediate way
Demand for medical
services is assumed
to remain constant,
which may not
be true No critical
assessment of the
adequacy of current
service levels
Incorporate a model of
demand: economic or
needs-based (or both)
Evaluate current level of
service through waiting
lists, overtime hours,
foreign workers, etc.
Accurate and up-to-
date accounting of
the current stock of
physicians and nurses,
migration rates, entry
and drop out rates
and expected retirees
Service usage levels
from the health-care
sector
Australia, Belgium,
Canada, Chile,
Denmark, Finland,
France, Germany,
Ireland, Israel, Japan,
South Korea,
Norway, Switzerland,
The Netherlands,
United Kingdom,
USA
Productivity Reorganize services and/or
economic incentives to
promote higher
productivity. Work
harder or work smarter
Physicians and nurses
act as rational agents
and react to economic
incentives like wage
increases
Does not require
a change in the
quantity of human
resources. Can be
implemented
immediately
Productivity
improvements may
not be enough to
accommodate large
gaps in the supply of
professionals
Do not preclude from
evaluating the number
of professionals necessary
given different
productivity levels
Operational indicators
like the number of
patients served with a
given number of FTEs
(or head counts)
Australia, Canada,
Japan, Korea,
Netherlands, Norway,
Switzerland, United
Kingdom, USA
Skill mix Delegate certain tasks to
other health professionals.
Substitution can be
horizontal (between
medical professions) or
vertical (between
physicians and nurses)
Professionals can
assume new roles
and perform new
tasks
Does not require
a change in the
quantity of human
resources. Can be
implemented
immediately
Enforcing such
changes can be a
political challange.
Does not solve
large gaps in the
supply
Providing success
stories to involved
stakeholders, health
authorities and
medical associations
Education schools
that can provide
advanced education to
the existing workforce
Netherlands, United
Kingdom
Worker-to-
population
ratios
Specifies desirable worker-
to-population ratios based
on direct comparison with
another region of country
Regions and/or
countries can be
directly compared
Extremely easy to
understand and
apply
Useful for
providing baseline
comparisons
Does not take into
account the intrinsic
differences between
regions and countries,
the productivity and
skill mix of the available
workforce
Does not take into
account the intrinsic
differences between
regions and countries,
the productivity and
skill mix of the available
workforce
Records of the current
workforce to popula-
tion ratios
Chile, France,
Ireland, Israel,
Switzerland,
United Kingdom
A
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Table 4 The methodological approaches established during the first phase of research (Continued)
Demand
Economic Estimates future
requirements by
projecting the
effect of demographic and
socio-economic factors on
the current level of
service
Current level of
service is adequate.
Skill mix and
distribution of health
service is appropriate
Demographic profile
of the population and
its effect on health-
care demand can be
accurately forecasted
Conceptually easy
to understand and
to apply
Allows
decoupling of the
various components
of demand and their
influence on the overall
aggregate demand
Tends to produce
estimates of HHR
demand that
exceed practical
limits
No critical
assessment of the
adequacy of current
service levels
Ignores the real
demand,
focusing instead on
the effective demand
Take financial constraints
into consideration
Evaluate current level of
service through waiting
lists, overtime hours,
foreign workers, etc.
Include a needs-based
evaluation
Accurate and long-
term demographic
estimates
Service-usage
levels from the
health-care sector
Macroeconomic
indicators and
statistical data crossing
income and usage
Australia, Belgium,
Canada, Denmark,
Finland, Germany,
Japan, Norway,
South Korea,
Switzerland, The
Netherlands, USA
Needs Considers the effect of
epidemiology on the
demand for health-care
services
Projects age- and gender-
specific needs
based on morbidity
epidemiological trends
All health-care
needs can and
should be met
Resources are used in
accordance to needs
Allows for a fine-grained
analysis of the
requirements of
each medical specialty
Is independent of
the current service-
utilization ratios
Easy to understand
Absence of
economic/efficiency
considerations may
render the projections
unattainable
Dependent on
epidemiological
projections which
may not be obvious
Does not consider
the current level
of provision nor
the capacity of the
country to deliver
health care
Consider an upper bound
for a practical result
Consider projections of
the most common health
patterns Incorporate
economic considerations
in the model
Demographic estimates
that are accurate
Service-usage levels
from the
health-care sector
Belgium, Canada,
Germany, United
Kingdom
Service targets Defines normative targets
for the production of
health-care services, which
are then converted to HHR
requirements
Assumes that
established service
targets are
achievable in terms of
financial and
physical capital
resources
Easy to define, interpret
and understand
Facilitates cost
estimation
Requires modest
data and planning
capabilities
May originate unrealistic
assumptions
Ignores financial
and other active
constraints
Incorporate economic
considerations in the
model
Current level of
service
aOECD Report
Source: adapted from Hall and Mejia [13], O’Brien-Pallas [11] and Dreesch [1]
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 15 of 19
Fig. 3 An integrated system that incorporates several methodologies to address the many facets of HHR planning
full-time equivalents (FTEs). Such conversion is critical to
properly assess the health-care workforce, as a significant
number of physicians and nurses work part-time only. For
this reason, FTE is a more accurate measure as it nor-
malizes the head counts. On the demand side, economic
(effective) demand can be initially measured by analysing
utilization indicators. How this demand will evolve in the
future will then be subject to typical economic factors
such as demography and the growth of the income/GDP.
