Establishing a labor rationing system in healthcare. You are tired of labor rationing in health care. Erroneous application of different types of labor standards
Planning methods:
1) analytical method - used to assess the initial and achieved levels when comparing the plan and analyzing its implementation; planned:
– provision of the population with medical and paramedical personnel, hospital beds
– indicators of the volume of medical care (percentage of hospitalizations, average number of visits per inhabitant per year)
- function of the medical office
– hospital bed function (bed turnover), etc.
2) comparative method- an integral part of the analytical, makes it possible to determine the direction of development processes, evaluate various indicators (morbidity, mortality, etc.) in dynamics in space (when compared with similar indicators of other administrative territories) and in time (when compared over a number of years)
3) balance method- ensures the proportionality of the development of the AE between real opportunities and planned indicators, allows you to reveal the emerging imbalances during the implementation of the plan; used in the preparation of intersectoral balances (balances of training and growth of the network of hospitals and outpatient clinics, etc.)
4) expert method– highly professional, independent, but does not always take into account the traditions of the country
5) economic and mathematical method- is used when it is necessary to scientifically substantiate the optimal options for the plan, most often use linear programming, theory queuing and a statistical test method.
6) normative method- the basis for planning the state system of zoning, its basis is the use of norms and standards approved by the Ministry of Health; is used in the preparation of any plan based on the use of the balance method, i.e. in all cases where it is necessary to ensure proportional development. This method is also widely used in the development and execution of the budget and estimates of CA institutions.
Norm- a quantitative indicator of the state of the environment, medical and preventive care, the activities of medical organizations in specific organizational and technical conditions.
standard- a calculated indicator that characterizes the totality of funds necessary to achieve the established norm under certain typical organizational and technical conditions.
The number of beds per 1 medical position is the standard, and the number of physiotherapy units per year per 1 nurse position is the standard.
Rules and regulations can be:
A) social- aimed at meeting the population's need for medical care (provision with general practitioners and district therapists - 1 doctor per 1300 inhabitants, beds - 9 ppm, pharmacies - 1 per 8 thousand inhabitants, ambulance crews - 1 per 2.5 thousand inhabitants ) And economic- aimed at ensuring the financial and economic activities of health care facilities (budgetary expenses for the HC - 170 USD per 1 inhabitant)
B) minimal- reflect the level of the conditions of life of people necessary at this stage of socio-economic development and the need for resources in the AE, below which there is a violation of the normal functioning of the health care system (standards for the need for medical care, specific capital investments in the development of the industry) and Rational- focused on the full satisfaction of the needs of the population and the industry (standards for medical personnel and paramedical personnel).
B) complex– characterize the socio-economic aspects of managing and providing the population with medical care and Private- characterize certain aspects of ongoing processes
The following rules and regulations apply in the ZO:
– by scope: local and industry
– by duration: temporary and conditionally permanent
- according to the method of construction: uniform and standard
– according to the justification method: evidence-based, statistical, experimental, averaged
- by unit of measurement: norms of time, norms of workload, service, number of personnel, material costs etc.
The norms and regulations in the ZO can be grouped into 4 groups:
1. provision of medical services (labor standards, standards for the development of a network of organizations, standards for the cost of medical services)
2. Consumption (wage standards, financing standards for CA)
3. development of the industry (the industry's need for specialists, etc.)
4. sanitary and hygienic (building codes and regulations, maximum standards for the content of substances in soil and air)
Basic principles for the development of norms and standards:
– use the assessment by the population of the degree of satisfaction of needs for the services of the HC system
– take into account public opinion on key issues of development of the zo
– take into account, when developing norms and standards, WHO recommendations and the level of satisfaction of needs for medical care in developed countries
– develop norms and standards not only for the country as a whole, but also for the regions, taking into account the level of medical care, the consumption of medical services by sex, age and professional groups population in the territorial context, as well as the structure of morbidity
Functions of norms and standards:
– analysis of the achieved level of development of the industry and the results of the activities of health care facilities
– planning and forecasting the activities of health care facilities
– control over the use of material, financial and labor resources
- a necessary element of the economic mechanism of the industry for the organization of work on the provision of medical services
7) extrapolation method- used to identify trends in morbidity rates for individual nosological forms, fertility, mortality, etc. in subsequent years, etc.
Territorial Programs of State Guarantees (TPSG) for the provision of medical care to the population determine the types and volume of medical care, as well as the conditions for their provision at the expense of the budget, contain standards for specific volumes of medical care and planned indicators of their financial support, are approved annually by the executive authorities.
The basis of the TPSG is the state-guaranteed volume of medical and drug care, which provides for the provision of quantitatively regulated medical care for the prevention, diagnosis and treatment of diseases, determined annually by the Ministry of Health of the Republic of Belarus in the form of state minimum social standards in the field of health care.
Legislative acts in the preparation of the TPSG:
1. Constitution of the Republic of Belarus
2. Law on State Minimum Social Standards
3. Decree of the Council of Ministers of the Republic of Belarus on the state minimum social standards in the field of ZO (2002)
4. Decree of the Ministry of Health of the Republic of Belarus on approval of the average republican standards for the volume of medical care provided by state organizations to citizens of the Republic of Belarus at the expense of the budget (the number of visits to the polyclinic is 10,600 per 1,000; ambulance calls 260 per 1 thousand, etc.)
5. Instructions for the development and implementation of the TPSG
It is also necessary to know the standards for providing medical care (budget funding standard per 1 person, provision with primary care doctors - 1 per 1300, provision with beds - 9 per 1000 population, pharmacies - 1 per 8000 inhabitants, ambulance teams - 1 per 12.5 thousand inhabitants ), health indicators (morbidity, mortality, disability), financial data.
Structure of TPPG:
2. List of types of medical care provided to the population at the expense of the budget of a particular district
3. Conditions for the provision of medical care to the population
4. Volumes of medical care
5. Duties and responsibilities local authorities authorities and bodies of the
Active Edition from 02.10.1987
| Document name | LETTER of the Ministry of Health of the USSR dated 02.10.87 N 02-14 / 82-14 "ON THE PROCEDURE FOR EXPANDING INDEPENDENCE AND INCREASING THE RESPONSIBILITY OF THE HEADS OF HEALTH CARE AUTHORITIES WHEN APPLYING THE ORDER OF THE MINISTRY OF HEALTH OF THE USSR OF AUGUST 13, 1987 N 955" |
| Type of document | letter, guidelines |
| Host body | Ministry of Health of the USSR |
| Document Number | 02-14/82-14 |
| Acceptance date | 01.01.1970 |
| Revision date | 02.10.1987 |
| Date of registration in the Ministry of Justice | 01.01.1970 |
| Status | valid |
| Publication |
|
| Navigator | Notes |
LETTER of the Ministry of Health of the USSR dated 02.10.87 N 02-14 / 82-14 "ON THE PROCEDURE FOR EXPANDING INDEPENDENCE AND INCREASING THE RESPONSIBILITY OF THE HEADS OF HEALTH CARE AUTHORITIES WHEN APPLYING THE ORDER OF THE MINISTRY OF HEALTH OF THE USSR OF AUGUST 13, 1987 N 955"
Chapter 2
2.1. Working time budget for medical staff
One of the main indicators in the design of labor standards in all types of health care institutions, the analysis of the volume of work of a position is the working time budget.
The definition of the annual budget of the working time of medical personnel has its own characteristics, in contrast to the one adopted in the production sector of the national economy.
When planning the number of workers in the main professions in the industrial sectors of the national economy, their attendance and payroll composition is taken into account and the methodology for calculating the number of employees, that is, the living labor force, is applied to fulfill the planned plan, taking into account all the factors that prevent the employee from being at the workplace.
Labor rationing in health care has its own specifics and is methodically solved according to job principle, according to which the performance of a certain amount of work under certain organizational conditions by one position is provided, regardless of the number of persons who will perform work in this position during the year. This involves working a specific time during the working day and the number of working days in a year. In health care institutions, therefore, it is not the number of living labor forces that is determined, but the number of staff positions.
A medical position is understood as the scope of duties and the specific amount of work of a doctor for a certain period of working time, regulated by the calculated norms of the doctor's workload, the duration of working hours and the duration of vacation. The position, as an indicator of the health plan, is a measure of the volume of the doctor's work in various areas of his activity.
The content of the concept of "medical position" corresponds to the concept of "doctor", as an individual, only if one doctor will perform work in one medical position and the balance of working time for this position will fully correspond to the actually worked working time by the doctor during the year in accordance with the established working hours in accordance with the current legislation.
However, during the year, doctors are absent from work due to illness, in connection with pre- and post-natal leave, caring for a child, sick family members. In addition, medical personnel are often distracted from work related to the provision of medical and preventive care to the population, to take advanced courses and specializations, work in various commissions and at meetings, and perform state and public duties. In these cases, the head of the institution during the absence of the employee has the right to invite another person as his deputy and thereby ensure the fulfillment of the planned scope of work. At the same time, an employee’s absence from work in a healthcare facility does not delay the work of other personnel, and the work itself can be performed on a different shift. At the same time, the absence in many cases of sufficient work to introduce full positions in a health care institution, it allows you to establish fractional parts of it and occupy it with part-time workers. Thus, the presence of part-time employment and substitution, which makes it possible to replace a doctor during his absence on vacation, due to illness and other valid reasons, actually predetermines the difference in labor rationing in healthcare from the industrial sectors of the national economy.
The calculation of the planned duration of working hours during the year of medical personnel is carried out by excluding weekends and holidays, the duration of vacation from the number of calendar days in the year.
There are 365 calendar days in a year, including 52 days off and 8 holidays. Since one of the holidays in the year usually coincides with Sunday, 59 days off and holidays in the year are taken into account. The total duration of leave for health workers entitled to one or more types of additional leave is the sum of the main leave of 12 working days and the duration of the additional leave(s). According to the "List of industries, workshops, professions and positions with harmful working conditions, work in which gives the right to additional leave and a shorter working day" (section "Health"), approved by the decision of the State Committee of the Council of Ministers of the USSR on labor and wages and Presidium of the All-Union Central Council of Trade Unions dated October 25, 1974 N 298 / P-22, medical workers have additional leave of 6, 12, 18, 24 and 30 working days, depending on their position and place of work. In addition, some employees are provided with additional paid holidays in excess of those provided for by this resolution:
An additional paid three-day leave is provided to doctors of district hospitals and outpatient clinics located in countryside, district therapists and pediatricians of territorial city polyclinics, mobile teams of stations and emergency and emergency medical care stations, air ambulance stations and departments of planned and emergency consultative assistance for continuous work in these institutions and territorial areas for more than 3 years;
Additional leave is granted to donors after each day of blood donation; mothers with 2 or more children at the age of 12, if the annual leave is total duration does not exceed 28 calendar days; students of higher and secondary specialized educational institutions for the period of performing laboratory work, passing tests and exams.
A necessary element in calculating the annual working time budget of a position is the number of hours worked per day.
For most doctors and nurses, a reduced working time is set - no more than 38.5 hours a week, due primarily to neuropsychic stress at work. Doctors and nurses, as a rule, are set a working day of 6.5 hours with six-day working week, junior medical staff - 7 hours On the eve of weekends and holidays, the working day is reduced by 30 minutes, and for workers with a 7-hour working day - by 1 hour. In some cases, due to harmful working conditions, for medical staff, a working day of 6 hours is established: in tuberculosis and infectious diseases hospitals and departments, psychiatric, neuropsychiatric, narcological and neurosurgical institutions and departments.In these cases, the working day is not reduced on weekends and holidays.For some medical workers, a working day of even shorter duration is established ; so, 5.5 an hourly working day are, for example, doctors of medical and labor expert commissions (VTEK) and medical advisory commissions, dentists (except for dental surgeons in a hospital), dentists and dental prosthetists.
In addition to junior medical staff, the following have a 7-hour working day:
Chief physicians and their deputies;
Doctors and paramedical personnel of general sanatoriums and rest homes;
Diet nurses of all medical institutions and paramedical personnel of dairy kitchens;
Dental technicians.
Based on the above data on the number of days the position works in a year and the daily working time, the annual budget of the position’s working time is calculated, expressed in hours or minutes.
As mentioned earlier, during the working day of a doctor, on average, about 30 minutes. time is spent on work not related to the reception of patients, the provision of medical and preventive care to them, and this time must be taken into account and excluded when calculating the annual budget of the working time of the position.
Thus, the calculation of the annual budget of the working time of the position (in hours) is carried out according to the formula:
B \u003d a x (c - c) - d
a - the number of working days of the position in a year;
c - daily working time;
c - time spent during the day, not related to diagnostic and treatment work;
d - reduction of working hours on weekends and holidays (in hours).
When calculating the number of positions of endoscopists, physiotherapy nurses, massage nurses, centralized sterilization nurses, etc., the annual time budget is determined, taken into account in conventional units.
Many researchers, analyzing the activities of outpatient clinics, come to the conclusion that the actual annual workload of doctors is lower than planned, while the daily workload of a doctor is often higher than it is provided for by the standards. This should be attributed both to the insufficiently satisfactory organization of the work of doctors, and to the fact that the doctor actually works at the reception for a significantly smaller number of days and hours than is provided for by the planned calculations of the workload of the medical position.
The problem of studying the loss of working time of medical personnel and ways to reduce them is given Special attention, since the incomplete use of working days in a year leads to a decrease in the availability, volume and quality of medical care.
As mentioned above, the days when a medical worker is absent from work, with the exception of weekends, holidays and vacations, are not taken into account when calculating the planned budget of the position’s working time, which is due to the system of substitution and part-time work in healthcare.
At the same time, health care facilities need to analyze the reasons for absenteeism, the possibilities of replacing an absent employee in accordance with current legislation(Fig. 4).
Based on the materials of a specially conducted study of the level and structure of loss of working time of 765 doctors in 20 outpatient clinics, the number of days a doctor is absent from work during the year averages 41.7 days.
More than half of these losses are due to temporary disability due to illness, pre- and post-natal leave. Specialization and improvement, business trips, performance of state duties, account for about 20%, i.e. 9 days.
The full use by the head of the institution of the possibilities of substitution and part-time work in monitoring the working out of the corresponding working time will contribute to a more rational distribution of personnel and reduce the difference between the planned budget of the working time of the position and the indicators of its actual use.
Rice. 4
ANNUAL BUDGET OF WORKING TIME OF MEDICAL STAFF
2.2. Regulation of the work of medical personnel of outpatient clinicsThe regulation of the work of medical personnel in outpatient clinics is based mainly on the study of the work of medical personnel. The design of standards for the positions of doctors conducting outpatient appointments is carried out according to two leading indicators:
1. The needs of the population in different types of medical care, expressed by attendance rates.
2. The planned function of a medical position.
The basis for determining the needs of the population in one form or another of medical care are intensive attendance indicators developed in scientific research for the prospective period, which reflect the nature of the pathology of the population, the incidence rate, the demographic situation, as well as the achievements of medical science and the effect of their implementation in healthcare practice. Indicators of the population's need for outpatient care are established on the basis of a comprehensive methodology, including the study of morbidity by request, in-depth medical examinations of the population, the use of an expert assessment of the completeness and quality of medical care. However, the lack of distribution of attendance by types of institutions (service levels), the purpose of the visit create significant difficulties in their application in regulatory research work. In addition, the morbidity identified as a result of additional medical examinations, taking into account the use of an expert method, as a rule, is not realized in the form of appeals from the population to healthcare institutions. The task of planning, of which labor rationing is an integral part, is the most rational combination of the real possibilities of health care institutions and the desire to satisfy the population's need for medical care to the maximum.
Determining the needs of the population in one form or another of medical care for the purposes of regulation is based on the study of three groups of data:
1. Materials of scientific research on the needs of the population in medical care.
2. Indicators of the activity of doctors of the studied types of institutions in 19 economic and geographical regions of the country, used as bases for collecting materials on labor.
3. Performance indicators of medical personnel in specially selected institutions, staffed, using advanced, progressive forms of service, methods of prevention, diagnosis and treatment.
As a rule, the difference in attendance rates between the second and third group of institutions is 15-20%. For example, the level of attendance of the population to phthisiatricians in city dispensaries for institutions of the second group was 168 per 1000 population, and the third group - 203.
To compare these data with the first group of indicators - the scientifically developed need of the population in one form or another of medical care - an appropriate analysis and refinement of the indicator is required.
This is due to the fact that in normative research studies the attendance of the population in a particular specialty in a particular type of institution is studied. The need is determined as a whole for the entire population at all stages of medical care. Recalculations of indicators taking into account the proportion of urban and rural residents, scientific research data on the distribution of attendance by stages of medical care provide a single summary indicator that reflects the population's need for a particular type of medical care. The implementation of meeting the needs of the population for the type of assistance being studied depends both on the degree of development of the service and on its accessibility.
Comparison of actual indicators of attendance of the population with the data of need is legitimate to carry out only in general for all specialties, taking into account the level of development specialized services, since a possible "underload" in the number of visits in one specialty or another can be compensated to a certain extent by higher performance indicators in another, broader specialty. However, even such a comparison cannot claim to be a complete analysis, since it does not take into account the proportionality or possible disproportions in the development of outpatient, inpatient and emergency medical care.
A prospective indicator of the population's need for outpatient services is determined on the basis of data on the actual attendance of the population in the third group of institutions with a retrospective analysis of attendance rates for a number of previous years (3-5 or more). Then, the average increase in the number of visits per year is calculated as the arithmetic mean using the formula:
| a = | b - b_1 | (2.2.1.) | |
| n |
a - average annual increase in the number of visits to doctors;
b - the level of attendance to doctors of the given accounting year;
b_1 - the level of attendance to doctors of the base year compared with the reference year;
n - duration of the base period in years.
At the same time, the optimal value of the standard requirement for a promising five-year period is determined by the formula:
| H=b+5a | (2.2.2.) |
H is the predicted attendance by the end of the 5-year period.
In a number of cases, during the formation and development of a new medical specialty, an increase in the number of visits can occur exponentially, and the planning of the regulatory need for the near future is carried out by extrapolating the exponential growth in attendance:
| H = b x (I + | b_2 | ) | n | <*> | (2.2.3.) | |
| 100 |
b_2 - annual increase in the number of visits in %%;
n is the duration of the planned period in years.
<*>G.A. Popov, 1974
Thus, the value of the attendance rate, taken as a starting point when designing the standard for the positions of doctors in outpatient clinics, is based on determining the level of attendance and analyzing its dynamics.
The function of a medical position is determined by the amount of work that must be performed within the annual balance of working hours for this position.
