Organization and regulation of labor of medical workers at medical facilities. The current situation with the rationing of labor in health care. Labor rationing of medical personnel: specifics, legal support

Organizational science (scientific management) in different periods solved the problems of rationalization and optimization of labor activity in order to increase productivity, reduce physical and material costs, combat unemployment, etc. Now these problems are becoming increasingly important. Consequently, more attention should be paid to the problems of labor rationing, which will rationalize and optimize various areas of work.

The processes taking place in the modern economy, characterized by different dynamics of market relations, represent a new stage in the history of the formation of social and labor relations. However, social and labor relations, as experience shows developed countries, can be effective only when a strong and stable state acts as a guarantor, the main parameters of which are: a constant growth rate of the gross national product, state controllability is unconditional, and the effectiveness of the economic course being pursued is confirmed by results visible to citizens. For federal state the most significant indicator is the socio-economic development of its subjects and municipalities determining the quality of life of the country's population.

And one of the main directions affecting the quality of life of the population is health care, the level of development of which is largely determined by the indicators of the efficiency of using the country's labor resources.

In healthcare, technologies for the provision of medical services, the structures of the pathology of diseases are changing, which requires constant improvement of methodologies in the field of labor regulation of personnel of medical healthcare institutions.

Quite a lot of attention was paid to the study of labor regulation problems, in particular, intersectoral, sectoral and local normative materials were developed on the norms of time for work performed, load norms and headcount standards, as well as studies were carried out to establish and consolidate the scope of work in the form of qualification reference books.

Improving the organization of work in health care institutions requires further development of a methodology for determining the norms of time for medical services, methods for calculating the workload of medical personnel, approaches to determining and planning the number of medical personnel.

To achieve the above goal, it is necessary to solve the following tasks:

shaping new system regulation of the work of medical personnel using world standards for technologies for the provision of medical services;
development of modern methods for the development of norms of time (labor intensity of work) for the provision of simple and complex medical services;
formation of a methodology for calculating the workload rates of medical personnel in health care institutions in three areas (outpatient reception, diagnostic services, hospitals), taking into account the priorities of health care development in the Russian Federation;
development of new approaches to determining and planning the number of medical personnel in health care institutions.

It should be noted that the basis of the functioning of medical institutions is labor resources, therefore, a special role should be assigned to the organization of labor, which should be based on the management of the personnel of medical institutions on the basis of scientifically rational (regulatory) activities. At present, a high organization of work gives better results, which will certainly lead to a higher dedication of the employee, an increase in his labor productivity, self-realization under an organized leadership designed to motivate and stimulate the employee by managerial means and, most importantly, ensures the necessary quality of medical services.

Obviously, only management organized on a scientific basis will make it possible to find optimal solutions for many social problems concerning the standard of living of not only medical personnel of health care institutions, but also potential workers.

The relationship of labor rationing with the general standard of living

In recent years, research has been carried out by the Federal State Unitary Enterprise "Research Institute of TSS" of the Ministry of Health and Social Development of Russia, intended for healthcare institutions of the Russian Federation.

Based on a volumetric analysis of the functioning of medical institutions, the materials collected and the expected prospects, it was revealed: with the help of labor rationing, it is possible to solve many problems related to the standard of living medical professionals both at micro and macro levels.

A health care institution, using a scientifically grounded organization of labor, manages to increase the effectiveness of all its activities, increase the productivity of its employees, and achieve an increase in the effectiveness of medical personnel performing their duties. In turn, this leads to an increase in remuneration for the work done in the form wages and thus to an increase in purchasing power. And the effective activities organized as a whole by the health care institution and the high-quality functioning of this institution as a whole lead to the improvement of its activities in state level... Thus, the possibility of a comprehensive influence on the standard of living of the country's population is achieved.

Rationing and efficiency

Labor rationing must be applied in determining and planning the number of medical personnel. It has a direct impact on the remuneration of the main and auxiliary medical personnel of health care institutions.

This direction now plays a key role in the formation of the strategy for the development of health care institutions. The efficiency of the work of the entire healthcare institution as a whole depends on how optimally the composition of the medical personnel is formed. Unfortunately, the current period of development is characterized by an acute problem of both the quality and the composition of the medical personnel of healthcare institutions.