In parallel, potential needs can be assessed by incorporat-
ing incidence and prevalence of diseases and then map-
ping a given disease to an estimate of FTE requirements.
Whether future supply forecasts should tackle all of the
estimated needs is a decision left to the consideration of
the policy maker, as this analysis does not incorporate
financial constraints. Such an integrated approach is more
complex, but not necessarily more difficult [12]. In fact,
policy-making cannot abstain from factoring in financial
and service planning considerations in a post hoc analysis,
since there may not be enough resources to accommo-
date for a sudden increase in the number of professionals.
Such analysis is not limited to a money perspective, to
the financial burden inputted on the system for educating
and hiring these medical professionals or to the installed
capacity in terms of medical schools, university hospitals,
hospital beds, primary care facilities and others, in order
to absorb planned increases in the health-care services
labour market.
Data requirements
None of these methodologies can be applied without the
adequate data to feed the model. A bare minimum of
information regarding the available medical workforce is
always required. Table 5 summarizes the most impor-
tant indicators for conducting a proper forecast. It is not
strictly necessary to possess all the information listed, but
the availability of the data increases the probability of a
more comprehensive projection.
Simpler approaches require fewer data. Worker-to-
population ratio benchmarks require a head count of
the number of licensed medical professionals, usually
made available by the government, medical and nurse
associations or by unions. Service targets use the cur-
rent level of service, which can be obtained from the
hospitals’ operational key performance indicators.
Needs
(potential) and economic (effective) demand, on the other
hand, require a more extensive set of indicators. For
needs, it is necessary to assess and validate current and
future incidence and prevalence of diseases and how that
may convert into necessary resources. Both tasks are
not straightforward and usually require acclaimed experts
in epidemiology to step in and provide both the esti-
mates, as well as an accounting of the resources that
will be necessary. Effective demand makes it necessary
not only to obtain metrics similar to those indispens-
able for a service-target analysis (such as the number of
inpatients and outpatients, number of occupied hospital
beds, average length of stay) but also demography and
socio-economic projections and how they affect demand.
Finally, modelling supply is also a challenging task in
terms of data requirements. Unless evidence is found
showing that the worker-to-population ratios will remain
constant for a long period of time, a supply-based anal-
ysis must be factored in. In such a case, it is necessary
to know the current stock of licensed providers, as well
as the number of intakes, exits and annual attritions,
which makes it necessary to model the training of medical
professionals.
Assuming that developing countries are in possession of
fewer data and that developed countries have more infor-
mation available, methodologies that require an extensive
set of data will be difficult to implement in developing
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 16 of 19
Table 5 Data requirements for making use of each of the different documented methodologies
Methodology Indicators Data requirements
Supply
Stock of licensed providers
Baseline stock, age/sex distribution, growth projections
High
Annual additions to licensed stocks
Graduates, in-migration (foreign-trained, immigrantes, on temporary work permits),
returned to profession
Education/training programmes
Number of programmes and students enrolled, attrition rates, years to complete
programme, number of graduates, costs
Annual attritions to licensed stocks
Retirements, mortality, career changes, emigration, abroad
Productivity
Labour market
Occupational participation rates, occupational employment rates, employment
projections, vacancy rates, turnover rates, wage rates, productivity growth, cyclical factors,
alternative career options
High
Employment status
Full-time, part-time, casual, full-time equivalent (FTE), average hours worked, direct patient
care hours, no longer practising, not licensed in jurisdiction
Skill mix
Government policy variables
HHR education funding, alternative delivery modes, licencing regulations, professional
roles/deployment, recruitment/retention strategies, immigration policy, remuneration
rates/types, HHR capacity-building
High
Worker-to-population ratios
Health labour workforce
Number of active and employed physicians and nurses Low
Economic
Population demographics
Total population, age/sex distribution, births/deaths, population projections
HighSocio-economic variables
Disposable income, GDP growth projections, ethnic factors
Needs
Population health status
Age/sex mortality, morbidity, acuity
HighEpidemiology
Incidence and prevalence rates, hospital discharges, health patterns of the population
Service targets
Utilization patterns
Number of occupied beds, number of inpatients and outpatients, number of
surgeries/screenings/consultations performed, etc.