A variety of factors influence the labor productivity of a doctor conducting an outpatient appointment, that is, the indicator of his workload: the structure of visits by nosological forms, the nature and severity of the pathology, the ratio of primary and repeated visits, as well as visits made in connection with morbidity, with a preventive purpose , dispensary observation, etc.; the level of qualification of the doctor, his technical equipment, the availability of assistants, the organization of work, etc. (Fig. 5). The average time spent on the first visit is an integrating value that reflects the influence of various factors related both to the nature of the visit and the age and sex composition of patients, and to the forms and conditions of the organization of work of doctors. This involves the development of differentiated labor standards and the subsequent calculation on this basis of a single load, taking into account the diversity of activities of medical personnel.
The final data on labor costs obtained as a result of consolidation, expressed in time, allow us to calculate them in the "visit" indicator, the number of which per unit of working time (hour) determines the medical workload at an outpatient appointment (60 min: M min \u003d H).
Rice. five
FACTORS CONSIDERED WHEN DESIGNING LABOR STANDARDS FOR OUTPATIENT INSTITUTIONS
In the future, the transition from indicators of labor costs to the indicator "position" is carried out. Currently, the indicator and measure of the volume of outpatient care in terms of health care is the "medical position".
The number of visits that a doctor's office must complete in a year is called the function of the doctor's office. It is expressed by the formula:
| F \u003d (A x t_a) + (B x t_b) + (C x t_s) x B | (2.2.4.) |
Ф - function of the medical position (number of visits);
A, B, C - doctor's workload for 1 hour of work in the clinic, during preventive examinations, providing assistance at home, respectively;
t_а, t_b, t_с - the number of hours of work per day for the given type of work;
The workload of a doctor at an appointment in a polyclinic and at home is regulated by the calculated standards of service for doctors in outpatient clinics, approved by the USSR Ministry of Health or obtained as a result of scientific research. The annual balance of working time is determined based on the number of working days in a year and the length of the working day, in accordance with the current labor legislation. The beginning and end of work, the distribution of working time by type of activity during the accounting period is established by the shift (work) schedule approved by the administration in agreement with the trade union committee, depending on specific conditions. The work schedule of medical personnel can be very different not only in different health care institutions, but also among doctors of the same specialty of the same outpatient clinic. The distribution of a doctor's working time for outpatient appointments and care for patients at home should be differentiated taking into account the size and age composition of the population, the level of morbidity and seeking medical care, and the characteristics of the site.
Since the norms of service for 1 hour of admission to the clinic, preventive examinations and the provision of medical care at home are not equivalent, the function of a medical position is different depending on the work schedule, all other things being equal.
Example. If, on average, a district general practitioner during a working day spends 4 hours on an appointment at a polyclinic, of which 1 hour is for preventive examinations, and 2 hours for providing medical care at home, then
F = (5 x 3) + (7.5 x 1) + (2 x 2) x 282 = 7473 visits.
With a different work schedule, in the case when the general practitioner allocates 2.5 hours for an appointment at a polyclinic, 1 hour for preventive examinations and 2.5 hours for home care, the planned function of a medical position will be
F = (5 x 2.5) + (7.5 x 1) + (2 x 2.5) x 282 = 7050 visits.
When developing standards for outpatient medical positions, it is necessary to have a stable indicator of a planned medical position, standardized for all the specified parameters. Such requirements are met by converting all types of visits into units equivalent to any one of them, for example, visits to a polyclinic. The method of conversion to equivalent units is quite widely used in health economics.
The calculation of the total number of visits in equivalent units is carried out according to the formula:
| P \u003d A x 1 + B x K_1 + C x K_2 | (2.2.5.) |
P is the total number of visits in equivalent units;
A - the number of medical and diagnostic visits to the clinic;
B - number of preventive visits;
C is the number of home visits;
К_1,2 - coefficient of conversion of the corresponding visits into units equivalent to visits in the polyclinic.
With this calculation, the planned function of the position of a local general practitioner, regardless of the work schedule, will be 8460 visits (5 x 6 x 282).
It is also possible to eliminate the influence of a different work schedule of a doctor during the day, month, year on the value of the function of the position and, consequently, the indicator of the staffing standard using another methodological approach, calculating the weighted average number of visits per 1 hour of work using the formulas:
| P = | 100 | or | (2.2.6.) | ||||||
| m | + | n | + | p | |||||
| M | N | P | |||||||
| P = | 60 | (2.2.7.) | ||||||||||||||
| ( | 60 | ) | x m | ( | 60 | ) | x n | ( | 60 | ) | xp | |||||
| M | + | N | + | P | ||||||||||||
| 100 | 100 | 100 | ||||||||||||||
P - weighted average number of visits per 1 hour of work;
m, n, p - the share of the number of medical and diagnostic, preventive visits and home visits in the total structure of attendance in%%;
M, N, P - design load rate on different kinds visits.
The final stage in the development of a normative indicator is the transition from a measure of the volume of activity of a position in the number of visits to a measure of "population", which is more convenient for practical use. The calculation of the standard is carried out according to the formula:
| H = | P x H | (2.2.8.) | |
| F |
N - the standard of a medical position;
P - attendance rate per 1 inhabitant per year;
P - the population for which the standard of a medical position is calculated (10 thousand, 100 thousand);
Ф - planned function of a medical position.
Calculation example. scientific research it was found that the planned number of visits per 1 adult resident per year to the local general practitioner is 4.3, including 2.4 treatment and diagnostic, 1.2 preventive and 0.7 visits to provide medical care at home (table 5) .
Table 5
Distribution of visits to the district general practitioner per 1 adult resident per year
| NN p/n | Type of visit | Number of visits | Structure of visits in %% | TO | Number of equivalent visits |
| 1 | 2 | 3 | 4 | 5 | 6 |
| 1. | Therapeutic-diagnostic | 2,4 | 55,8 | 1.0 | 2.4 |
| 2. | Preventive | 1,2 | 27,9 | 0,667 | 0,8 |
| 3. | at home | 0,7 | 16,3 | 2,5 | 1,75 |
| Total: | 4,3 | 100,0 | 4,95 |
1 calculation option (according to formula 2.2.5.). The function of the position of a local general practitioner in conditional outpatient medical and diagnostic visits is 8460 visits. The planned number of conditional equivalent visits is obtained by multiplying the number of various kinds of visits (column 3) by the value of the coefficient (column 5) and is 4.95 conditional visits taken into account, and then the value of the standard for the position of a district general practitioner is 5.9 positions in per 10,000 adults:
| H = | 4.95 x 10000 | = 5,9 |
| 8460 |
2 calculation option (according to formula 2.2.6). The weighted average number of visits per 1 hour of work of a district general practitioner with this structure of visits will be 4.342:
| P = | 100 | = 4,342 | |||||
| 55,8 | + | 27,9 | + | 16,3 | |||
| 5 | 7,5 | 2 | |||||
The same result is obtained when using formula 2.2.7 when calculating the weighted average load per 1 hour of work.
| P = | 60 | = 4,342 | |||||||||||
| ( | 60 | ) | x 55.8 | ( | 60 | x 27.9 | ( | 60 | x 16.3 | ||||
| 5 | + | 7,5 | + | 2 | |||||||||
| 100 | 100 | 100 | |||||||||||
From here, the function of the position of a general practitioner will be equal to 7347 visits per year (6 x 4.342 x 282) and the size of the staff standard - 5.9 positions of a district general practitioner per 10 thousand of the adult population:
| H = | 4.3 x 10000 | = 5,9 |
| 7347 |
The main task of hospitals in medical institutions is to ensure the full scope of examination and treatment of the patient in accordance with the material and human resources at different periods of his stay in the hospital (admission, examination, treatment, discharge) and at various stages of care (resuscitation and intensive care, active treatment, post-treatment and rehabilitation treatment) in conditions of continuity of the diagnostic and treatment process during the day.
The amount of time spent by medical personnel when servicing patients in a hospital is influenced by numerous factors, the main of which are: the composition of patients according to nosological forms of diseases; medical measures corresponding to the period of the patient's stay in the hospital, depending on the order of admission (scheduled or emergency hospitalization); average length of hospital stay (Fig. 6).
In addition, the degree of satisfaction of the needs of the population in hospital care, other things being equal, has an indirect impact on the standards for the work of medical personnel in hospitals.
The consolidation of the worker's load indicators depending on the indicated factors to obtain a single weighted average is carried out, as in the case of labor rationing in outpatient clinics, using a stepwise method.
Rice. 6
STANDARD FORMING FACTORS CONSIDERED IN THE DEVELOPMENT OF LABOR STANDARDS IN HOSPITAL INSTITUTIONS
In carrying out this work, the researcher uses a different sequence of calculations. For example, at the first stage, the labor costs for servicing patients with various nosological forms of diseases are determined, taking into account the age and sex composition of those hospitalized by periods of inpatient treatment.
Photochronometric observations, which are usually carried out within two weeks, do not always reveal the true workload of an employee for a number of work performed during the year, especially for rarely performed instrumental and hardware methods of examination. In this case, the data of photochronometric observations are supplemented by timing measurements. If it is impossible to implement them, data on time costs obtained from workers directly carrying out these manipulations and studies are used. The number of these studies during the year is established on the basis of the performance of the unit for the calendar year, obtained from the "Map of the volume of activity of the medical personnel of the healthcare institution" based on the data of the accounting documentation.
So, for example, a urologist, according to photochronometric observations, spends 30 minutes on these types of activities, i.e. an average of 1.2 min. per treated patient. The volume of these studies is established from the "Map of the scope of activities ...", it is 0.8 examinations per patient, and, therefore, the estimated time spent per patient with an average length of stay in the hospital of 13 days will be 1.85 minutes.
Thus, comparison of data from direct observations with the annual volume of an employee's activity makes it possible to more objectively establish the costs of his labor for certain types of work.
Further calculation of the aggregated indicator is carried out according to the formula:
| M + K x M_l x (-2 - | n | ) + M_v | |||
| M = | 7 | (2.3.1.) | |||
| n- | n | ||||
| 7 |
M - weighted average time spent on direct patient care per one examination (in minutes);
M_n - the doctor's time spent on providing medical care to the admitted patient (in minutes);
M_l - the doctor's time spent on providing medical care to the patient on the day of the examination (in minutes);
M_v - the doctor's time spent on providing medical care to a discharged patient (in minutes);
K - coefficient of frequency of medical examinations of treated patients per doctor's working day;
N is the average duration of inpatient treatment (in days);
7 is the number of days in a week.
As a rule, a doctor examines a patient in a hospital daily, then K = I. In some cases, due to the specifics of medical work and the contingent served, the number of patient examinations per day deviates from one in one direction or another. So, in the departments (wards) of resuscitation and intensive care, in the maternity ward, during the working day, the doctor interviews and examines the patient several times. In psychiatric hospitals, sanatoriums, aftercare departments, a medical examination is possible once every 2, 3 or more days, in children's sanatoriums - once every 5 days, etc. Therefore, the inspection frequency coefficient is 0.5, respectively; 0.3 and 0.2.
This method calculates the doctor's costs directly related to patient care: interview, examination, medical care and documentation. In the future, the time during the working day spent on other types of work (auxiliary activities, official conversations, transitions, etc.) and personal time is determined.
When rationing the work of medical personnel, the work of the doctor in the evening and at night, on generally established weekends and holidays (the so-called "duty") is also taken into account. Medical care for patients at this time, as a rule, is provided by doctors, whose positions are provided for by staff standards for this institution, within their working hours for the accounting period. Physicians conducting medical work are involved in these works. Radiologists engaged exclusively in diagnostic work, laboratory assistants, and bacteriologists are not involved in "duty" duties. These physicians may be assigned to the so-called "duty" in their specialty.
"On duty", the duration of which, as a rule, should not exceed 12 hours, is carried out for the hospital as a whole, and in large hospitals, in addition, for a group of departments, if there are at least 200 beds in the group. Rural health facilities and maternity hospitals in cities may introduce "home calls".
The obtained data on the doctor's time spent on all types of work performed make it possible to calculate them in the "patient" indicator according to the formula:
| N_b | T - V - D | (2.3.2.) | |
| M |
Where H_b is a measure of the indicator "sick" (the doctor's workload per working day);
T - the duration of the working day for this position (in minutes);
B - the average time during the working day, not related to the direct service of patients (in minutes);
D - the average time excluded from the duration of the working day for the performance of "duty" (in minutes);
M - the average estimated time for servicing 1 patient (from formula 2.2.1.).
Calculation example.
The therapist spends an average of 15 minutes daily. for one patient. During the month, 24 hours are provided for "duty", i.e. daily working time is reduced by an average of 1 hour; the average time during the working day, not related to the direct service of patients, is 0.5 hours, therefore:
To move to the indicator adopted for calculating the staff of hospital institutions - "bed", the following methodological technique is used. It is known that the planned duration of a bed in a year is not the same in institutions of various types: for city hospitals it is 340 days, for rural hospitals - 320, for infectious diseases - 310, maternity hospitals - 300. Thus, during the year, part of the hospital beds are idle, since not occupied by patients for a number of reasons. Therefore, when moving from the "sick" indicator to the "bed" indicator, it is necessary, taking into account the planned duration of the bed occupancy in a year, to increase the previously obtained calculated indicator:
| N_k | 365 | x N_b | (2.3.3.) | ||||||
| P | |||||||||
| T = SUM(n_1 x t_1 + n_2 x t_2 +... + n_1 x t_1) | (2.4.1.) |
T - annual volume of activity, expressed in minutes or the number of conventional units;
n - number of studies, procedures;
t - in minutes or conventional units per study, procedure.
In cases where in one structural unit there are estimated time standards, expressed both in minutes and in conventional units, T is determined separately for these indicators.
The calculation of the required number of posts (W) to perform the annual volume of work is carried out according to the formula:
| W= | T | (2.4.2.) | |
| B |
T - corresponds to the formula 2.4.1;
B - the annual budget of the working time of the position.
The annual budget of working time for the positions of medical personnel of the auxiliary medical and diagnostic service can be expressed, as indicated in the relevant section, in minutes or in conventional units. Thus, the annual budget of a laboratory assistant, laboratory assistant, doctor and nurse for functional diagnostics is 101,910 minutes, a radiologist - 66,240 minutes, a physiotherapy nurse - 15,000 conditional physiotherapeutic units, a massage nurse - 8340 massage units.
As a rule, the indicator by which the standard for the position of medical personnel of an auxiliary medical and diagnostic service in outpatient and polyclinic institutions is determined is medical positions leading an outpatient appointment, and in hospital and sanatorium institutions - a bed.
The standard for the positions of medical personnel of the auxiliary medical and diagnostic service is calculated by the formula:
| N= | F | (2.4.3.) | |
| W |
N - position standard;
F - indicator of the standard (number of medical posts conducting outpatient appointments or number of beds);
W - corresponds to the formula 2.4.2.
Table 6
CALCULATION OF THE ANNUAL COST OF TIME OF THE LABORATORY MEDICAL STAFF FOR LABORATORY STUDIES
| Name of the study | Number of studies (n) | Time for 1 examination in min. (t) | Total Time (T) | ||
| for a laboratory assistant | for laboratory doctor | for a laboratory assistant | for laboratory doctor | ||
| Leukocyte count | 50000 | 2 | 6 | 50000 x 2= 100000 | 50000 x 6 = 300000 |
| Determination of the blood group | 1000 | 5 | 1000 x 5 = 5000 | ||
| Determination of amylase (diastase) in urine | 20000 | 15 | 20000 x 15 = 300000 | ||
| Examination of tumor punctures | 500 | 6 | 14 | 500 x 6= 3000 | 500 x 14 = 7000 |
| Total: | 100000 + 5000 300000 + 3000 = 435000 | 300000 + 7000 = 307000 | |||
An example of calculating the standard for the position of a laboratory assistant in an outpatient clinic
The volume of work indicated in the previous example, corresponding to 4.268 positions of laboratory assistants, is carried out in a polyclinic with 33.75 positions of outpatient doctors:
Those. the standard is set at the rate of 1 position of a laboratory assistant for 8 positions of doctors conducting outpatient appointments.
An example of calculating the standard for the position of a laboratory assistant in a hospital institution
The specified amount of work, corresponding to 4,268 positions of laboratory assistants, is carried out in a hospital with 210 beds.
| F x D x T x H |
N - position standard;
B - the annual budget of the working time of the position;
Ф - bed turnover;
D - the proportion of patients in need of research, procedures (in%%);
T - average estimated or standard time for 1 study, procedure, examination;
N - the number of procedures, studies, examinations for a course of treatment.
Formula 2.4.4. It is convenient because its components can be used to evaluate to a certain extent the organization of the treatment and diagnostic process, the completeness and quality of medical care for patients and make adjustments based on expert assessments. This formula is applicable mainly in scientific research.
Calculation example
In the hospital, the bed turnover is 20, of all patients, 30% need therapeutic massage, the number of conventional units of massage per procedure is 2.2 units; an average of 12 procedures are performed per course of treatment
| N= | 8340 x 100 | = 52.6 beds |
| 20 x 30 x 2.2 x 12 |
Those. the position of a massage nurse is established for 50 beds.
When changes are made to one of the indicators, the standard changes. So, if the selection of patients for treatment is determined not at 30, but at 60%, then the standard for the position will be 25 beds, with a decrease in the average number of procedures from 12 to 10-60 beds, etc.
In a number of cases, when rationing the work of paramedical personnel of an auxiliary medical and diagnostic service, a ratio standard is used. Thus, the number of positions of radiologists is set according to the number of positions of radiologists.
Introduction
The current stage of healthcare development raises questions of the quality of medical care provided to the population in a new way. The proper level of medical care can be achieved only with the appropriate staffing of health care institutions. The formation of the number of medical personnel, the establishment of labor standards, the rational placement and use of personnel are the most significant components of the labor rationing system in healthcare, which are based on industry-specific labor regulations. Currently, the regulatory framework developed by the Ministry of Health of the USSR in the late 80s is used. Normative documents on labor are not focused on the organizational and technical conditions for the operation of medical and preventive health care institutions, as well as the incidence of the population and the demographic situation that take place in Russia at the present time. The need to update the existing regulatory framework and develop modern labor regulations is quite obvious. First, the crisis in the economy and the deterioration of the environmental situation in recent years have significantly changed the nature of the pathology and the severity of the course of diseases of the population served, as well as the frequency of visits, the duration and intensity of treatment. In this regard, it became necessary to develop new modern norms and standards for labor and improve existing ones. Secondly, the staffing standards for most of the main types of institutions (regional, city hospitals, adult and children's city polyclinics, etc.), developed 25–30 years ago and corresponding to the technology of the treatment and diagnostic process adopted at that time, do not meet modern requirements and need to be revised. Thirdly, the rapid development of medical science, the introduction of new technologies and modern equipment in the treatment and diagnostic process, the improvement of instrumental research methods have significantly changed the nature and content of the doctor's work and also require a serious revision and updating of the regulatory framework in healthcare.