One of the most pressing problems for government agencies health care is the lack of industry-approved materials on labor standards for admissions departments covering the full scope of medical functions performed. In this regard, the following uncertainties arise in the process of determining the size of wages and the number of personnel in admissions departments:

the lack of labor standards for the staff of the admission departments of public health institutions;
lack of labor standards for auxiliary personnel (nurses, orderlies) in the admission departments of public health institutions;
the need to determine the labor intensity of the personnel of the admission departments of public health institutions;
standard criteria for the work of admission departments by type of health care institution have not been developed.

Currently, there are no regulatory documents on the workload of doctors, middle and junior medical staff in admission departments (with the exception of the Order of the USSR Ministry of Health No. 560 dated 05/31/1979, which is currently advisory in nature, is significantly outdated, and therefore inapplicable in practice).

All of the above problems make it difficult to develop an adequate remuneration system that takes into account the labor intensity of the main and auxiliary personnel of the admission departments of public health institutions. As a result, all this affects the quality of medical services provided to the population.

Methodology for calculating labor rationing

Almost every medical institution faces the above-described difficulties. Separate rates exist simply because they have always existed, even if the load on them falls. There are no rates for other works and loads, since the management of the institution, when they are clearly in demand, does not always know how to justify and calculate their need.

For a detailed analysis of the described problems and as a way of solving, we give an example of calculating the necessary rates based on the actual work performed and the time spent by the doctor of the admission department of the State Healthcare Institution.

Magazine "Chief Nurse"

Topic: General issues of personnel work, Remuneration of medical workers and motivation, Labor protection, social protection, pension provision
Source: Chief Nurse # 8-2008

The main tasks of labor rationing in health care are to determine labor costs, workload and the number of personnel, to find optimal proportions for its various groups when performing a particular work, planning certain areas of health care development.

The current state of labor rationing in health care is determined by the following trends:
decentralization of labor rationing management;
lack of timely revision of existing labor standards and new regulatory documents;
expanding the scope of use of labor standards, for example, their application in pricing practice, as well as in the economic justification of territorial programs of state guarantees for the provision of free medical care to Russian citizens, the preparation of municipal orders, etc.

These positions dictate the need to determine the technology of labor rationing in health care, a methodological apparatus for the design of labor standards used at the municipal, regional and federal levels of government (appendix).

General methodological issues of labor rationing *

In health care, as in other sectors of the economy, they use well-known methods of labor rationing, which are widely presented in the special literature. These methods are divided into two groups: analytical and summary (Fig. 1).

The analytical, or element-by-element, method provides for the differentiation of the labor process into separate components, the establishment of standard labor costs for each element and the design of labor standards, taking into account the rational organization of the labor process as a whole, the quality of the work performed.

Depending on the ways of developing labor standards analytical method subdivided into analytical-research and analytical-calculation.

The analytical research method consists in measuring the time spent on all components of the labor process in optimal organizational and technical conditions, corresponding to the modern technology of the treatment and diagnostic process. The method is associated with timing and is used due to its significant labor intensity, duration, the need for special training for its implementation, as a rule, in scientific organizations when developing industry standards for labor.

Depending on the objectives of the study, either timing measurements are used to establish the duration of individual repetitive labor operations, or a photograph of working time in order to clarify and eliminate the irrational use of working time, redistribution of functional responsibilities, etc.

The method of photo-timing observations includes a combination of timing measurements with photographs of working hours.

The timing methodology provides for the observance of the rules for its conduct, the main of which are listed below.

1. It is necessary to comply with the technology of the treatment and diagnostic process: organizational forms of work must comply with current state health care, and the specialist, whose activities are being monitored, must have sufficient work experience, high qualifications.

2. A highly qualified specialist who is well aware of the technology of the treatment and diagnostic process and is able to conduct an examination of the volume and quality of the assistance provided is involved in timing.

3. Before timing, it is advisable to compile a list (dictionary) of individual labor operations and types of work included in the functional duties of the observed, which allows, during statistical processing of materials, to identify the performance of work that is not typical for a particular group of personnel.

The classification of labor costs of medical personnel includes

7 types of activities: main, auxiliary, other activities, work with documentation, official conversations, personal necessary and unloaded time.