Low to high
countries. Therefore, such countries may start by using
simple techniques such as the worker-to-population ratio
or service-based benchmarks to tackle their present
imbalances. Developed countries should continue collect-
ing data and enhancing their models, adding less tangible
and yet relevant dimensions, such as productivity or skill
mix if they are not present already.
Conclusion
In this paper, we reviewed over 60 years of publications
in HHR planning. While doing so, we observed the evolu-
tion of the field, when and how methodologies emerged,
how they have been applied and the robustness of the
results, and we also identified the current trends in the
field. This work was called for because there is still no
accepted methodology to address HHR planning. Given
the rampant costs in the health-care sector and the over-
all influence that health care has on the general welfare
of society, as well as the potential impact of shortages on
the worldwide supply of medical professionals, an assess-
ment of what has been done and achieved and what
remains to be done was necessary to properly guide fur-
ther developments in this relevant field. Moreover, when
we contemplate the complex training process required
to earn a licence as a practitioner, we understand that
a shortage in medical professionals cannot be accom-
modated fast enough by decree, either by increasing the
number of intakes to medical schools or by inviting more
foreign-trained doctors or nurses.
Despite the abundance in approaches and techniques to
determine supply and need for professionals, none of the
methodologies has ultimately proved to be superior [85].
Recent studies testing current forecasting models show
that there is still plenty of room for improvement given
the gap between projected and actual results [12].
It becomes even clearer that workforce planning should
be accurate and performed in due time given the attri-
tions and the delays in enacting policies in the health-care
Amorim Lopes et al. Human Resources for Health (2015) 13:38 Page 17 of 19
sector. Adapting medical schools, altering legislation and
changing roles is an effort that may take years to bring
forth. Therefore, planning has to target a long enough
time horizon if it is to be useful and applicable and has to
be done pre-emptively.
It now seems obvious that, like any other complex prob-
lem, all the determining pieces of the system and their
interdependent relationships must be duly accounted for.
Therefore, pressing for integrated approaches is still a
valid and up-to-date concern. Furthermore, envision-
ing the health worker in its entire complexity makes
it possible to address the problem more comprehen-
sively, leaving room to improvements in productiv-
ity and in the distribution of work without having to
directly interfere with the training process or with the
health providers. Operations research and lean manage-
ment are particularly relevant in this area. This strat-
egy may be, in fact, a first attempt to solve the lack of
professionals.
The results of our review point in one clear direc-
tion: accurate HHR planning requires an approach that
is both integrated and flexible, featuring supply and
demand (potential and effective) and incorporating less
tangible factors, such as skill mix and productivity.
The road to accurate HHR planning cannot abstain
from this.
aHenceforth, the term ’approach’ is used loosely to refer
to the conceptual methodology employed rather than to
the technical and scientific apparatus used to obtain a
projection or forecast.
HHR: Health-care human resources; OECD: Organisation for Economic
Co-operation and Development; WHO: World Health Organization.
The authors declare that they have no competing interests.
Authors’ contributions
MAL proceeded with the literature review and drafted the paper, with BAL and
ASA providing guidance, critical assessment and peer review of the writing.
The three authors read, reviewed and approved the final manuscript.
We are extremely grateful to all the reviewers for their insightful comments
and contributions, as they significantly contributed to the improvement of this
paper. Also, we would like to thank several members of the European
Operations Research Society and the scientific committee of the EURO
Operational Research applied to Health, which provided insightful ideas and
feedback on the ongoing work.
1INESC TEC, Faculdade de Engenharia, Universidade do Porto, Porto, Portugal.
2Faculdade de Economia, Universidade do Porto, Porto, Portugal.
Received: 10 November 2014 Accepted: 2 May 2015
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Evolution of the field
First phase: factor of production
Supply-based methodologies
Demand-based methodologies
Second phase: economic agent
Supply-based methodologies
Demand-based methodologies
Integrated methodologies
Third phase: fundamental resource
Integrated methodologies
Discussion
An integrated approach
Data requirements
Conclusion
Endnote
Abbreviations
Competing interests
Acknowledgements
Author details
References