The purpose of this work is to consider the types of labor rationing methods, methods for studying the cost of working time and approximate calculations of labor rationing for middle and junior medical personnel.
The work uses various sources, publications, educational literature.
The work consists of several sections. The first section characterizes the concepts of labor standards, its types, defines the functions, tasks and principles of labor rationing, as well as the procedure for introducing, replacing and revising labor standards. The second section discusses the types of labor rationing, methods for studying the cost of working time. The third section shows the calculations of labor rationing for middle and junior medical personnel of various departments of a medical institution.
In conclusion, conclusions about the work done and a list of references are given.
Theoretical aspects labor rationing in health care
The essence of labor standards and its types
The labor norm is the amount of work established for the employee per hour, day (shift), week, month, year, which he is obliged to perform under normal working conditions. The employer is obliged to ensure normal working conditions: good condition of mechanisms, equipment, fixtures, timely provision of technical documentation, proper quality materials and tools for work, their timely supply, safe and healthy working conditions. Labor standards - the norms of output, time, service - are established in accordance with the achieved level of technology, technology, organization of labor and production, and if they change, they must be systematically reviewed. Labor standards are subject to mandatory replacement as well as the certification of workplaces, the introduction of new equipment, technology, technical re-equipment of production, ensuring an increase in labor productivity. The introduction, revision and replacement of labor standards is carried out by the employer, taking into account the opinion of the trade union committee, local regulations. Employees are notified of the introduction of new norms at least two months in advance.
There are the following types of labor standards: production standards; time norms; service standards; population norms; normalized tasks; enlarged and complex norms used in collective forms of organization and remuneration of labor (in the production team). According to their scope, labor standards are single, standard, intersectoral, sectoral (departmental) and local. In practice, there are always local ones, which are developed on the basis of standard, sectoral and other centralized norms of a recommendatory nature.
The output rate is the amount of work established in units of production, work operations that an employee must perform per hour, day (shift), month, working year.
The norm of time is the amount of working time (in hours, minutes) for the production of a unit of output or a work operation, it is used to calculate, determine production rates and other labor standards.
Service rates are the volume of maintenance of production mechanisms, machine tools, and areas established per employee. Their variety is the norm of manageability - the number of workers in a given production, which must be managed by one leader (foreman, site manager, foreman, etc.). This is also a calculation norm for determining the staff of labor managers.
The norm of the number of employees is the established number of working personnel of a certain profession, qualifications for performing work at a given production site, for example, repair workers for servicing machine tools or all employees of a workshop, department, enterprise, institution, organization.
The norm of the number and the norm of service are interrelated, since the norm of the number is determined by the norm of service, and vice versa.
The enlarged and complex norms used in the collective work of the production team along a single line are calculated for the entire team of the team, that is, this is the amount of work that the team must perform per day, week, month.
With a piecework wage system, a piecework rate is applied - this is payment for a unit of a product (working operation) of good quality (without marriage). The piece-rate under a simple piece-rate system is always the same, no matter how much the worker produces; under the piece-progressive system, it is the same within the limits of production, and for products made in excess of the norm, it progressively increases (but this system is rarely used, since it is reflected in the cost of production). Piece rates are set by the administration and are also revised with the revision of labor standards.
The normalized task is the total amount of work per working day (shift) for an employee or team, established with a time-based wage system based on time standards and production standards, is used to improve the efficiency of workers with time wages. Depending on the time the task is set for, daily (shift) and monthly normalized tasks are distinguished. In essence, this is a special production rate used for time workers.
Functions, tasks, meaning and principles of labor rationing
The main functions of labor rationing are distribution according to work, scientific organization of labor and production, production planning, evaluation of the labor activity of individual workers and teams, which serves as the basis for moral and material encouragement and dissemination of best practices.
Labor regulation includes:
¾ study and analysis of working conditions and production opportunities at each workplace;
¾ study and analysis of production experience to eliminate deficiencies, identify reserves and reflect best practices in labor standards;
¾ designing a rational composition, method and sequence of performing elements of the labor process, taking into account technical, organizational, economic, physiological and social factors;
¾ establishment and implementation of labor standards;
¾ systematic analysis of the implementation of labor standards and revision of obsolete standards.
The main tasks of labor regulation are to:
¾ justify the necessary and sufficient value of the cost of working time per unit of production in specific conditions;
¾ design rational labor methods;
¾ systematically analyze the implementation of labor standards to reveal production reserves;
¾ constantly analyze the implementation of labor standards to reveal production reserves;
¾ constantly study, generalize and disseminate production experience, revise labor cost standards as working conditions change.
The solution of these problems will make it possible to facilitate the work of workers, increase labor productivity and increase the volume of production.
The regulation of labor is the basis of the scientific organization of labor. With the help of the methods used in the regulation of labor, losses and unproductive expenditures of working time are singled out. By studying labor movements the most economical, productive and least tiring methods of work are developed. This contributes to the growth of labor productivity. Further improvement of the organization of labor is impossible without improving its rationing.
Also, the regulation of labor is the basis of the organization of wages. The establishment of labor standards aims to guarantee society a certain productivity of labor, and the worker a certain level of wages. According to the performance of labor standards, the labor activity of each employee is evaluated and his work is paid. Without labor rationing, it is impossible to implement the economic law of distribution according to work.
Labor rationing is an important means of organizing production. The organization of production is the management of the process of production of material goods, i.e. interaction between labor force and means of production to achieve the maximum economic effect in specific conditions. Through the organization of labor, the influence of labor rationing on the organization of production is manifested.
Scientifically based labor standards make it possible to evaluate the results of the labor activity of each employee, each team and compare their results. Only by comparison are leaders and laggards revealed.
Scientifically substantiated labor standards, correctly reflecting specific conditions, ensure an increase in labor productivity. If labor standards are too low, they can give rise to complacency or pessimism, which negatively affects the results of productivity; if the standards are too high, they are not feasible. In both cases, the growth of labor productivity will be hampered. Thus, all changes in the organization of labor and production, equipment and technology of work are reflected primarily in labor standards. And the level of labor standards is an indicator of the level of organization of production and labor at the enterprise.
Labor rationing is the basis of labor planning. For long-term, current and operational planning, a whole system of norms is used: norms for the consumption of materials, fuel energy, norms for the productivity of machines, norms for the expenditure of working time. Thus, labor standards play an important role in the system of norms used in planning at the enterprise.
Drawing up a plan for labor and establishing labor costs in accordance with the volume of production is impossible without scientifically based labor standards. Greater independence of enterprises in matters of labor planning enhances the interest of teams in the implementation of scientifically based labor standards.
The following principles should form the basis of labor regulation:
¾ scientific validity of labor standards;
¾ equal intensity of labor standards at the same jobs in identical conditions;
¾ preservation of the main productive force of society - workers;
¾ participation of workers in the establishment of labor standards.
The labor norm acts not only as the value of the necessary expenditure of working time, but also as an expression job duties each participant in the production.
The procedure for the introduction, replacement and revision of labor standards
According to Art. 160 Labor Code RF labor standards should be established in accordance with the achieved level of technology, technology, organization of production and labor.
The introduction, as well as the replacement and revision of labor standards, are formalized by local regulatory acts of the organization (order, order, regulation on rationing, etc.) and taking into account the opinion of the representative body of workers (trade union body, labor collective council, etc.).
The most rational and preferred method of designing regulatory materials is the analytical and computational method, since it is the most perfect and cost-effective.
To develop labor standards, the following activities are organized and carried out:
1. Preparatory and organizational and methodological work.
In the course of the work, the goals and objectives of the development of regulatory materials for labor rationing are determined, the types of norms are specified, and the terms of reference are drawn up.
The terms of reference are developed by the executing organization of the regulatory research work and approved by the customer organization.
The current technology, instructions, regulations, organizational and technical conditions and methods of performing work at workplaces are studied, equipment passports, characteristics of the tools used, fixtures, raw materials, materials, equipment operating modes, the content of technological and labor processes are selected; the possibility of developing normative materials using time standards, including microelement ones, using electronic computers for designing rational labor processes and calculating labor standards is established.
A methodological program of work on the development of a regulatory document is being developed, reflecting the following issues:
¾ selection of enterprises (institutions, organizations), their structural subdivisions, on the basis of the organization of production and labor of which progressive technological (labor) processes and rational organizational and technical conditions for their implementation, provided for in the design of labor cost standards, will be developed;
¾ use of existing regulatory materials for labor rationing, including microelement standards;
¾ determination of the factors influencing the time spent in the performance of individual works and ensuring the greatest accuracy of standards and norms with the least complexity and laboriousness of their development;
¾ instructing employees who monitor and analyze the cost of working time and design norms and standards, the use of devices, video equipment for this work, computer technology, statistical, operational and other reporting data;
¾ verification of the draft regulatory materials in a production environment;
¾ design of the collection of normative materials as a whole.
2. The study of the cost of working time in the workplace.
Said works include:
¾ preparation for observations: performers are selected, whose work will be monitored, the compliance of technology, organization of the workplace and its maintenance with those designed is clarified;
¾ carrying out direct measurements of working time (timekeeping, photographs of working time, video filming of labor processes, etc.) or momentary observations; at the same time, materials related to the establishment of labor costs at selected enterprises are used to the maximum;
¾ carrying out technical calculations, experimental and other research work, processing the collected materials.
3. Processing of collected materials.
These works include:
¾ analysis and generalization of the results of the study of the cost of working time, the development of standards (norms) of labor costs;
¾ clarification of the main factors affecting the amount of labor costs; conclusion of empirical (based on experience) formulas of dependencies between the values of influencing factors and the values of labor costs;
¾ preparation of a draft regulatory document in the first edition, as well as instructions on the procedure for its verification directly at the enterprise;
¾ identification of specific enterprises (institutions, organizations), their structural subdivisions for conducting verification of regulatory materials on them;
¾ sending a draft regulatory document with instructions on the procedure for its verification to selected enterprises (institutions, organizations), to their structural divisions.
4. Verification of normative materials in production conditions.
The purpose of the audit is to identify the nature of the clarifications and additions to be made to the project.
5. Preparation of the final version of regulatory materials.
An analysis and study of the results of checking the draft regulatory document in a production environment, summarizing the feedback, comments and suggestions received is carried out.
Established labor standards in accordance with Art. 160 of the Labor Code of the Russian Federation may be revised as new equipment, technology is improved or introduced, and organizational or other measures are taken to ensure the growth of labor productivity, as well as in the case of the use of physically and morally obsolete equipment.
It should be noted that the achievement of a high level of production (delivery of services) by individual employees through the use of new methods of work and improvement of workplaces (that is, advanced methods and forms of labor organization) cannot be a basis for revising previously established norms.
The replacement and revision of uniform and standard norms is carried out by the bodies that approved them. The revised norms are drawn up by a local regulatory act of the organization and communicated to employees no later than two months before the introduction.
Verification of the labor standards in force at the enterprise (in an institution, organization) is carried out by attestation commissions approved by the heads of enterprises (institutions, organizations).
Based on the results of the check for each norm, a decision is made: to certify or not to certify. Technically substantiated norms corresponding to the achieved level of engineering and technology, organization of production and labor are recognized as certified.
Outdated and erroneously established norms are recognized as not certified and are subject to revision. Outdated, in particular, should be considered the norms in force at work, the labor intensity of which has decreased as a result of a general improvement in the organization of production and labor, the growth of professional skills and the improvement of the production skills of workers and employees. Norms can be considered erroneous if the organizational and technical conditions were incorrectly taken into account or inaccuracies were made in the application of normative materials or in the calculations.
When checking the norms of labor costs, the administration is obliged to ensure a thorough check of the implementation of the technology provided for by the norms in all operations of the labor process, the compliance of the actually performed volume of work with the volumes laid down in the calculation of the norms. At the same time, the administration, based on specific production conditions, is obliged to rationalize the technological processes of those operations, the conditions for which, provided for by the norms, do not correspond to the achieved level of organization of production and labor, best practices.
Revision of obsolete norms is carried out within the terms and in the amounts established by the management of the enterprise in agreement with the trade union committee. The revision of erroneous norms is carried out as they are revealed in agreement with the trade union committee.
The basis for the application of correction factors to the norms and standards may be the development of production capacities, new equipment, technology, new types of products or the discrepancy between the actual organizational and technical conditions of production provided for in the newly introduced norms and standards.
Labor rationing methods
Types of labor rationing methods
Improving medical care for the population requires not only building up the material and personnel base of health care, but also further improving the style and methods of work, organizational activities at all levels, taking into account the economic efficiency of the measures taken. One of the important tasks of further improvement of healthcare is the rational use of all resources. Determining the scope of activities of a particular group of medical personnel, establishing a direct link between indicators and wages, calculating the cost of providing medical care to the population as a whole and its individual types is especially important during the introduction of economic management methods in health care and the transition to insurance medicine.
A significant tool for solving these problems is labor rationing. To date, the needs of the population for certain types of medical care remain insufficiently studied, scientifically based proposals have not been developed on a number of healthcare institutions, their structural divisions and positions of medical personnel, as well as recommendations on rational forms of labor organization.
The method of labor rationing is a set of techniques for studying and analyzing labor processes, determining the cost of working time, identifying and accounting for norm-forming factors, designing a rational organization of labor and developing standards.
The regulation of the work of medical workers is the most difficult issue, reflecting the specifics of the industry and requiring a careful approach and scientific justification in its solution. In health care, as in other sectors of the national economy, there are two types of labor rationing methods: analytical and summary (Fig. 1).
Figure 1- Methods of labor rationing
The analytical method provides for the division of the labor process into separate components. Depending on the methods of developing labor standards, this method is divided into analytical research and analytical and calculation.
The analytical research method is a method in which the labor rate is set on the basis of a study of the cost of working time using photochronometric observations directly at the workplace. It involves a detailed study of the production process and labor costs for the constituent elements. Based on these data, the most rational technological modes of equipment operation and the organization of the workplace and labor are designed.
The analytical and calculation method provides for the calculation of time costs according to pre-established time standards, equipment operating modes, as well as formulas for the dependence of time on factors affecting the duration of the operation. This method establishes the normalized number of auxiliary workers, managers, specialists and technical performers.
The total method of labor rationing establishes the cost of working time as a whole per unit of output of a particular work process without analyzing the latter. The way the work is done is determined by the worker. Varieties of the total method are experimental, statistical and comparative methods.
Experienced method. The expert gets acquainted with the workplace, means and working conditions and intuitively, based on his subjective impressions and previous experience, determines the labor rate. The established labor rate is not an average value, but only a particular value of the possible costs of working time. Its validity, compliance with the conditions of the workplace entirely depend on the experience of the expert. This method is not able to provide the same intensity of norms. In addition, it only reflects past experience. Practice shows that labor standards established by an experienced intuitive method are, as a rule, of poor quality. This is evidenced by the significant overfulfillment of such norms by the majority of workers.
statistical method. Labor standards are set mainly on the basis of statistical reporting data on the volume of work. This method can be used only if you are sure that the doctor, on the one hand, does not have underloaded working hours, and on the other hand, the technology of the diagnostic and treatment process is followed, and the patient is provided with proper medical care in full.
The comparative method of establishing labor standards is used when the technology of personnel work is similar to that for which there are already standard indicators. For example, activity medical registrars, statisticians, etc. is homogeneous in all types of institutions.
The total method, which does not fully take into account the content and organization of the labor process, the rational use of working time, cannot be recommended for widespread use in the development of labor standards. At the same time, its simplicity and efficiency in some cases makes it preferable to this method.
Thus, at present, for the centralized development of labor standards, it is advisable to apply mainly the analytical research method. In healthcare institutions, to determine the number of personnel required for a particular amount of work, to establish a number of standard indicators, the calculation and analytical method should be widely used. In cases where there are no developed standards for personnel workloads, for example, when introducing new types of instrumental studies, when organizing a new service, you can apply summary rationing methods to establish temporary standards so that in the next 2–3 years, based on existing work experience, their scientific basis.
Methods for studying the cost of working time
There are 4 methods for studying the cost of working time (Fig. 2).
 |
Figure 2 - Methods for studying the cost of working time
Let's consider each of them.
Timing, methodology.
Timekeeping is a method of studying the cost of working time by measuring the repeating elements of an operation.
Its main purpose is to identify the most optimal methods of work and determine the corresponding time standards. Timing allows you to evaluate the organization of the workplace, differentially study the structure of an individual operation and the conditions for its implementation. The timing process includes three steps.
At the first (preparatory) stage, the operation is divided into separate elements using fixing points. A fixing point is a distinct external sign, perceived by the eye or by ear, signaling the beginning and end of one or another element of the operation. At the same stage, the worker is instructed and the workplace is studied. This is documented on the front side of the time-observation card, where data on the operation is entered, the number of products produced at a certain time, the types and condition of the means of labor, the nature of the process, the qualifications and length of service of the performer, the wage system used are indicated.
At the second stage, observation and time recording is carried out. Time measurements are made in a collective and cumulative way using a two-hand stopwatch. The observer must mark the time by fixing points and enter the stopwatch readings into the observation sheet of the time card, follow the order of the operation.
At the third stage, the data is processed and the duration of the operation element is determined. The obtained values of the duration of the operation element are recorded in the timing variation series, where the top line of the option is the measurements in ascending (descending) order of the duration of the measurements (t), and the bottom line of frequencies (p) shows how often this option occurs in the timing series. The total sum of frequencies must be equal to the number of measurements. Inaccurate (defective) measurements are preliminarily excluded and then the quality of the time series is assessed.
Photo of working time, types and methods of carrying out
A photograph of working time is the observation, measurement and sequential recording of all, without exception, the time spent during a work shift or other period.
If the observation period coincides with the length of the working day, it will be a photograph of the working day.
Photo of working time is used to identify the loss of working time and the reasons that cause them, as well as to establish the relationship between individual types of time spent. The data obtained are used as initial data for normalization.
The subject of the photo can be workers, machines or the production process as a whole. If the object of observation is one worker, then the photo of working time is individual, and if a group of workers is group. When the costs of working time are fixed by the worker himself, a self-photograph of working time takes place in order to study the losses of working time and their causes.
Photography of working time is carried out in three stages.
At the first stage, a preliminary study of the work is carried out, the choice of the object of observation. The object is selected depending on the purpose of observation. If it is necessary to obtain stable indicators of exemplary work, then the best worker is selected, and if it is necessary to study the reasons for non-compliance with the norms, then lagging workers.