4. Timing should be sufficient to obtain representative data on labor costs for all labor operations.

The required number of time measurements is determined by the formula recommended by the Research Institute of Labor:

N = 2500 x ((K² x (Ku - 1) ²) / (C² x (Ku + 1) ²)) (1)

Where n is the number of time measurements;

K is the coefficient corresponding to a given confidence level (with a probability of 0.95 K = 2);

Ku - standard coefficient of chronosequence stability;

С - required observation accuracy (%).

In a number of cases, for example, to take into account the amount of remuneration of personnel when calculating cost indicators, it becomes necessary to determine the costs of working time of various groups of personnel not for a separate labor operation, but for the entire labor process as a whole. This situation is typical for the blood service, when carrying out a set of works for the issuance of one or another conclusion by the institutions of the State Sanitary and Epidemiological Supervision, etc. In this case, along with determining the time spent on individual labor operations, they fill in the flow chart.

When carrying out normative research work, the choice of a normative indicator for labor is extremely important.

The main requirements for the normative indicator for labor are as follows:
taking into account the modern level of technology of the treatment and diagnostic process, the form of organization of medical care, methods of work;
correspondence in terms of the degree of consolidation to the conditions and nature of the activity inherent in a particular type of institution;
coverage of the most common options for performing work;
convenience for calculating headcount standards, compliance of the indicator with the accounting and reporting documentation kept in the institution;
ensuring the required accuracy when calculating the number of personnel.

These requirements are met following indicators:
visit, case of outpatient services (SPO) in outpatient clinics;
bed-day, hospitalization, bed in hospital facilities, patient-day in day hospitals;
specific types of research, procedures, manipulations carried out by the medical personnel of the auxiliary medical and diagnostic service.

Determining the time spent on a more differentiated indicator for labor rationing, for example, for individual labor operations in dentistry, simple and complex medical services, can be considered only as an intermediate stage for the formation of standard costs for the indicated aggregated indicators recorded in the accounting and reporting documentation of the healthcare facility.

When designing time norms, the following mathematical and statistical methods are used: calculation of average values; graphic-analytical processing of initial data, calculation of normative regression equations (formulas) by the method of multiple correlation; calculation of normative regression equations (formulas) taking into account the influence of qualitative factors by the method of multiple correlation using the theory of pattern recognition, etc.

When designing labor standards, one should take into account the so-called norm-forming factors, the degree of influence of which makes it possible to carry out organizational, technical, psychophysiological and economic substantiation of normative indicators.

The presence or absence of a connection between the studied factors and their values is established by conducting a correlation analysis, with the help of which it is possible to determine to what extent this value depends on changes in other factors.

The method of correlation analysis in the selection of factors provides for the calculation of the coefficients of pair correlation, mutual (partial) correlation, multiple correlation, described in detail in the special literature on mathematical statistics.

When statistically processing timekeeping materials, the costs of a particular type of work are calculated by the formula:

Pt = Σti × ki, (2)

Where Tch is the time spent on a certain type of work;

Ti is the time spent on individual labor operations;

Ki is the frequency of repetition of individual labor operations.

The frequency of repetition of individual labor operations is established according to actual data with a possible correction of this indicator by expert means.

In health care institutions, and in some cases - in the design of labor standards for federal level the analytical calculation method is used. With this method, the calculation of the number of personnel is carried out on the basis of sectoral indicators of labor costs for a particular type of work and the actual volume of activity.

The total method of labor rationing does not imply the division of the labor process into components; it can be used due to its simplicity and availability for the prompt determination of labor costs, as well as for rarely performed work. The total method is subdivided into statistical, experimental, comparative (interpolation and extrapolation). The main disadvantage of the summary method is the lack of analysis of the internal content of the labor process on the basis of its separate organization.

The development of labor standards must be carried out according to certain rules and stages of carrying out regulatory research work.

At the initial stage, on the basis of the available methodological and regulatory materials, special publications, a research methodology is developed. The main areas of work are determined based on the materials of a special study. organizational forms the work of the institution (unit), personnel, the need for a particular type of medical care, technologies of the medical and diagnostic process, etc.

The main stage of regulatory research is measuring the cost of working time and statistical processing of the collected materials, preparation of the project regulatory document.

The final stage is associated with the economic substantiation of the labor standard, discussion with specialists and its experimental verification.