The second stage includes direct observation and study of all time expenditures with an accuracy of one minute. The results are recorded in special observation sheets. At the same time, the types of work and breaks, as they are registered, are entered in the column "Name of the time spent", and the moment of their completion - in the column "Current time".
At the third stage, based on the data of the observation sheet, a table of the same costs and the actual balance of working hours are compiled. In conclusion, an analysis of the results of the observations carried out is carried out, irrational costs and direct losses of working time are established, which are excluded when compiling the projected balance, and the coefficient of a possible increase in labor productivity by eliminating losses and irrational costs of working time is determined.
Photochronometry
Photochronometry is a type of observation in which timekeeping is carried out simultaneously with a photograph of working time during its individual periods. It is advisable to use it when studying the time spent on individual elements of work that are not repeated cyclically during the working day.
In the practice of labor work, individual and group photochronometry is used. Thus, group photo timing is recommended to be carried out when establishing the composition of the brigade and distributing functions between its members, whose individual elements do not have cyclic repetition.
Observations and measurements are carried out by the accepted methods of processing the results of observations, the analysis of the data obtained and the design of rational labor processes during photo timing are carried out separately according to the data of timing observations and photographs in the prescribed manner.
Method of instant observations
The method of momentary observations allows you to register and take into account during the observation period the same-name costs of the working time of a group of performers or the time of work and breaks in the work of a different number of equipment and, on this basis, determine the specific weights and absolute values of time costs. The method is characterized by low labor intensity and simplicity of conducting observations and processing the results, the efficiency of the study, a wide coverage of various objects by observation, as well as the involvement of personnel in research while simultaneously performing their main work, etc. The disadvantages of the method include: obtaining only average values of working time and time of use of the equipment; lack of data on the sequence of execution of the processes under study, as well as possible changes, etc.
When conducting research, it is recommended to use pointer clock instruments (clocks, one- and two-pointer stopwatches), special equipment that allows you to automatically record both time and content, structure and method of performing normalized processes (oscillography, photo-video and film equipment).
Filming ensures the objectivity and high accuracy of recording all elements of the labor process in time and space, as well as the conditions that determine it, the completeness of the characteristics of the process under study (trajectories and speeds of movements, distances of movement of objects of labor, the sequence and degree of combination of techniques, actions and movements, etc. .)
Rationing of labor of middle and junior medical personnel
Rationing of work of middle and junior medical personnel of outpatient clinics
The positions of middle and junior medical personnel in outpatient clinics are established according to the number of positions of outpatient doctors of a particular specialty (to calculate the number of positions of nurses and nurses in the respective rooms). The positions of outpatient doctors include all positions of doctors of outpatient clinics, except for the positions of doctors of clinical laboratory diagnostics, bacteriologists, radiologists, radiologists, physiotherapists, reflexologists, manual therapy, endoscopists, anesthesiologists, resuscitators, statisticians, doctors of points (departments) of medical care at home , in physiotherapy, sports medicine, functional or ultrasound diagnostics, health centers, city and district pediatricians, as well as medical leaders of all ranks.
The need to allocate medical posts for outpatient appointments is due to the fact that, depending on their number, according to staff standards, the number of posts of doctors and paramedical personnel of auxiliary and some other medical and diagnostic units is determined:
The total number of posts of outpatient doctors: nurses in the treatment room, medical registrars (to calculate the number of positions of nurses in the treatment room, medical registrars);
· the total number of positions of doctors (to calculate the number of medical statisticians);
Changing the work of a unit or institution (to calculate the number of nurses in the procedural, vaccination rooms, registry);
The number of the population and its individual contingents (to calculate the number of nurses in vaccination rooms, nurses for collecting breast milk, etc.);
Mixed procedure for establishing positions: to calculate the number of paramedics or filter nurses in a children's city polyclinic (job change and number of children).
Most of the current staffing standards for outpatient clinics were approved more than 25 years ago: the staffing standards for urban and children's urban polyclinics located in cities with a population of over 25 thousand people were determined by order of the USSR Ministry of Health dated October 11, 1982 No. 999, in cities and towns of urban type with a population of up to 25 thousand people. by order of the USSR Ministry of Health of 09.26.1978 No. 900. In 2001, an order was approved according to the staffing standards of children's polyclinics that are part of city and children's city hospitals, medical and sanitary units with hospitals (order of the Ministry of Health of Russia of 10.16.2001 No. 371), however, the lack of substantiation of the main provisions of this order makes it unacceptable for healthcare practice.
According to the nature and volume of activities of the nursing staff established for outpatient doctors in various specialties, these positions can be divided into the following groups:
nurses carry out outpatient reception of patients together with the doctor;
Along with outpatient appointments, together with the doctor, the nurses of district general practitioners, pediatricians, general practitioners (family medicine) also carry out doctor's appointments to provide appropriate medical, diagnostic and preventive care at home to the population of the site.
Nurses of surgeons, traumatologists and orthopedists carry out dressings, applying and removing plaster, etc.
The first group includes most of the positions of nurses of outpatient doctors. The normative ratio of middle and medical personnel in this group is, as a rule, 1: 1, i.e., one position of a nurse is planned for one position of a doctor. At the same time, in such specialties of doctors as neurology, endocrinology and dentistry, this ratio is violated and, in accordance with the current staffing standards, 0.5 positions of a nurse are established for one position of a doctor in these specialties. It is difficult to find a logical explanation for such standards, and in the absence of relevant recommendations at the sectoral level, it is advisable for the heads of healthcare institutions to establish the number of posts of paramedical personnel in these specialties, corresponding to the medical one, on the basis of the rights granted to them to form the number of personnel of healthcare facilities. By order of the Ministry of Health and Social Development of Russia dated April 14, 2006 No. 289, this provision for the children's dental clinic was corrected, and the positions of nurses in medical offices are established at the rate of 1 position for each position of a pediatric dentist, dental surgeon and orthodontist. Such a standard is fully consistent with modern technologies of the diagnostic and treatment process in dentistry using modern composite materials, “four-handed” work, and ethical and legal standards for receiving a patient in a separate office.
In recent years, in connection with the introduction of compulsory health insurance in the territories where payment is made for certain medical services, classifiers of medical services are developed and approved, which establish the appropriate time standards for the doctor and nurse. The expediency of such a separate establishment of time standards for those specialties where the standards define an equal number of doctors and paramedical personnel raises serious doubts. So, for example, in one of the classifiers in otolaryngology, where, according to staff standards, one position of a nurse is established for one position of a doctor, the time spent on anterior tamponade of the nose (including after bleeding) is determined in the amount of 2.0 UET for a doctor and 1.5 UET for a nurse, i.e. 20 and 15 minutes, respectively. It is unlikely that a nurse, having completed the procedure before a doctor, will provide assistance to another patient without an appropriate medical examination and appointments. The situation becomes more complicated when the indicated costs of the doctor's working time are less than those of the nurse. For example, to replace the cystostomy drainage, the urologist was given 3.0 THU, i.e. 30 minutes, and the nurse - 4.0 THU, i.e. 40 min. After completing this operation, the doctor will accept the next patient without a nurse, which may lead to a violation of the technology of the treatment and diagnostic process, which involves the joint work of a doctor and a nurse, or wait for the nurse to complete this labor operation within 10 minutes.
Thus, the establishment of different time standards for individual labor operations for a doctor and a nurse conflicts with industry labor standards that determine the ratio between the number of posts of nurses and outpatient doctors in a particular specialty.
Moreover, as noted in the Recommendations, the determination of the time spent on individual labor operations, as well as on simple and complex medical services, can only be considered as an intermediate stage for the formation of standard costs for a more aggregated indicator recorded in the reporting and accounting documentation of health facilities, i.e. for a visit.
The normative number of positions of junior medical personnel is also differentiated according to the specialties of outpatient doctors. So, in urban polyclinics located in cities with a population of over 25 thousand people, the positions of nurses are established at the rate of 1 position for each position of a surgeon, traumatologist, orthopedist, infectious disease specialist; for every 2 positions of physiotherapy doctors, allergists-immunologists; for every 3 positions of other doctors conducting outpatient appointments.
Rationing of labor of middle and junior medical personnel of hospitals
The rationing of the labor of middle and junior medical personnel of hospital institutions has certain features, which are listed below:
the need to provide round-the-clock service to patients in the hospital;
· the indicator serving as the basis for calculating the number of posts is the number of beds;
Establishment of workload (service) standards for the day of the patient's stay in the hospital or shift.
The norms for the number of middle and junior medical personnel of hospital institutions are expressed in the number of beds per position, or per one round-the-clock post. Depending on this and the norms of time are set either on the day of the position, or on the day.
I stage. Normative costs of working time of medical personnel of hospitals are determined per 1 patient per day or per day. The stay of the patient in the hospital for the calculation of standard indicators for labor is differentiated as follows:
the day of receipt;
day of treatment
day of release.
Time costs are usually set on the basis of timing.
The calculation of the weighted average indicator of the cost of the working time of a nurse or a nurse working daily, on the day of the patient's stay in the hospital (Tday) is carried out according to the formula:
Tday \u003d (tp + tl x 0.825 (m - 2) + tv) / (m x 0.825), (1)
where tp is the time spent by a nurse or doctor on a patient on the day of admission;
tl is the time spent on the patient during the treatment period per one day;
tv - time spent on the patient on the day of his discharge;
m is the average duration of inpatient treatment (in days).
A coefficient of 0.825 has been introduced into the formula, showing the reduction in the number of days the nurse or nurse works during the entire period of stay due to holidays and weekends. When calculating the coefficient, 12 holidays and 52 days off are taken into account when working on a six-day working week: (365-52-12) / 365 ≈ 0.825.
Under the indicated regimen, i.e., nurses work daily, providing individual care for seriously ill patients, dressing rooms, procedural nurses, barmaids, nurses.
Calculation example
The time spent by a nurse for organizing individual care for seriously ill patients per 1 day of the patient's stay is 100 minutes on the day of admission, 80 minutes daily during the treatment period and 70 minutes on the day of discharge. The weighted average with an average length of stay of a patient of 13 days, calculated according to formula 1, is 83.5 minutes.
(100 + 80 × 0.825 × (13 2) + 70) / (13 × 0.825) ≈ 8.4.
There are approximately 10% of seriously ill patients in the department, therefore, this indicator per one hospitalized is 8.4 minutes (83.5: 10).
Most of the middle and junior medical staff of hospitals work around the clock. In this case, a 2 or 3 power queuing system is introduced.
The use of a 2-degree system provides for the care of patients by a doctor and a nurse. At the same time, the ward nurse fully and directly serves the patient, and the nurse performs only sanitary and hygienic functions in the wards and utility rooms. The forced performance by ward nurses of the functions of junior medical personnel, for example, cleaning rooms in the absence of the proper number of nurses, certainly worsens the quality of medical care and is contrary to sanitary and hygienic requirements.
With a 3-degree system, a doctor, a nurse and a nurse are involved in patient care.
The calculation of the weighted average cost of the working time of a nurse or a nurse per day of a patient's stay in a hospital (Tsut) is calculated using a formula similar to formula 1, but without taking into account the coefficient 0.825:
Tsut \u003d (tp + tl x (m - 2) + tv) / m, (2)
All designations correspond to formula 1, not per day, but per day of the patient's stay in the hospital.
The weighted average time costs are calculated separately for patients admitted in a planned manner and for emergency indications, and for surgical departments, in addition, for operated and non-operated patients. Then, taking into account the proportion of emergency hospitalization and operational activity, an indicator of the average time spent by a nurse or nurse per patient is determined. This method of calculation allows modeling the effective indicator of the average time spent per patient according to the profile of the department, depending on changes in the basic working conditions: an increase or decrease in the volume of emergency hospitalization, the number of surgical interventions, changes in the average duration of a patient's stay in a hospital, etc.
Calculation example.
The cost of the working time of a nurse per one patient per day for periods of stay in a hospital, admitted for emergency indications and in a planned manner.
Calculations of the time spent per patient per day, carried out according to formula 2, show that for those admitted in a planned manner with an average length of stay equal to 12 days, they will be 40.8 minutes:
(73.8 + 34.6 (12 2) + 70.2) x 12 ≈ 40.8.
The cost of working time for patients admitted on an emergency basis, with an average length of stay in the hospital equal to 8 days, will be 107.4 minutes: (396.6 + 60.8(8 2) + 97.8) / 8 ≈ 107, 4.
The average time spent for a 10% emergency hospitalization is 47.5 minutes: (107.4 × 10 + 40.8 × 90) / 100 ≈ 47.5.
The average time spent for a 30% emergency hospitalization is 61.8 minutes: (107.4 × 30 + 40.8 × 70) / 100 ≈ 61.8.
Thus, an increase in the share of hospitalization for emergency indications from 10 to 30% leads to an increase in the cost of the nurse's working time per patient per day from 47.5 to 61.8 minutes, i.e. by 30%.
II stage. The estimated load (service) rates for medical personnel of hospitals are expressed in the number of patients served per day or per day according to the formula:
Nb = (B x k) / T, (3)
where Nb - the norms of the load on the medical staff of the hospital;
B - daily working hours of medical personnel (according to a six-day working week) or daily working hours;
k is the coefficient of using the working time of the nursing staff for the main and auxiliary activities;
T is the average time spent per patient per day (from formula 2).
The main activity of medical personnel is, as a rule, work carried out directly with the patient, i.e., the time of direct contact of personnel with the patient, namely the performance of various procedures and manipulations. However, some categories of medical personnel have no contact with patients at all, for example, a cleaning nurse with a two-stage service system, so their main activity is to perform a direct production task.
All preparatory work carried out to perform the main activity and carried out both in the presence and in the absence of the patient is ancillary activities: preparation and cleaning of the workplace, preparation for manipulation, procedure, transfer to another department, etc.
During the working day, the staff needs short-term rest, meals, and sanitary and hygienic measures. These costs relate to personal time needed.
Intersectoral methodological materials recommend devoting about 10% of working time to personal necessary time. The experience of labor rationing in health care shows that the coefficient of working time for the main and auxiliary activities for most positions of medical personnel (except for the auxiliary medical and diagnostic service) is 0.923, i.e., out of a 6.5 hour working day, about 30 minutes are allocated to other types of work : (6.5 - 0.5) / 6.5 = 0.923.
For further calculations, you can take a coefficient of 0.9.
Calculation example.
The estimated norms of the workload of a nurse for organizing individual care for seriously ill patients with the cost of working time per one hospitalized is 8.4 minutes. The norms of the workload (service), calculated according to formula 3, are 42 hospitalized:
(6.5 × 60 × 0.9) / 8.4 ≈ 42.
Calculation example.
Estimated workload rates for a nurse at the cost of working time per 1 patient per day, equal to 47.5 minutes, determined by formula 3, are 27 hospitalized: (24 × 60 × 0.9) / 47.5 ≈ 27,
and at a cost of 61.8 minutes, 21 patients: (24 × 60 × 0.9) / 61.8 ≈ 21.
III stage. The standard for the position of medical personnel of a hospital, expressed in the number of beds per position, is calculated by the formula:
Nk = (Nb x 365) / R, (4)
where Nk is the number of beds per position;
Nb - load in the number of patients per day (from formula 3);
R is the planned number of bed days per year.
The value of the indicator R in formula 4 is:
· for city, regional hospitals - 330–340 days;
for hospitals located in rural areas - 320 days;
· for infectious diseases hospitals – 310 days;
· for maternity hospitals – 300 days.
Calculation example.
The standard for the position of a nurse for organizing individual care for seriously ill patients of a department of a city hospital, calculated according to formula 4, with the time spent per patient per day equal to 8.4 minutes and the number of patients served equal to 42, is 45 beds ((42 x 365 ) / 340) for one position.
Calculation example.
To ensure the activities of the ward nurse of the department in the conditions of a city hospital with the cost of working time per 1 patient per day equal to 47.5 minutes, and the estimated workload of 27 patients, a round-the-clock post for 29 beds is required ((27 x 365) / 340), and at costs equal to 61.8 minutes and load norms for 21 patients, a round-the-clock post for 23 beds ((21 x 365) / 340).
The calculation of the number of posts to ensure the operation of a round-the-clock post is carried out according to the formula:
Dpost = (24 × 60 × 365) / B, (5)
where Dpost - the number of posts to ensure the work of a round-the-clock post;
B - the annual budget of the working time of the position.
The annual working time budget (B in formula 5) is calculated according to the formula presented in the Methodological recommendations “Development of labor rationing technology in healthcare”:
B \u003d m × d - n - z,
where B is the annual working time budget;
m - the number of hours of work per day for a five-day working week;
d is the number of working days in a year according to a five-day working week;
n - the number of hours of reduction in the length of the working day or shift on holidays (during the year);
z - the number of working hours per vacation period, which is determined by multiplying the weekly working hours by the number of weeks of vacation.
In accordance with Art. 350 of the Labor Code of the Russian Federation for medical workers, a reduced working week is established - no more than 39 hours. Decree of the Government of the Russian Federation of February 14, 2003 No. 101, in connection with the special working conditions for a number of categories of medical personnel, established a reduced working week of 24, 30, 33 and 36 hours.
In accordance with the clarification of the Ministry of Labor of Russia of December 29, 1992 No. 5, approved by Decree No. 65 of December 29, 1992, the daily norm of working time is calculated according to the calculated schedule of a five-day working week with two days off on Saturday and Sunday. The length of the working day is determined by dividing the weekly length of working time by 5 days.
In accordance with Art. 95 of the Labor Code of the Russian Federation, the duration of the working day or shift immediately preceding a non-working holiday is reduced by 1 hour.
If a weekend and a non-working holiday coincide, the day off is transferred to the next working day after the holiday. For the purpose of rational use by employees of days off and non-working days, the Government of the Russian Federation has the right to transfer days off to other days. As a rule, as a result of such transfers, there are 7 or 8 pre-holiday days during the year. Currently, the number of non-working holidays in Russian Federation is determined by the Law of the Russian Federation of December 29, 2004 No. 201 “On Amendments to Article 112 of the Labor Code of the Russian Federation”:
When calculating the number of workers, holidays, non-working and pre-holiday days in a year, it is advisable to use the Production Calendar.
In 2009 - 250 working days on a five-day working week, 7 pre-holiday days.
In connection with the adoption of the Labor Code of the Russian Federation, a transition was made to the calculation of labor leave in calendar days (Article 115 of the Labor Code of the Russian Federation), however, the duration of the leave remained the same. In calculating the annual budget, it is advisable to define vacation time as the product of weekly working time by the number of weeks.
Calculation example.
The annual budget of working time for the position of a nurse in a city hospital with a 39-hour working week, 28 days of vacation (in terms of calendar days), calculated for 2009, is 1787 hours: (39 / 5) × 250 - 7 - 4 × 39 = 1787 h or 107220 min (60.0 × 1787).
Calculation example.
The number of nursing positions to ensure the operation of a round-the-clock post with an annual working time budget of 1787 hours, calculated according to formula 5, is 4,916 positions ((24 x 366) / 1787)
The calculation of the number of posts in a particular department is carried out according to the formula:
Dotd = (Dp × K) / P, (6)
where Dotd is the number of positions in the department;
Dp - the number of posts per 1 post;
K - the number of beds in the department;
P - the number of beds per 1 post (according to the standard).
Calculation example.
In a department with 30 beds, with a standard indicator of 20 beds per 1 post, and the number of nurse positions (ward), to ensure the operation of one round-the-clock post, equal to 4,916 positions (with a 39-hour working week and 28 days of vacation), 7,374 positions of a ward nurse: (4.916 × 30) / 20 = 7.374.
The calculation was carried out according to formula 6.
Peculiarities of labor rationing of middle and junior medical personnel in day hospitals
In recent years, hospital-replacing types of care have received significant development. The staffing standards for medical personnel of day hospitals establish the position of a senior nurse (regardless of the total number of beds). The positions of nurses are introduced at the rate of 1 position for 15 beds, the positions of ward nurses or junior nurses for patient care are established according to the positions of nurses (order of the Ministry of Health of Russia dated 09.12.1999 No. 438).
The volume of work of middle and junior medical personnel is associated with the need to organize care and fulfill medical appointments during the daytime, and in different institutions the hours of operation of the day hospital are determined depending on specific local conditions and range from 5 to 9 hours daily. In some cases, a two-shift operation of a day hospital is practiced. When calculating, it is necessary to take into account the number of days of work of a day hospital in a year: on a five-day or six-day working week, without weekends and holidays, etc.
The calculation of the number of middle and junior medical personnel in day hospitals can be performed based on the data of photochronometric observations. However, given the complexity of photochronometric observations to determine the time standards in healthcare facilities, it can be recommended to use the existing regulatory framework for labor for these groups of personnel in hospitals, but taking into account the working hours of a day hospital.
Headcount planning ward nurses, nursing assistants for patient care, ward nurses, ward nurses-cleaners of hospital institutions are carried out by establishing round-the-clock posts for a certain number of beds. When organizing the work of this staff, the load (service) norms during the daytime, as a rule, increase, and at night they decrease. For example, when planning one post for 20 beds during the day, you can set a load of 15 beds, and at night - 40–50 beds.
However, the differences in the composition of patients in a day hospital compared to a regular hospital department, the mobility of patients and the ability to self-service allow us to take the total number of beds per post as the basis for planning the number of middle and junior medical personnel in a day hospital.
The calculation of the number of positions of ward nurses, ward nurses in a day hospital is carried out according to the formula:
Dday = Dpost x (T / W) x (K / N), (7)
where Ddnevn - the number of positions of ward nurses and nurses in a day hospital;
Dpost - the number of positions of nurses or nurses to ensure the work of a round-the-clock post;
T is the number of hours of operation of the day hospital during the year;
W is the number of hours of operation of a round-the-clock post per year;
K - the number of beds in the day hospital;
N is the standard number of beds in a hospital with round-the-clock stay at 1 post.
Calculation example.
The therapeutic day hospital for 25 beds operates from 10 am to 6 pm, i.e. 8 hours daily for 303 days (according to a six-day working week).
Therefore, T = 2424 hours (8 × 303). A round-the-clock post of a ward nurse in the therapeutic department of the city hospital is set up for 20 beds, and for cleaning nurses - for 30 beds (with a two-stage service system). 4,916 positions are needed to ensure the work of a round-the-clock post (with a 39-hour work week and 28 days of vacation). Calculations according to formula 7 show that in this day hospital in 2009 1,696 posts of nurses and 1,131 posts of nurses are needed.
In accordance with the procedure for rounding off posts, 1.75 positions of a ward nurse and 1.25 positions of a ward nurse-cleaner can be introduced into the staff list.
Conclusion
The formation of a socially oriented market economy and its development is impossible without developed labor relations. The material basis of any society is the labor activity of people. Labor is a condition of human existence independent of any social forms and constitutes his eternal natural necessity. All areas of work need to be regulated. In this regard, the regulation of labor in health care is becoming even more relevant.
Currently, there is no single base for labor regulation for medical institutions, which affects the quality of medical services provided. All developed materials in the field of labor regulation, which are used in the organization of work in health care institutions, were either developed in the late 1980s or were published several years ago without serious revision, taking into account the current situation in the modern health care system of the Russian Federation. The modern organization of labor rationing in healthcare requires improvement in terms of determining and using in further calculations the coefficients for the use of working time for the main and other activities, as well as for operational and auxiliary time.
As can be seen from the work done, scientifically based labor standards, correctly reflecting specific conditions, provide an increase in labor productivity. If the labor standards are too low, they can give rise to pessimism, which negatively affects the results of productivity; if the standards are too high, they are not feasible. In both cases, the growth of labor productivity will be hampered. Thus, all changes in the organization of labor and production, equipment and technology of work are reflected primarily in labor standards. And the level of labor standards is an indicator of the level of organization of production and labor at the enterprise. Labor rationing is the basis of labor planning.
In health care organizations, work on labor rationing should be carried out in a timely manner in order to further reduce the time spent on providing medical services to the population, taking into account the use of new working methods, best practices, as well as improving workplaces and equipment used. The result of using the proposed guidelines developed rational load norms for medical personnel of medical institutions will act.
Bibliography
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2. Kadyrov F.N. Incentive wage systems in health care. Moscow: Grant, 2000.
3 . Organization and regulation of labor / Ed. V.V. Adamchuk. - M.: CJSC "Finstatinform", 1999.
4 . Shipova V.M. Organization of labor rationing in health care / Ed. acad. RAMS O.P. Shchepin. Moscow: Grant, 2002.
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7 .Methodological recommendations “Development of labor rationing technology in health care”, approved by the Ministry of Health and Social Development of Russia on December 20, 2007 No. 250-PD / 704. The authors-developers are employees of the National Research Institute of Public Health of the Russian Academy of Medical Sciences: O.P. Shchepin, A.L. Lindenbraten, V.M. Shipova, V.V. Kovaleva, N.K. Grishina, V.I. Filippova, S.M. Golovina, O.A. Kozachenko, N.B. Solovyov.
8. Shipova V.M. Planning the number of medical personnel in hospitals. M.: Grant. 1999.
9. Margulis A. L., Shilova V. M., Gavrilov V. A. The number of posts of health care facilities // Methodological and regulatory materials for calculating the number of posts and compiling the staffing tables of medical institutions. – M.: Agar, 1997.
The current stage of development of labor rationing in health care is characterized by two opposite trends.
The current stage of development of labor rationing in healthcare is characterized by two opposite trends:
- at the intersectoral level, a number of decisions are made aimed at creating a system of labor rationing, including in healthcare institutions; in one of the research institutes of the Ministry of Health of Russia, a division for the regulation of the work of medical workers was opened;
- The Ministry of Health of Russia approves legal documents on labor that contain a lot of erroneous provisions that are both editorial and semantic in nature and do not correspond to the theory and practice of labor rationing.
1. Organizational technologies of labor rationing
As positive measures to create a labor rationing system, one should recognize the approval of the Orders of the Ministry of Labor of Russia: dated May 31, 2013 No. 235 “On approval of guidelines for federal executive authorities on the development of standard industry labor standards” and dated September 30, 2013 No. 504 “On approval of methodological recommendations on the development of labor rationing systems in state (municipal) institutions”.
Order No. 235 contains:
- conditions and terms for the revision of standard industry labor standards;
- normative factors;
- methods of labor rationing;
- labor intensity;
- stages of normative research work.
The appendix to the order provides statistical tools for the development of standard industry labor standards.
The main provisions of the order coincide with the methodological materials on labor rationing in the healthcare sector [ Shipova V.M. Fundamentals of labor rationing in health care (textbook) Edited by Academician of the Russian Academy of Medical Sciences O P. Shchepin: - M .: GRANT Publishing House, 1998. - 320 p.; Labor rationing in health care, lectures No. 1-No. 10 M .: RIO FGBU "TsNIIOIZ", 2013-2017. ]. However, when applying Order No. 235, the specifics of the work of medical workers should be taken into account. Recently, there has been an increased interest of the heads of medical organizations in the development of local labor standards, including timing. In the process of timing, an examination of the volume and quality of work is carried out, an assessment of the compliance of medical and diagnostic measures with the diagnosis and state of health of the patient, and medical prescriptions. This work can only be carried out by an appropriate specialist who knows the technology of the diagnostic and treatment process well. It is a mistake to involve economists, personnel department employees, commissions in timing the activities of medical workers, since, firstly, these workers not only cannot conduct an expert assessment, but even accurately determine the name of the labor operation, and, secondly, the presence of persons who do not have medical education, is unacceptable when contacting a medical worker and a patient.
Order No. 504 defines the types of labor standards and establishes a connection between them. These provisions are of great importance to healthcare organizers and to all healthcare professionals. The fact is that the issues of labor rationing are still not included in the program of diploma and postgraduate training of doctors and paramedical workers, these issues are not considered in textbooks on public health.
Order No. 504 contains certain innovations in organizational technologies for labor rationing. The document provides recommendations for state (municipal) institutions on the development of the Regulations on the labor rationing system, which is either approved by the local regulatory act of the institution, taking into account the opinion of the representative body of workers, or included as a separate section in the collective agreement.
- labor standards applied in the institution;
- the procedure for implementing labor standards;
- the procedure for organizing the replacement and revision of labor standards;
- measures aimed at compliance with established labor standards.
The most important for medical organizations, taking into account the existing regulatory framework for labor in the healthcare sector, is the first section, in the annexes to which the following data is indicated:
- references to standard labor standards used in determining labor standards;
- the applied methods for determining the population rate based on the typical time rate, the number rate based on the typical service rate and the service rate based on the typical time rate (if calculations were made);
- calculation of the correction of standard labor standards, taking into account the organizational and technical conditions for the implementation of technological (labor) processes in the institution (if a correction was carried out);
- methods and means of establishing labor standards for individual positions (professions of workers), types of work (functions) for which there are no standard labor standards.
Order No. 504 also defines the circle of persons who should be involved in the development of a labor rationing system in an institution.
Taking into account the number of employees and the specifics of the activities of the institution for the performance of work related to labor rationing, it is recommended to create a specialized structural unit (service) for labor rationing in the institution. In its absence, the performance of work related to the regulation of labor may be entrusted to a structural unit (employee), which is in charge of staffing the activities of the institution, organization of labor and wages.
The implementation of these recommendations in medical organizations should be addressed, in our opinion, as follows. Given that health professionals do not have, as noted, necessary knowledge and skills in labor rationing, the deputy chief physician for economic issues should be responsible for organizing labor rationing in medical organizations. In the absence of this position, the organization of labor rationing can be entrusted to the personnel department, accounting staff, while it should be emphasized that it is organization regulation of labor.
The direct development and establishment of labor standards on the basis of standard norms approved at the federal level, or in the absence of such, is carried out by the heads of structural medical and diagnostic units, chief and senior nurses, taking into account the specifics of the specific conditions of labor organization.
2. Analysis of the modern regulatory framework for labor in the healthcare sector
The labor standards of medical workers have been set out in recent years in the following departmental legal documents:
- orders of the Ministry of Health of Russia on the procedures for the provision of medical care;
- letters from the Ministry of Health of Russia on the formation and economic justification of the territorial program of state guarantees of free provision of medical care to citizens for the corresponding financial year and planning period (hereinafter referred to as the territorial program);
- letters of the Ministry of Health of Russia, FFOMS "On methodological recommendations on methods of paying for medical care at the expense of compulsory medical insurance" (labor standards for dentistry).
The mass approval of the orders of the Russian Ministry of Health on the procedures for providing medical care, of which the recommended staffing standards are an integral part, began in 2009 and, after a short break in 2014, continues to this day. To date, there are 67 orders. Unfortunately, the erroneous provisions of the labor standards given in these documents, as a rule, are not corrected during the revision, and in some cases new errors are added to them.
The systemic erroneous provisions of modern legal documents on labor are as follows.
2.1. Erroneous application of different types of labor standards
In health care, the following types of labor standards are used: norms of time, workload (service), number. The values of these indicators are presented in the methodological materials on labor rationing in health care and, as indicated, in Order No. 504 of the Ministry of Labor.
Time standards in health care are expressed in minutes, conventional units, conventional units of labor intensity (UUT), load (service) norms - in the number of visits per hour, year, patients per day, number of examinations, procedures per day, year or for any other period of time .
The size standards are presented in terms of the population or its contingents, the number of beds or round-the-clock posts per 1 medical position, the volume of a particular work.
In the orders for the procedures approved before 2012, the norms of time for visits in certain specialties were cited, erroneously called the norms of workload or workload. When reviewing such orders, these data are not indicated. However, in the current order for coloproctology (dated April 2, 2010 No. 206n), the time standards for a diagnostic and treatment appointment are given, called the load rate.
In the territorial programs, starting from 2008 and up to the present, a table is provided, the title of which indicates “the load indicator for 1 position of a doctor (middle medical worker)”, and the content of the table shows the number of beds per 1 medical position and the number of beds per 1 post of nurses, i.e. population standards.
2.2. Unjustified change in the format of presentation of labor standards
The standards for the number of personnel in health care institutions are determined by the staffing standards used for medical workers, and the standard staff used to standardize the work of employees and workers of a medical organization. The difference between these documents is that staffing standards are set based on some indicator, for example, at the rate of 1 position of a general practitioner for 25 beds. The vast majority of typical states do not require such a calculation, and one or another position is established on the basis of the presence or a certain capacity of an institution, unit, for example, the position of deputy chief physician for economic issues is established in a medical facility with 100 or more beds and including outpatient clinics. divisions.
The recommended staffing standards given in the orders on procedures are modeled on model staffing that do not provide for calculation and are used for non-medical personnel. With the transition to this new form of population norms, i.e. the use of model states instead of staff standards, the words so necessary for staff standards have also disappeared: “the position is established on the basis of ...”, which can lead to different workloads for medical workers with the same amount of work. For example, if the position of a doctor is set as “1 for 20 beds”, this leads to the fact that only one position can be established for 20 beds, and for 30, and for 35 beds, which obviously leads to a different workload for the doctor. If the position was established “based on 20 beds”, as is customary in staffing standards, then 1.5 positions can be installed for 30 beds (30: 20 = 1.5), and 1.75 positions for 35 beds ( 35:20=1.75).
Only in two orders (dated November 15, 2012 No. 923n “Procedure for the provision of medical care in the field of neurosurgery” and dated November 15, 2012 No. 918n “The procedure for providing medical care to patients with cardiovascular diseases”) and only in hospital departments of the position of medical workers are set “based on 30 beds”.
2.3. Violations of the nomenclature of medical organizations, specialties and positions of medical workers, hospital beds
Currently, the following legal documents on nomenclatures are in force:
- Order of the Ministry of Health of Russia dated 08/06/2013 No. 529n "Nomenclature of medical organizations";
- Order of the Ministry of Health of Russia dated 07.10.2015 No. 700n "Nomenclature of specialties of specialists with higher medical and pharmaceutical education" with additions made by order of the Ministry of Health of Russia dated 11.10.2016 No. 771n;
- Order of the Ministry of Health and Social Development of the Russian Federation dated April 16, 2008 No. 176n with subsequent additions “Nomenclature of specialties for specialists with secondary medical and pharmaceutical education in the healthcare sector of the Russian Federation”;
- Order of the Ministry of Health of Russia dated December 20, 2012 No. 1183n “Nomenclature of positions of medical and pharmaceutical workers”;
- Order of the Ministry of Health of Russia dated October 08, 2015 No. 707n “Qualification requirements for medical and pharmaceutical workers with higher education in the direction of training “Health care and medical sciences””;
- Order of the Ministry of Health of Russia dated 10.02. 2016 No. 83n "Qualification requirements for medical and pharmaceutical workers with secondary medical and pharmaceutical education";
- Order of the Ministry of Health and Social Development of the Russian Federation of May 17, 2012 No. 555n "Nomenclature of the bed fund according to the profiles of medical care."
Compliance with these nomenclatures is mandatory for medical organizations. Incorrect names of positions and specialties in the staffing tables of medical organizations lead to complications in the provision of pensions for employees, the establishment of a work and rest regime, wages, and so on. Moreover, such violations are unacceptable in legal documents. However, in almost every order on orders there are names of positions and specialties that do not correspond to the current nomenclatures. So, for example, in orders on orders, the positions of a gynecologist are given instead of the position of an obstetrician-gynecologist, a dermatologist instead of a dermatovenereologist, a traumatologist instead of an orthopedic traumatologist, a neuropathologist instead of a neurologist, a laboratory assistant instead of a clinical laboratory diagnostics doctor, a ward nurse instead of a ward nurse (guard), a bacteriologist instead of a bacteriologist, a massage therapist instead of a massage nurse, etc., as well as positions that are not in the nomenclature, for example, a microbiologist, a senior laboratory assistant, a senior radiologist, etc.
When applying orders on the nomenclature, one should keep in mind a number of existing contradictions between the nomenclature of positions, the nomenclature of specialties and qualification requirements. A number of medical positions indicated in the nomenclature of positions are not included in the nomenclature of specialties. These positions include: a diabetes doctor, a medical prevention doctor, a clinical mycologist, a laboratory mycologist, a palliative care doctor, a medical rehabilitation doctor. These positions are also absent in order No. 707n on qualification requirements, although for most of these positions there are labor standards defined in the relevant orders on procedures.
The order of the Ministry of Health of Russia dated October 11, 2016 No. 771n made its “mite” to the incompatibility of orders on the nomenclature of specialties, positions and qualification requirements, which included a number of specialties as an addition to the nomenclature of specialties of specialists with higher medical and pharmaceutical education.
These changes in the nomenclature of specialties are not accompanied by changes in either the nomenclature of positions or in the document on qualification requirements.
2.4. Erroneous data on the number of posts to ensure round-the-clock work
The organization of the activities of medical organizations involves different modes of operation of units and relevant positions for their functioning. So, for example, an ambulance station (department) operates around the clock; in the hospital, to ensure round-the-clock provision of medical and diagnostic medical care, round-the-clock posts of middle and junior medical workers, a number of positions of doctors are established. The orders on procedures indicate the specific number of posts to ensure round-the-clock work: from 1 to 5.7 posts.
The number of posts to ensure round-the-clock work depends on two main groups of data:
- the number of working days and pre-holiday days in a year in which there are reductions in working hours;
- mode of work and rest positions.
The number of working and pre-holiday days in which there is a reduction in working hours changes annually.
The regime of work and rest differs not only in the names of positions, but even in the same position, but working in medical organizations in different regions of the country, for example, in an institution in the Central Strip of Russia and in the regions of the Far North due to different vacation duration.
Therefore, it is not a different number of posts to ensure round-the-clock work, specified in orders on procedures, that is erroneous, but the very indication in the normative record of this number of posts. The normative record on the staffing of round-the-clock work should contain only the number of beds for organizing this mode of operation, or a certain amount of work, for example, the number of emergency calls and, consequently, the number of teams. The specific number of positions must be calculated in a medical organization annually, depending on the mode of work and rest of the position and the number of working and pre-holiday days in the year in which the reduction of working time occurs.
2.5. Unreasonable introduction of new indicators for labor rationing
When choosing an indicator for labor rationing, the following requirements must be observed:
- taking into account the current level of development and organization of medical care, labor organization, equipment, compliance with the relevant technologies of the treatment and diagnostic process;
- compliance with the degree of integration of the indicator to the conditions and nature of the work of a particular type of institution, ensuring the necessary accuracy in setting staffing standards; the influence of the main norm-forming factors and the need to take them into account in the normative indicator;
- coverage of the most common options for performing work, convenience for calculating staffing standards;
- the specific content of normative indicators, the possibility of establishing their quantitative value.
The following indicators meet these requirements:
- the number of the population or its individual contingents to establish the positions of outpatient doctors;
- the number of beds to establish the positions of medical workers in hospitals;
- the number of outpatient doctors and the number of beds or the amount of work to establish the positions of medical personnel of the auxiliary medical diagnostic service, most of the positions of middle and junior medical workers.
An unreasonable change in these indicators for the normalization of labor in the absence of their value fixed by statistics makes these data very manageable and leads to the possibility of an unjustified increase or decrease in the number of employees. An example of the erroneous introduction of a new labor indicator is the establishment in orders of orders of the position of an anesthesiologist-resuscitator for the number of workplaces of operating tables.
It is quite obvious that the number of workplaces, operating tables does not indicate the volume of work of the personnel, in this case it is necessary to determine at least the number of surgical interventions on one operating table, or the hours of operation of the operating table, and so on. According to earlier orders of the USSR Ministry of Health, the standard number of these doctors was set to the number of surgical beds, and, in our opinion, there are no grounds for changing this indicator.
Another example of changing the indicator for labor rationing is to establish the standard number of nurse positions per office. In fact, the number of offices, as premises for the work of a doctor, is not in the statistics, and the indicator for the standard for the number of positions of a nurse should be the number of positions of a doctor of a particular specialty.
Another "novelty" of orders on orders is the change in the normative indicator for the position of chief physician, head of the department. Thus, the number of these positions in the children's polyclinic, according to the relevant order (dated April 16, 2012 No. 363n), is set for 10 thousand attached population. If you follow the "letter" of this order, then in a children's polyclinic serving 20 thousand children, you can establish 2 positions of chief doctor, and 30 thousand - 3 chief doctors, which is contrary to public health practice.
2.6. Lack of regulatory support for a number of departments of healthcare facilities, individual positions
In a number of modern regulatory documents, positions or entire divisions are “missing”. Thus, the order on the order in the inpatient department of traumatology and orthopedics (dated March 31, 2010 No. 201n) did not provide for the positions of a dressing and operating room nurse. When this document was revised (No. 901n dated November 12, 2012), the position of a dressing nurse was introduced into the structure of this unit, and the position of an operating room nurse is still missing. In the staffing standards of the dermatovenerologic dispensary, there is no staffing of medical workers in the admissions department, in the staffing standards of the children's polyclinic - the security of the registry, etc.
2.7. Erroneous wording of the standard for the position of the head of the department
In the staff list of a medical organization, the position of the head can be established only in the form of one position, although the procedure for establishing this position may be different: instead of the whole or part of the position of a doctor or in addition to medical positions. At the same time, the position of the head in outpatient departments is established by the number of positions of outpatient doctors of the corresponding specialty, in hospital departments - by the number of beds. In orders on orders, in some cases it is recommended to establish a fractional number of posts: 0.25; 0.5 or 0.75 posts.
The position of the head of the hospital department in a number of cases is established, as indicated, "based on 30 beds." Such a record is quite acceptable for most positions, but these positions include the head of the department. At the same time, the question of the number of positions of managers in a department of a different capacity, for example, in a department with 45 or 50 beds, remains open. Following the specified standard, in a department with 45 beds, 1.5 positions of the head can be established (45:30 = 1.5), and in a department with 50 beds - 1.75 (50:30 = 1.667, rounded 1.75). Thus, the presented establishment of the positions of heads of departments is contrary to public health practice.
2.8. Inconsistency in the values of labor standards in different, simultaneously valid documents
In simultaneously acting orders on orders, a different standard is indicated for the same position. For example, the position of a surgeon, according to one of the orders, is set as 1 position per 10.0 thousand of the adult population, according to another - 0.65 positions. It is quite characteristic that both of these orders were approved in 2012 and entered into force almost simultaneously - in November-December 2012. The standard for the position of a pediatric urologist-andrologist has a two-fold difference: according to one of the orders on orders, this position is established for 10.0 thousand of the attached child population, according to another - for 20.0 thousand.
In addition to orders on orders, labor standards are also indicated in territorial programs, while for a number of profiles there is a discrepancy between these values and orders on orders. So, for otorhinolaryngology, according to the territorial program for 2016, a standard is set equal to 12 beds per 1 doctor's position, and according to the order on order - for 20 beds, for nephrology - for 12 and 15 beds, respectively, and so on.
There are no coincidences indicated in the territorial program and in the orders of the Ministry of Health, in terms of the standard labor costs for a visit: according to the order approved in mid-2015, the following typical time standards for a visit were established: for a district general practitioner - 15 minutes, for a general practitioner (family doctor) - 18 min. The territorial program for 2016 states the following: “The recommended time limit for 1 visit to a district therapist, general practitioner, district pediatrician is an average of 20 minutes.”
Such conflicting data on the value of standard labor indicators specified in simultaneously valid legal documents approved by the same department require urgent action at the federal level of health management.
2.9. Recommendations for the use of one indicator out of several given in the standard
In staff standards, the establishment of a particular position is possible for several indicators. In these cases, the number of posts is calculated for each indicator, and then the calculated number of posts is summed up. In the orders on procedures approved in 2016 (dated March 1, 2016 No. 134n, dated March 24, 2016 No. 179n), the union “or” is included in the normative record. This union is used in Russian to connect two or more sentences, as well as homogeneous members of a sentence that exclude each other. Thus, the normative record with the union "or" suggests that you need to choose only one of the given indicators. However, the logic and practice of applying labor standards suggests that if a position in one of the medical organizations is set for one of the indicated indicators, for example, in one of the medical and physical education dispensaries for the number of people involved in sports, and in another - for another indicator, for example, on the urban population living on the territory of the dispensary, this will lead to a different standard number of positions that does not reflect the full scope of work and the load on servicing all the contingents of the population and athletes indicated in the document.
2.10. Economic groundlessness of new labor standards
All the shortcomings of regulatory documents indicated in the previous paragraphs can be considered as editorial, although they are unacceptable in documents of this kind. If desired, erroneous provisions can be corrected: you can introduce a calculation method for the formation of labor standards, bring the names of positions and specialties into line with the nomenclatures, change the normative records for establishing the positions of heads of departments, set the required indicator for round-the-clock work, eliminate contradictions in simultaneously acting normative and legal documents and so on.
The medical and economic assessment of modern labor standards was carried out according to the methodology of labor rationing in healthcare. Within the framework of this publication, it is not possible to describe all the methodological approaches used, they are presented in sufficient detail in the relevant literature and are used in medical organizations in the economic analysis of the activities of medical workers and departments.
Carrying out calculations of the normative number of medical positions only according to orders approved over the past two years (except order No. 134n), showed that over 30 thousand additional positions are needed for their implementation, including the need to increase the positions of narcologists by more than 3 times compared to their actual number, geriatricians - 10 times and so on. Moreover, the calculations were carried out only on those indicators that have statistical security.
A striking example of the economic unreasonability of labor standards is Order No. 134n “On approval of the procedure for organizing the provision of medical care to persons involved in physical culture and sports (including the preparation and conduct of physical culture and sports events), including the procedure for medical examination of persons wishing to undergo sports training , engage in physical culture and sports in organizations and (or) fulfill the test standards (tests) of the All-Russian Physical Culture and Sports Complex "Ready for Labor and Defense".
If, when calculating the normative number of medical positions, only one indicator is used: the number of people involved in sports and health clubs, organizations and groups, which is currently 39071.4 thousand people [ Healthcare in Russia, 2015: Stat. Collection / Rosstat. - M., 2015. - 174 p.], i.e., contrary to common sense, to use the word “or” indicated in the normative record, it turns out that in order to implement only this provision of the order, the number of medical positions is required that exceeds the actual number of all doctors in the country. For comparison, we note that the previous order (dated August 9, 2010 No. 613n) established the standard number of doctors in sports medicine and physiotherapy equal to more than 25 thousand positions, and the actual number of these doctors is 3.9 thousand positions. Moreover, these positions include not only doctors working in medical and physical education dispensaries, but also in hospitals, sanatoriums, and polyclinics. Under these conditions, with such a lack of staff standards of the current order, the very decision to revise the regulatory document is erroneous.
With regard to the standard number of middle and junior medical workers, a different trend is revealed: a decrease in the number of average medical personnel and the disappearance of the standard for the number of junior medical workers. In accordance with the new order (dated 05.05.2016 No. 279n), the standard for the positions of paramedical workers in sanatorium-resort organizations has been reduced tenfold compared to the previously existing ones, and the standard for the position of a ward nurse (according to the nomenclature in force during the period of approval of this standard) or the standard for junior there is no nurse to care for the sick (according to the current nomenclature) at all.
The introduction of order No. 279n of the Ministry of Health of Russia into healthcare practice does not allow organizing the work of a sanatorium for children with less than 250 beds and a sanatorium for adults with less than 500 beds, primarily because of such a reduction in the standard number of middle and junior medical workers and the impossibility of their round-the-clock work. In sanatoriums of greater capacity, the reduction in the number of round-the-clock posts of ward nurses (guards) and the complete lack of standard provision of junior medical workers will lead to significant difficulties in organizing the provision of medical care.
There are no standards for the positions of orderlies in the recommended staffing standards for the department (office) of medical prevention for adults (dated September 30, 2015 No. 683n), the audiology room (dated April 9, 2015 No. 178n), the geriatric department and the geriatric office (order No. 38 dated January 29, 2016). ) etc.
The reduction in the actual number of junior medical personnel in medical organizations is due to an attempt in this way to fulfill the May 2012 decrees of the President of Russia. In medical organizations, the positions of nurses are being transferred to the positions of cleaners, i.e., these positions are being excluded from the number of medical workers, and for several months of 2016, according to Rosstat, about 50 thousand nurses quit [ Chief nurse, 2016. - No. 10. - P.8.]. It should be noted that such a transfer is not always justified, since in a number of cases the nurse performs not only the functions of a cleaner, but also takes part in providing medical care to the patient to a certain extent, i.e., performs the functions of a junior nurse to care for the sick, especially in the provision of hospital and sanatorium care. But in this case, we are talking about the standard provision of junior medical personnel, and in order to transfer the positions of nurses to the positions of cleaners, it is necessary to have a standard for the position of a nurse. In this regard, we consider it erroneous to exclude the positions of junior medical personnel from staff standards.
Conclusion
The current stage in the development of labor rationing can be viewed as a transition to the creation of a system of labor rationing. The measures taken to create this system are apparently not enough, since legal documents containing such obvious errors are still being approved.
The critical mass of erroneous provisions of orders on procedures in terms of labor standards, the main of which is economic unreasonableness, determines the need to revise these legal documents. In modern conditions of organizing labor rationing and functioning in one of the research institutes of the Ministry of Health of Russia, the labor rationing unit, all documents of this kind should be developed jointly with labor rationing specialists, or at least undergo an appropriate expert assessment before they are approved. Such work is partially carried out, but, in our opinion, it should be extended to all draft legal documents on labor standards.
In order to improve the development of labor standards, it is necessary to include labor rationing issues in the training program for doctors and paramedical personnel and postgraduate training in the specialty "Health Organization and Public Health", "Organization of Nursing", holding seminars, lectures on this topic, and, first turn, for the developers of labor standards and specialists who approve these standards.
For chief physicians, heads of departments of medical organizations, representatives of ministries and departments in the field of healthcare: we suggest that you familiarize yourself with the program of the symposium, which will be held on August 21-25, 2017 "Management of a medical institution in modern conditions" .
We invite you to take part in the International Conference for Private Clinics , where you will get the tools to create a positive image of your clinic, which will increase the demand for medical services and increase profits. Take the first step towards the development of your clinic.
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Keywords
LABOR REGULATION/ LABOR STANDARDS / STATE (MUNICIPAL) INSTITUTIONS / EFFICIENT CONTRACT / INDICATORS AND CRITERIA FOR ASSESSING ACTIVITIES / LOCAL REGULATION / STATE (MUNICIPAL) INSTITUTIONS/ NORMING OF THE LABOR / LABOUR NORMS / EFFICIENT CONTRACT / INDEXES AND CRITERIA OF EVALUATION/ LOCAL NORMATIVE ACTannotation scientific article on economics and business, author of scientific work - Kadyrov F. N.
Despite the recommendations issued by the Ministry of Labor of Russia, the editorial office is often asked to talk about the system labor rationing, on the rights of health care institutions in matters labor rationing etc. Today we publish the first material on this topic. This theme will be continued in the following issues. Questions labor rationing are becoming increasingly important due to the need to establish indicators and criteria for evaluating the effectiveness of employees' activities in the framework of the introduction effective contract. Logically labor rationing must precede the introduction effective contract. but labor rationing a complex and lengthy process, which, moreover, must occur continuously. Therefore, these processes are largely parallel. The starting document for institutions (along with the recommendations of state (municipal) bodies should be local regulation Regulations on the system labor rationing in the institution.
Related Topics scientific papers on economics and business, author of scientific work - Kadyrov F. N.
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Rationing of labor activity in supporting subdivisions of bodies and institutions of the Ministry of Internal Affairs of the Russian Federation: main characteristics, trends, problems and ways to overcome them
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The order for developing the regulation on labor system norms in a state (municipal) healthcare institution
Questions with regards to the labor norming standards are becoming gradually relevant due to the necessity of establishing indexes and criteria for evaluating employees' activity efficiency in the frames of introducing an efficient contract. Logically speaking, norming of the labor should come first before introducing the efficient contract. However, norming the labor is a complex and time-consuming process, which has to run consistently on an ongoing basis. Therefore, these processes, to a large extent, develop parallel one to another. The starting document for institutions (along with the recommendations of state (municipal) bodies has to become a local normative act Resolution regarding the system of norming the labor in institution.
The text of the scientific work on the topic "Procedure for the development of the Regulations on the system of labor rationing in a state (municipal) healthcare institution"
From the editor:
Despite the recommendations issued by the Ministry of Labor of Russia, the editorial office is often asked to talk about the labor rationing system, the rights of healthcare institutions in matters of labor rationing, etc. Today we publish the first material on this topic. This theme will be continued in the following issues.
Chief editor N.G. Kurakova
F.N. Kadyrov,
Federal State Budgetary Institution "TsNIIOIZ" of the Ministry of Health of Russia, Moscow, Russia
PROCEDURE FOR THE DEVELOPMENT OF THE REGULATIONS ON THE SYSTEM OF LABOR REGULATION IN THE STATE (MUNICIPAL) HEALTH CARE INSTITUTION
UDC 614:338.26
Kadyrov F.N. The procedure for developing a regulation on the system of labor rationing in a state (municipal) healthcare institution (FGBI "TsNIIOIZ" of the Ministry of Health of Russia, Moscow, Russia)
Annotation. The issues of labor rationing are becoming increasingly important due to the need to establish indicators and criteria for assessing the effectiveness of employees' activities in the framework of the introduction of an effective contract. Logically, labor rationing should precede the introduction of an effective contract. However, the rationing of labor is a complex and lengthy process, which, moreover, must occur continuously. Therefore, these processes are largely parallel. The starting document for institutions (along with the recommendations of state (municipal) bodies should be a local normative act - the Regulations on the labor rationing system in the institution.
Key words: labor rationing, labor standards, state (municipal) institutions, effective contract, indicators and criteria for evaluating activities, local regulations.
The main regulatory documents relating to labor rationing in an institution include:
Labor Code of the Russian Federation (Chapter 22).
Decree of the Government of the Russian Federation of November 11, 2002 No. 804 "On the rules for the development and approval of standard labor standards."
Decree of the Government of the Russian Federation dated November 26, 2012 No. 2190-r “On approval of the Program for the gradual improvement of the wage system in state (municipal) institutions for 2012-2018”.
Order of the Ministry of Labor and Social Protection of the Russian Federation dated September 30, 2013 No. 504 “On approval of the methodology
The issues of labor rationing are becoming increasingly important due to the need to establish indicators and criteria for assessing the effectiveness of employees' activities in the framework of the introduction of an effective contract. The basic document for the development of a labor rationing system for institutions (along with the recommendations of state (municipal) bodies should be a local normative act - the Regulations on the labor rationing system in an institution (hereinafter - the Regulations).
These issues are disclosed in most detail in the Order of the Ministry of Labor and Social Protection of the Russian Federation dated September 30, 2013 No. 504 “On approval of guidelines for the development of labor rationing systems in state (municipal) institutions” (hereinafter referred to as the Recommendations).
However, the Recommendations do not cover all aspects of the problem under consideration. In addition, they do not take into account the specifics of the healthcare sector. Therefore, the purpose of this publication is to analyze and summarize the normative and methodological materials on the issues of labor rationing in healthcare institutions and to develop proposals for the development and content of the Regulations on the labor rationing system in a healthcare institution.
Within the framework of the adopted system of labor rationing, the main types of labor standards are: time norms, production (load) norms, service norms and headcount norms.
In addition to labor standards, there are also labor standards. The fundamental differences between them are that the labor standards are calculated in relation to the specific conditions of the normalized process for certain values
factors. And the standard is the estimated value of the cost of working time, material and monetary resources used in labor rationing, planning. Labor standards are established for various types of standardized or averaged organizational and technical conditions. An example of such standards are staffing standards, which serve to calculate the number of staff positions when compiling the staffing table.
Labor standards are set for a specific job and are systematically reviewed. Labor standards are repeatedly used to calculate labor standards and operate without revision for a long time, since changes in organizational, technical and other conditions for a set of jobs occur more slowly than at specific workplaces.
There are the following standards: labor standards, time standards, headcount standards.
Let's take a closer look at labor standards.
Labor rationing establishes a measure of labor for the performance of a certain amount of work, that is, reasonable norms for the expenditure of working time for the performance of various works.
Labor standards are the expression of the measure of labor:
Time limits;
Load norms;
production standards;
Service standards;
Number norms.
They characterize, from various angles, the labor costs required to perform a certain amount of work by workers of appropriate qualifications in certain organizational and technical conditions.
Norms of time - the cost of working time to perform a unit of work (function) or provide a service by one or a group of employees of appropriate qualifications (regulated duration
performance of a unit of work in certain organizational and technical conditions). Time norms are expressed in seconds, minutes, hours, arbitrary units, conventional units of labor input (UET-ah).
Load norms - the amount of work performed per unit of time under certain organizational and technical conditions. Load indicators are such as the number of visits per hour, patients per day, number of examinations, procedures per day, month, year (function of a medical position), etc.
The rate of production - the number of products produced per unit of working time. Production rates are expressed in volume or cost indicators. In health care, volumetric in-kind indicators of output are not widely used (with the exception of UETs). Such indicators as the cost of services rendered, profit, conditional profit, etc. can act as cost indicators.
Workload norms and production norms in healthcare are often used as synonyms, or workload norms are considered as production norms in relation to healthcare (as a sphere of non-material production).
Service rates - the number of objects (jobs, equipment, areas, etc.) that an employee or a group of employees of appropriate qualifications are required to service during a unit of working time.
The differences between the load (production) norms and the service norms lie in the fact that the service norm is the number of production facilities that an employee or a group of employees of appropriate qualifications must service during a unit of working time in certain organizational and technical conditions.
Moreover, the amount of work for each individual object is not regulated either in time or in established units (in contrast to
depending on the norms of production or load) - it is calculated on an average and depends on specific conditions, therefore, in some cases, in practice, in principle, it can be equal to zero.
As production units that act as objects of service in health care, a bed or a person usually acts.
Therefore, service rates are the number of beds or people served by a given doctor, nurse, etc., while load rates reflect precisely the volume of work: the number of visits, discharged patients, etc. per doctor, etc.
The task of establishing service standards is to achieve the normal functioning of an object, while the task of establishing load (output) standards is to determine the value of an indicator characterizing the amount of work without linking to a specific object.
Headcount norms - the established number of employees of a certain professional and qualification composition, necessary to perform specific production, management functions or scope of work.
Norms of time and norms of load (maintenance) have an inverse mathematical relationship.
The employer is responsible for the state of labor rationing in the institution. The organization of work related to the regulation of labor, including the implementation of organizational and technical measures, the introduction of rational organizational, technological and labor processes, the improvement of the organization of labor, can be carried out both directly by the head of the institution, and in the prescribed manner can be entrusted by the head to one of his deputies.
The development (determination) of a labor rationing system in an institution should be carried out by specialists with the necessary knowledge and skills in the field of
organization and regulation of labor. Taking into account the number of employees and the specifics of the activities of the institution for the performance of work related to labor rationing, it is advisable to create in the institution a specialized structural unit (service) for labor rationing, for example, a labor rationing department. In its absence, the performance of work related to labor rationing may be entrusted to a structural unit (employee) in charge of economics, labor organization and wages (for example, the department of labor and wages, the planning and economic department) and / or staffing the activities of the institution (HR department, etc.).
The names of the positions of the relevant departments may be different: economist, engineer, etc. In particular, the Qualification Handbook of the Positions of Managers, Specialists and Other Employees, 4th edition, supplemented (approved by the Decree of the Ministry of Labor of the Russian Federation of August 21, 1998 No. 37) (as amended and supplemented), contains such positions as “Engineer for labor rationing ” and “Timekeeper”.
In the general case, the regulation of labor (including the analysis of the norms used, their revision, etc.) should logically precede the conclusion of an employment contract (additional agreement to an employment contract) as part of the introduction of an effective contract. This is related to the following:
The introduction of an effective contract involves the establishment of indicators and criteria for employees to evaluate the effectiveness of their activities, which in many cases are based on labor standards (load indicators, etc.);
The procedure for notifying employees of changes in labor standards generally coincides with the procedure for notifying employees of changes in the terms of an employment contract when an effective contract is introduced, which makes it advisable to combine these procedures.
However, labor rationing is a complex and lengthy process, which, moreover, must occur constantly. Therefore, in practice, these processes are largely parallel. In this regard, it is permissible to introduce an effective contract within the framework of previously used labor standards (which may be revised later) or even without specifying specific labor standards (in this case, in the concluded labor contract or additional agreement an entry is made to the employment contract that labor standards will be determined for the employee in the prescribed manner).
In accordance with Article 162 of the Labor Code of the Russian Federation (hereinafter referred to as the Labor Code), local regulations providing for the introduction, replacement and revision of labor standards are adopted by the employer, taking into account the opinion of the representative body of employees.
Therefore, it is recommended that the labor rationing system in an institution be established in the Regulations on the labor rationing system of the institution, which is either approved by the local regulatory act of the institution, taking into account the opinion of the representative body of employees, or is included as a separate section in the collective agreement. In the first case, the Regulation is approved by an order for the institution, which may be called: “On approval of the Regulation on the system of labor rationing in the institution” (hereinafter - the Order).
The order must be adopted taking into account the opinion of the representative body of workers (trade union organization, etc.). In this regard, the draft order should be sent for approval to the organization that is the representative body of the employees of this institution.
The procedure for taking into account the opinion of the elected body of the primary trade union organization when adopting local regulations is established by Article 372 of the Labor Code.
The elected body of the primary trade union organization no later than five working days
from the date of receipt of the draft local regulatory act, sends the employer a reasoned opinion on the draft in writing.
If the reasoned opinion of the elected body of the primary trade union organization does not contain agreement with the draft local normative act or contains proposals for its improvement, the employer may agree with it or is obliged to conduct additional consultations with the elected body of the primary trade union organization within three days after receiving the reasoned opinion. employees in order to reach a mutually acceptable solution.
If agreement is not reached, the disagreements that have arisen are documented in a protocol, after which the employer has the right to adopt a local normative act, which can be appealed by the elected body of the primary trade union organization to the appropriate state labor inspectorate or to the court. The elected body of the primary trade union organization also has the right to initiate the procedure of a collective labor dispute in the manner prescribed by the Labor Code.
Upon receipt of a complaint (application) from the elected body of the primary trade union organization, the State Labor Inspectorate is obliged to conduct an inspection within one month from the date of receipt of the complaint (application) and, if a violation is detected, issue an order to the employer to cancel the local normative act, which is mandatory for execution.
The structure of the Regulations is not strictly regulated. However, in accordance with paragraph 22 of the Recommendations, it is proposed to include the following sections in the Regulations:
a) “Labor standards applied in the institution”;
b) "Procedure for the implementation of labor standards";
c) "The procedure for organizing the replacement and revision of labor standards";
d) "Measures aimed at compliance with established labor standards."
In our opinion, at the stage of the beginning of systematic work on labor rationing in an institution, the structure of the Regulations should be somewhat different. Indeed, according to the Recommendations, section a) “Labor standards applied in the institution” should contain not only references to the standard labor standards used in determining labor standards, but also the applied methods for determining the number norm based on the typical time norm, the number norm based on the standard norm service and service rate based on the typical time rate (if calculations were made).
However, one of the tasks of rationing is precisely the systematization of the standards used, making calculations, deciding in which cases (in which departments, etc.) standard labor standards are used, and in which - developed in the institution itself, etc. d. In other words, at the current stage, the Regulations should primarily determine the directions and methods of normalization, and not fix the results of normalization (which, in fact, do not yet exist).
Therefore, we propose a slightly different structure of the Regulations on the labor rationing system in the institution, which is given below. In the future, the structure of the Regulations may be closer to that provided for in the Recommendations. So, we propose the section "Procedure for timing", which is more methodical than organizational in nature. It is important because of the novelty of timing issues for most institutions. In the future, this section, like some others, may be deleted.
In addition, the proposed version of the Regulations provides for the creation of a Commission on labor rationing, which is not mentioned in the Recommendations. In practice, the functions of this commission may
Manager
be wider than those proposed, including the issues of rationing consumables (detergents, food, etc.). In this case, it is advisable to use the following (wider) name of the commission: "Rating Commission" (without using the word "labor").
Below is a sample of the Order for a healthcare institution “On approval of the Regulations on the system of labor rationing in an institution” (it contains samples of not all documents approved by the Order). It can be used not only in state (municipal) healthcare institutions, but also in medical organizations with other organizational and legal forms.
We draw attention to the fact that an example of creating a special
social division - the department of labor rationing. In practice, due to the small size of institutions, limited financial resources, etc. such departments will not be created in all institutions. As mentioned above, in such cases, these functions should be assigned to employees of other departments.
In conclusion, we note that in regulatory legal acts and other materials on labor rationing, phrases like: “in order to introduce rational organizational, technological and labor processes” are often found. With regard to healthcare, these conditions are, in particular, the conditions provided for by the procedures for the provision of medical care in order to implement standards of medical care, clinical recommendations, etc.
1. Margulis A.L., Shipova V.M., Gavrilov V.A. The number of posts of health care facilities. Methodical and normative materials on the calculation of the number of posts and the preparation of staffing tables of medical institutions. - M.: AGAR, 1997. - 72 p.
2. Reference information: "Labor standards" (Material prepared by ConsultantPlus specialists). - http://base.consultant.ru/cons/cgi/online.cgi?req=home#doc/ /LAW/148265/4294967295/0.
3. Shipova V.M. Staffing of hospital care in modern conditions / deputy chief physician: medical work and medical expertise.
2009. - S. 12-22.
4. Shipova V.M., Belostotsky A.V., Kindarov Z.B., Ermolova M.V. The current state of the regulatory framework for labor in health care//Deputy chief physician: medical work and medical expertise. - 2010. - No. 6. - S. 22-28.
5. Shipova V.M., Gavrilov V.A. staffing health care institutions// Under the editorship of Academician of the Russian Academy of Medical Sciences O.P. Shchepin. - M.: GRANT, 2001. - 160 p.
6. Shipova V.M., Gavrilov V.A., Margulis A.L. Rationing of the work of medical personnel (instruction for conducting regulatory research work).
Moscow: VNII im. ON THE. Semashko, 1987. - 130 s.
7. Shipova V.M., Gaidarov G.M., Belostotsky A.V., Kindarov Z.B. Modern approaches to the staffing of health care facilities//Ed. Academician of the Russian Academy of Medical Sciences O.P. Shchepin. - Irkutsk: NTsRVH SO RAMN, 2010. - 52 p.
8. Shipova V.M., Kindarov Z.B. Complex issues of planning the number of medical personnel in hospitals to fulfill the volume of medical
of Qing assistance under the program of state guarantees for 2010// Deputy chief physician: medical work and medical examination. - 2010. - No. 4. - S. 22-27.
9. Shipova V.M., Margulis A.L., Gavrilov V.A. Guidelines for determining the number of positions of medical personnel in the context of the transition to medical insurance. - M., Research Institute. H.A. Semashko RAMN, 1993. - 50 p.
10. Shipova V.M., Minin O.G., Frolova Yu.V. Planning the number of doctors in hospitals (divisions) in modern conditions // Children's Hospital. - 2011. - No. 2. - S. 8-10.
11. Shipova V.M., Minin O.G. Planned and normative indicators for inpatient care for 2013//Deputy. ch. doctor. - 2013. - No. 4. - S. 20-26.
(name of institution)
PRINCIPLE 3
(locality)
□6 approval of the Regulations on the system of labor rationing in the institution
In order to develop a system of labor rationing in an institution, taking into account the opinions of employees (representative body of employees) (protocol No. _ot_)
I ORDER:
1. Approve
Regulations on the system of labor rationing in the institution (Appendix No. 1);
Regulations on the Commission on labor rationing (Appendix No. 2);
Form of notification of changes in labor standards (Appendix No. 3);
Regulations on the department of labor rationing;
The staffing of the labor rationing department.
2. Put into effect this order with "_"_20_g.
3. To impose control over the execution of this order on the deputy chief physician for economic issues_.
Chief Physician
(signature)
(full name)
Application No. 1
REGULATIONS ON THE SYSTEM OF REGULATION OF LABOR
IN THE INSTITUTION
1. General Provisions
This Regulation on the labor rationing system in an institution (hereinafter referred to as the Regulation) was developed on the basis of the Labor Code of the Russian Federation (hereinafter referred to as the Labor Code), Decree of the Government of the Russian Federation dated November 11, 2002 No. 804 “On the rules for the development and approval of standard labor standards”, Decree of the Government of the Russian Federation of November 26, 2012 No. 2190-r “On approval of the Program for the gradual improvement of the wage system in state (municipal) institutions for 2012-2018”, Methodological recommendations for federal executive bodies on the development of standard industry labor standards approved by the Order of the Ministry of Labor Russia dated May 31, 2013 No. 235, Order of the Ministry of Labor and Social Protection of the Russian Federation dated September 30, 2013 No. 504 "On approval of guidelines for the development of labor rationing systems in state (municipal) institutions."
In accordance with the Labor Code (Article 159), employees are guaranteed:
State assistance to the systemic organization of labor rationing;
The use of labor rationing systems determined by the employer, taking into account the opinion of the representative body of employees or established by a collective agreement.
The labor rationing system is developed taking into account the organizational and technical conditions for the implementation of technological (labor) processes in institutions (the equipment and materials used, technologies and methods for performing work, other organizational and technical factors that can significantly affect the value of the labor norm).
The system of labor rationing in the institution determines:
Labor standards applied in the institution by types of work and workplaces in the performance of certain types of work (functions) (hereinafter - labor standards), as well as methods and methods for their establishment;
The procedure and conditions for the introduction of labor standards in relation to specific production conditions, workplace;
The procedure and conditions for replacing and revising labor standards as new equipment, technology is improved or introduced and organizational or other measures are taken to ensure the growth of labor productivity, as well as in the case of using physically and morally outdated equipment;
Measures aimed at compliance with established labor standards.
The main objectives of the labor rationing system in the institution are:
Creation of conditions necessary for the introduction of rational organizational, technological and labor processes (procedures for the provision of medical care, standards of medical care, clinical protocols, etc.), improving the organization of work;
Ensuring a normal level of tension (intensity) of labor in the performance of work (provision of state (municipal) services);
Improving the efficiency of medical care.
Organization of work related to labor regulation includes:
Carrying out organizational and technical measures;
Implementation of rational organizational, technological and labor processes;
Improving the organization of work.
Labor standards are used in the process
development of wage systems in the institution and preparation of labor contracts with employees.
When developing a labor rationing system, labor standards are determined in relation to technological (labor) processes and the organizational and technical conditions for their implementation in an institution.
Analysis of the labor process based on the standard for the provision of state (municipal) services (standard of medical care), dividing it into parts;
The choice of the optimal variant of technology and organization of labor, effective methods and techniques of work;
Designing modes of operation of equipment, techniques and methods of work, systems for servicing workplaces, modes of work and rest;
Determination of labor standards in accordance with the characteristics of technological and labor processes, their implementation and subsequent adjustment as the organizational and technical conditions for the implementation of technological (labor) processes change (medical care procedures, medical care standards, clinical recommendations, etc.).
When carrying out this work, the approaches established in the methodological recommendations for federal executive bodies on the development of standard industry labor standards are used, approved
Order of the Ministry of Labor of Russia dated May 31, 2013 No. 235 (in terms of organizing work and calculating labor standards) and in other materials on rationing.
When purchasing new equipment in accordance with the established procedure, institutions are recommended to conduct a comparative calculation of the impact on the labor rate of the introduction of purchased equipment. At the same time, it is recommended to provide for a comparison of the characteristics of the purchased equipment with the characteristics of the equipment used in the development of standard labor standards (in the absence of standard labor standards, with the equipment used in the institution).
Along with the labor standards established in the institution for an indefinite period, temporary and one-time labor norms can be applied for technological (labor) processes that are stable in terms of organizational and technical conditions.
Temporary labor standards are established for the period of development of certain works in the absence of approved regulatory materials for labor rationing.
The period of validity of temporary labor standards determined by the institution is recommended to be set no more than 3 months.
One-time labor standards are determined by the employer for individual work that is of a single nature (unscheduled, emergency).
The main requirements for labor standards and norms are as follows:
Accounting for the current level of development of medical science, organization of medical care, organization of work, equipment, compliance with relevant technologies of the treatment and diagnostic process;
Compliance in terms of the degree of consolidation with the conditions and nature of the work of a particular type of institution, unit or employee, ensuring the necessary accuracy in setting staff standards - the degree of consolidation of standards depends
Manager
from the influence of the main norm-forming factors and the need to take them into account in the normative indicator;
Coverage of the most common options for performing work, convenience for calculating staff positions.
3. Analysis of the used labor standards and organizational and technical conditions
Work on labor rationing begins with an analysis of the state of affairs with rationing in the institution, which includes:
Inventory of used labor standards;
Analysis of organizational and technical conditions for the implementation of technological (labor) processes.
When analyzing the organizational and technical conditions for the implementation of technological (labor) processes in an institution, the following should be taken into account:
Used technologies, methods;
The degree of provision of procedures for the provision of medical care, applicable standards of medical care;
Parameters of operation and maintenance of the equipment used;
working conditions in the workplace;
Forms of labor organization, work and rest regimes, including regulated breaks;
Other parameters: characteristics of the work performed, the rationality of the division and cooperation of labor, etc.
4. Use of standard labor standards
When determining labor standards, an analysis is made of the existing standard (intersectoral, sectoral, professional and other) labor standards approved by the federal executive authorities in accordance with Decree of the Government of the Russian Federation of November 11, 2002 No. 804 "On the rules for the development and approval of standard labor standards" (hereinafter referred to as standard labor standards), and their correlation with the actual
technical organizational and technical conditions for the implementation of technological (labor) processes in the institution.
In the absence of standard norms established in accordance with the above order, as such (in terms of assessing the appropriateness of their use), the norms of a recommendatory nature established by the current orders of the executive authorities of the USSR and the Russian Federation in the field of healthcare, as well as the norms recommended specialized scientific organizations (Research Institute named after Semashko, TsNIIOIZ, etc.).
On the basis of model labor standards, appropriate labor standards can be determined for use in an institution.
Labor norms can be determined for a separate type of work, an interconnected group of works (aggregated labor norm) and a complete set of works (complex labor norm). An example is the labor standards for a patient treated in a hospital. The degree of consolidation of labor standards is determined by the specific conditions of the organization of medical care and labor.
Labor standards can serve to establish a standardized task (a set amount of work that an employee or group of employees performs per work shift or in another unit of working time).
Such indicators as the number of patients treated in the department, financial plan, etc. can act as a normalized task.
When determining labor standards on the basis of standard labor standards, comprehensively substantiated labor cost norms are used, established for homogeneous work, in relation to typical technological (labor) processes and typical organizational and technical conditions for their implementation in healthcare (for example, a doctor's visit).
If the organizational and technical conditions for the implementation of the technological
ical (labor) processes in the institution, standard labor standards are used.
A similar decision is made if the existing differences in the organizational and technical conditions for the implementation of technological (labor) processes cannot significantly affect the labor rate. The decision on the significance of differences in the organizational and technical conditions for the implementation of technological (labor) processes is made taking into account the opinion of the representative body of employees.
Comprehensively justified norms of labor costs provide for progressive modes of operation of equipment, rational techniques and methods of work, organization and maintenance of workplaces, optimal employment of workers, maximum use of workplace opportunities, high quality products (works, services), maintaining the health and working capacity of workers. At the same time, comparison of the existing organizational and technical conditions with the conditions provided for by the procedures for the provision of medical care, standards of medical care, equipment sheets, etc. is used as criteria.
When creating more progressive organizational and technical conditions for the implementation of technological (labor) processes or their non-compliance with standard labor standards, it is recommended to use standard labor standards as a basis for determining and justifying labor standards by adjusting them taking into account the actual organizational and technological conditions for performing technological (labor) processes in the institution.
When planning measures to improve the efficiency of the provision of state (municipal) services, it is recommended to use standard labor standards as a reference:
For institutions in which the organizational and technical conditions are below the level for which the standard norms are designed;
In the study of the cost of working time and the analysis of the loss of working time.
After taking measures to change the organizational and technical conditions for the implementation of technological (labor) processes, labor standards in the institution can be revised in established by law okay.
In the absence of standard labor standards for certain types of work and workplaces, the relevant labor standards are developed in the institution, taking into account the recommendations of the organization exercising the functions and powers of the founder, or with the involvement of relevant specialists in the prescribed manner.
5. Timing procedure
To determine the time spent on a particular repetitive operation, for example, for individual studies, manipulations, surgical interventions, medical appointments, etc., time measurements are used.
Timing refers to the analytical and research method of labor rationing, which consists in measuring the time spent on all the constituent elements of the labor process in optimal organizational and technical conditions corresponding to modern technology medical diagnostic process.
To conduct timing, statistical tools are being developed:
Dictionary (list) of activities and labor operations,
observation sheet,
patient card,
Map of reference data to the list of observations.
At the same time, the unit of observation is determined (for example, the time spent per patient for certain diseases or the average for a doctor of this specialty; the time spent per hospitalized in a planned manner, according to emergency indications, or an average per patient according to the profile of the department, regardless of the order of admission, etc. .d.).
The experience of labor rationing in health care shows that when designing the standard for a particular position, it is enough to conduct 2-week photochronological observations of 2-3 positions.
When conducting chronometric measurements, the volume of observations is limited, as a rule, to 30 similar studies and manipulations.
In some cases, for example, when calculating cost estimates, developing incentive measures, etc. there is a need to determine the cost of working time of various groups of personnel not for a separate labor operation, but for the entire labor process (for example, the time spent on treating one patient in a hospital).
When conducting timekeeping, the following basic rules must be observed:
Timing should be carried out by a highly qualified specialist who knows the technology of the diagnostic and treatment process well.
In the process of chronometric observations, an examination of the volume and quality of work is carried out, an assessment of the compliance of medical and diagnostic measures with the diagnosis and state of health of the patient;
Before carrying out photochronometric observations, a list (dictionary) of labor operations characteristic of the position and specialty of the observed is compiled;
When processing chronometric statistical data, the frequency of conducting certain types work, structure of the working day, etc.
6. Calculation of the number of employees
Calculation of the regular number of employees is part of the process of labor rationing, which consists in establishing the norms of the number - the number of employees required to perform a certain amount of work.
The calculation of the number of employees is based on:
Standard labor standards, which in this case include staffing standards;
Calculation method based on the values of other norms (time norms, load norms, service norms).
The institution establishes the methods used to determine the size norm (based on the standard norm of time, norms adopted in the institution, staff standards, etc.).
7. Labor rationing as part of the introduction of an effective contract
When concluding an employment contract with an employee, he must be familiar with labor standards. If the employee establishes norms of time for the performance of work (provision of services) or norms of service, it is recommended to indicate in the employment contract with the employee that their performance is carried out within the limits of the working time established for him.
It is advisable in an employment contract with an employee, concluded under the effective contract being introduced, to clearly state that the employee’s duty is to comply with labor standards, stipulating what exactly for this employee is the labor norm (the volume of services rendered in certain units, the cost of services rendered, etc. .), as well as the magnitude of these norms.
8. The procedure for the introduction, replacement and revision of labor standards
Labor norms - production norms, time norms, number norms and other norms - are established in accordance with the achieved level of technology, technology, organization of production and labor (Article 160 of the Labor Code).
Employees are notified of the introduction of new labor standards no later than two months before their entry into force. In a similar period of time, employees are notified of the correction of erroneous labor standards (labor standards during the establishment of which were incorrectly
the organizational and technical conditions for the implementation of technological (labor) processes are taken into account or inaccuracies are made in the application of regulatory materials or in the calculations).
Taking into account the opinion of the representative body of workers on the reduction of erroneous labor standards, workers can be notified in a shorter period.
The form of notification of the introduction of new labor standards is determined by the institution independently. At the same time, it is recommended to indicate the previously existing labor standards, new labor standards, the factors that served as the basis for the introduction of new labor standards or their adjustment.
Before the introduction of new labor standards, it is necessary to instruct and train employees in the most effective methods and techniques for performing work, while both individual and group forms of their implementation can be used.
When carrying out work on the development of labor standards, an analysis of the degree of development of work by each employee is carried out on the basis of data on the implementation of standards.
When mastering labor standards in connection with the introduction of new equipment and technology, when, along with mastering rational methods of labor, workers need to acquire new theoretical and practical knowledge, workers are trained.
When mastering new types of work (including the introduction of medical care standards, etc.) or when the actual organizational and technical conditions for the implementation of technological (labor) processes do not correspond to those designed in the newly introduced labor standards, correction factors are applied.
The term for conducting an analysis to determine the advisability of revising the applicable labor standards is at least once every five years. Based on the results of the analysis, a decision can be made to maintain the established norms.
labor or on the development of new labor standards. Until the introduction of new labor standards, the previously established ones continue to apply.
Labor standards may be revised as new equipment, technology is improved or introduced, and organizational or other measures are taken to ensure the growth of labor productivity, as well as in the case of the use of physically and morally obsolete equipment.
Other grounds for revising labor standards are not established by labor legislation.
Overfulfillment of labor standards by individual employees, including due to a high level of personal professional qualities, the use of new methods of work on their initiative and the improvement of workplaces cannot be considered as a basis for revising the labor standards established in the institution.
In other words, the achievement of a high level of product development (rendering of services) by individual workers through the use of new methods of labor and improvement of jobs on their initiative is not a basis for revising previously established labor standards.
The revision of erroneous labor standards is carried out as they are identified, taking into account the opinion of the representative body of workers.
9. Organization of work on labor rationing
The organization of work related to the regulation of labor is assigned to the Deputy Chief Physician for Economic Affairs.
The performance of work related to labor rationing is assigned to the labor rationing department.
To facilitate the implementation of labor rationing in the institution, a Commission is being created
The purpose of the Commission's activity is planning work on labor rationing and collegial assessment of labor standards proposed for implementation.
The tasks of the Commission are:
Approval of the work plan for labor rationing;
Preliminary consideration of the proposals of the labor rationing department on the establishment and revision of labor standards, the use of rationing methods, etc.;
Making proposals on the use of standard labor standards.
The composition of the Commission includes, in accordance with the position:
Head of Human Resources Department;
Legal Counsel;
Labor protection engineer.
The decision of the commission is taken by a simple majority of votes. In case of equality of votes for and against the proposed decision, the vote of the chairman (acting chairman) of the Commission is decisive.
The commission draws up its decision in minutes.
Draft orders on the institution, agreed upon at a meeting of the Commission and drawn up in the minutes, do not need additional approval by the officials of the institution. In this case, the sheet
approval of the project, only the number and date of the minutes of the meeting of the Commission are indicated and the signature of the chairman or secretary of the Commission is put.
10. Measures aimed at compliance with established labor standards
The efforts of both the employees themselves and the head, as well as other officials of the institution (hereinafter referred to as the Administration of the institution), should be directed towards the implementation of labor standards.
The administration of the institution takes measures aimed at observing the established labor standards, including the provision of normal conditions for the employees to comply with labor standards. These conditions include, in particular:
Good condition of premises, structures, machines, technological equipment and equipment;
Timely provision of technical and other documentation necessary for work;
Proper quality of materials, tools, other means and items necessary for the performance of work, their timely provision to the employee;
Working conditions that meet the requirements of labor protection and production safety.
In case of failure to comply with these measures, employees have the right to file claims against the Administration of the institution in accordance with labor legislation.
The following measures of influence aimed at the implementation of labor standards are applied to employees:
1. Moral and ethical.
2. Disciplinary.
3. Economic.
Moral and ethical measures of influence suggest:
Encouragement (public recognition, gratitude, praise, presentation for diplomas, awards, etc.);
Condemnation (negative assessment, condemnation of the team, etc.).
Disciplinary measures are applied in accordance with labor legislation, including, in particular, disciplinary sanctions. Compliance with labor standards is the responsibility of the employee - Article 21 of the Labor Code, dedicated to the rights and obligations of the employee, establishes that the employee is obliged to comply with the established labor standards. In accordance with Article 192 of the Labor Code, for committing a disciplinary offense, that is, non-performance or improper performance by an employee through his fault of the labor duties assigned to him, the employer has the right to apply the following disciplinary sanctions:
1) remark;
2) reprimand;
3) dismissal on appropriate grounds.
Accordingly, for non-fulfillment of labor duties by an employee in the form of non-fulfillment of labor standards, a disciplinary sanction may be imposed on him in the form of a remark or reprimand, and in case of further non-fulfillment of labor duties, he may be dismissed.
Economic measures of influence are based on material incentives
in accordance with the accepted system of remuneration, deductions from wages in cases provided for by law, etc.
When deciding on the application of measures of influence to employees in case of non-compliance with labor standards, the issue of who is to blame for the failure to comply with labor standards is considered without fail.
In accordance with Article 155 of the Labor Code, in case of non-fulfillment of labor standards, non-fulfillment of labor (official) duties through the fault of the employer, remuneration is made in the amount not lower than the average wage of the employee, calculated in proportion to the time actually worked.
In case of non-fulfillment of labor standards, non-fulfillment of labor (official) duties for reasons beyond the control of the employer and employee, the employee retains at least two-thirds of the tariff rate, salary (official salary), calculated in proportion to the time actually worked.
In case of non-fulfillment of labor standards, non-fulfillment of labor (official) duties due to the fault of the employee, payment of the normalized part of wages is made in accordance with the volume of work performed.
Application No. 2
REGULATIONS ON THE COMMISSION FOR LABOR REGULATION
1. General Provisions
1.1. This Regulation on the Commission on Labor Standardization (hereinafter referred to as the Commission) was developed in order to implement the Order of the Ministry of Labor and Social Protection of the Russian Federation dated September 30
2013 No. 504 “On approval of guidelines for the development of labor rationing systems in state (municipal) institutions” and provides for the formation procedure, main tasks, functions and rights of the Commission.
1.2. In its work, the Commission is guided by the legislative and other regulatory legal acts of the Russian Federation on labor, regulation and labor protection, the collective agreement, local regulatory legal acts of the institution.
1.3. The commission is an integral part of the labor regulation management system in the institution.
1.4. The work of the commission is based on the principles of social partnership, which is expressed by the inclusion of a representative of workers (trade union organization) in the Commission and taking into account the opinion of a representative of workers in the work of the Commission.
1.5. The composition of the Commission includes, in accordance with the position:
Deputy Chief Physician for Economic Affairs - Chairman of the Commission;
Chief Accountant - Deputy Chairman of the Commission;
Head of the Labor Regulation Department - Secretary of the Commission;
Deputy Chief Medical Officer (Chief Medical Officer);
Head of Human Resources Department;
Chairman of the trade union organization of the institution - as agreed;
Legal Counsel;
Labor protection engineer.
The personal (surname) composition of the Commission is approved by order of the chief physician.
The nomination of representatives of the employees of the institution to the commission is carried out on the basis of the decision of the trade union committee.
Other employees of the institution with an advisory vote may be involved in the work of the Commission.
2. Functions of the Commission
2.1. The purpose of the Commission's activity is to promote the organization of labor rationing in an institution by planning work on labor rationing, a collegial assessment of labor standards intended for implementation, etc.
2.2. The Commission performs the following functions:
Coordination of the work plan for labor rationing in the institution;
Preliminary consideration of the proposals of the labor rationing department on the establishment and revision of labor standards;
Making proposals on the use of standard labor standards;
Ensuring public control over the state of working conditions and safety measures directly at the workplace, the implementation of measures to improve the conditions and labor standards provided for by the collective agreement (agreement);
Informing the employees of the organization about the state of labor rationing in the institution and ongoing measures to improve labor standards;
Consideration of proposals from the Administration of the institution, representatives of employees and individual employees on the issues of labor regulation;
Creation of a system of measures aimed at compliance with established labor standards.
3. Order of work of the Commission
3.1. The Commission is headed by the Chairman of the Commission.
3.2. The Deputy Chairman of the Commission, on the instructions or in agreement with the Chairman of the Commission, as well as during his absence, performs his functions and has the right to sign documents in the absence of the Chairman.
3.3. The secretary of the commission carries out:
Operational control over the implementation of plans, decisions and recommendations of the Commission;
Implementation of the instructions of the Chairman or Deputy Chairman of the Commission;
Preparation of draft work plans of the Commission, recommendations, decisions, conclusions of the Commission on relevant issues, controls their progress and necessary approvals;
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Notifying the members of the Commission, as well as the specialists involved in working with it, about the time and place of the events held (sessions of the Commission, etc.);
Keeping minutes of meetings of the Commission;
By agreement, in accordance with the established procedure, he can represent the Commission at public events, in public organizations, and carry out the necessary communications with the media.
3.4. The Commission carries out its activities in accordance with the regulations and work plan developed by it, which are considered and approved at its meetings and are an integral part of the work plan of the institution.
3.5. Commission meetings are held as necessary, but at least once a quarter, and are considered competent if more than half of the commission members participate in their work.
3.6. Decisions of the commission are made by open voting by a majority of votes in the presence of a quorum and are advisory in nature. In case of equality of votes for and against the proposed decision, the vote of the chairman of the commission (acting chairman) is decisive.
3.7. The commission draws up its decisions in minutes.
3.8. Draft orders on the institution, agreed upon at a meeting of the Commission and drawn up in the minutes, do not need additional approval by the officials of the institution. In this case, only the number and date of the minutes of the meeting of the Commission shall be indicated in the project approval sheet and the signature of the chairman or secretary of the Commission shall be affixed.
3.9. The Commission reports on the work done to the Administration and the staff of the institution at least once a year. The chairman of the commission informs the trade union committee about the decisions made by the commission.
3.10. The activities of the commission are provided (including, if necessary, financed) by the Administration of the institution. By agreement of the Administration of the institution with the trade union organization, the activities of the Commission may be fully or partially financed by the representative of the employees (trade union organization).
4. Rights of the Commission
The Commission has the right:
4.1. Receive information from the Administration of the institution:
On the state of working conditions at workplaces, industrial injuries and occupational diseases, the presence of harmful production factors and measures to protect against them, the existing risk of damage to health;
On the standards of labor and labor standards used.
4.2. Hear at committee meetings:
Messages from the Administration of the institution, heads of structural divisions and other employees of the institution about the labor standards used, their implementation, etc.;
Proposals for improving the regulation of labor in the institution.
4.3. Participate in the preparation of proposals for the section of the collective agreement on issues within the competence of the Commission.
4.4. Submit proposals to the Administration of the institution on encouraging employees of the organization for active participation in the work on labor rationing.
4.5. To freely visit workplaces and relevant services of the institution to clarify issues within the competence of the Commission;
4.6. Facilitate the resolution of labor disputes related to violation of labor regulation legislation, changes in working conditions.
Manager
Appendix No. 3 NOTIFICATION OF CHANGES IN LABOR STANDARDS
Subdivision employee
institutions _
position_
In accordance with Art. 162 of the Labor Code of the Russian Federation, we inform you that
that in connection with the introduction of new equipment (_), which reduces labor costs
to perform one study, at least two months after the date of familiarization
You with this notice (namely, from _ 20_) instead of the previously existing norms
labor (load) -_ new labor standards (load) are introduced, namely_.
(head position)
Notice received _
(signature, full name of the head)
(employee's signature)
KadirovF.N. The order for developing the regulation on labor system norms in a state (municipal) healthcare institution (FSHI "Health Organization and Informatics" Ministry of Health Care of Russia, Moscow, Russia) Annotation. Questions with regards to the labor norming standards are becoming gradually relevant due to the necessity of establishing indexes and criteria for evaluating employees' activity efficiency in the frames of introducing an efficient contract. Logically speaking, norming of the labor should come first before introducing the efficient contract. However, norming the labor is a complex and time-consuming process, which has to run consistently on an ongoing basis. Therefore, these processes, to a large extent, develop parallel one to another. The starting document for institutions (along with the recommendations of state (municipal) bodies has to become a local normative act - Resolution regarding the system of norming the labor in institution.
Keywords: norming of the labor, labor norms, state (municipal) institutions, Efficient contract, indexes and criteria of evaluation, local normative act.
Healthcare-2014
REGIONS WILL RECEIVE 29.57 BILLION. RUBLES FOR DRUG SUPPLY FOR CERTAIN CATEGORIES OF CITIZENS
The volumes of federal subsidies provided in 2014 to regional budgets to provide certain categories of citizens with necessary medicines have been specified, medical devices as well as specialized products medical nutrition for disabled children. The corresponding Decree No. 1492-r of 08/09/2014 was signed by Prime Minister Dmitry Medvedev.
In total, 29.57 billion rubles are provided for these purposes. The largest volume of subsidies is provided for Moscow (4.66 billion), St. Petersburg (1.29 billion), Moscow (1.24 billion), Sverdlovsk (973.9 million) and Rostov regions (719.5 million .).
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