When discussing and finally adopting the value of the normative indicator for labor, a number of factors are taken into account, and first of all, the technology of the treatment and diagnostic process and the prospects for its implementation in healthcare practice, the provision of modern equipment, the possibility of using recommendations for the management of patients set out in the standards (protocols) of treatment, and etc.

Of all the normative indicators for labor (time norms, load (service) norms, headcount norms), time norms are fundamental, the rest of the data are calculated.

The stages of calculations, the ratio of these indicators and the necessary data for their calculations are schematically shown in Fig. 2.

When forming the norms of time, approved in different years in a centralized manner, certain types activities (main, auxiliary work, personal necessary time, etc.) were included in different proportions. Thus, the estimated time norms for a visit included the main and auxiliary activities, and the time norms for research carried out in the radioisotope diagnostics room included all types of activities, including personal time required. In this regard, the coefficient of the use of working time for the main activity of different positions takes on different values, presented in table 1.

Rice. 2. The stages and the necessary data for calculating the standard indicators for labor

Table 1

The ratio of using the working time of the position on the main activity
Job title
The value of the coefficient (in fractions of 1.0)

Outpatient doctor, hospital physician
0,923

Clinical laboratory diagnostics doctor
0,800

Laboratory assistant, paramedic laboratory assistant
0,750

Ultrasound diagnostics doctor, functional diagnostics doctor, endoscopist, nurses of the corresponding offices, physiotherapy instructor
0,850

Radiologist
0,900

Radiologist
1,000

Physician in physiotherapy exercises and sports medicine, instructor-methodologist
0,692

Massage nurse
0,770

Physiotherapy Nurse
1,124

The annual budget of the working time of the position is determined established by law RF, as well as the mode of work and rest. It is calculated by the formula:

B = m × d - n - z, (3)

Where B is the annual budget for working hours;

M - the number of hours of work per day for five days working week;

D - the number of working days in a year for a five-day working week;

N - the number of hours of reducing the duration of the working day or shift on pre-holiday days (throughout the year);

Z is the number of working hours per vacation period, which is determined by multiplying the weekly working hours by the number of vacation weeks.

Calculation example No. 1

The annual budget of the working time of a functional diagnostics doctor with a 39-hour working week, 28-day vacation (in the number of calendar days), calculated for 2007 according to formula 3, is 1780.2 hours (39/5 x 249 - 6 - 4 x 39) or 106,812 min (60.0 x 1780.2).

The presented general methodological approaches to labor rationing are used in all types of health care institutions. However, the organizational and technical conditions of their functioning determine the need to consider the specifics of labor rationing for the main types of institutions and groups of personnel.
Rationing of work of middle and junior medical personnel

RATING OF LABOR OF SECONDARY AND JUNIOR MEDICAL PERSONNEL

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 corresponding offices). 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 exercises, 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 positions for outpatient admission is due to the fact that, depending on their number, according to staff standards, the number of positions of doctors and nurses in auxiliary and some other medical and diagnostic units is determined:
the total number of outpatient doctor positions: treatment room nurses, medical registrars (to calculate the number of treatment room nurses, medical registrars);
the total number of positions of doctors (to calculate the number of medical statisticians);
change in the work of a unit or institution (to calculate the number of nurses in a procedural, vaccination room, registry);
the number of the population and its individual contingents (for calculating 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 the children's city polyclinic (change of work and the number of children).

Most of the current state standards for outpatient clinics were approved more than 25 years ago: staff standards city and children's city polyclinics located in cities with a population of more than 25 thousand people are determined by order of the Ministry of Health of the USSR dated 11.10.1982 No. 999, in cities and urban-type settlements with a population of up to 25 thousand people. by order of the Ministry of Health of the USSR No. 900 dated September 26, 1978. In 2001, an order was approved according to the standard standards of children's polyclinics, which are part of city and children's city hospitals, medical units with hospitals (order of the Ministry of Health of Russia dated October 16, 2001 No. 371), however, the lack of substantiation of the main provisions of this order makes it unacceptable for health care practice.

By the nature and scope of activities of nursing staff assigned to outpatient doctors in various specialties, these positions can be divided into the following groups:
nurses together with the doctor carry out outpatient reception of patients;
Along with outpatient appointments, together with a doctor, nurses of district general practitioners, pediatricians, and general practitioners (family medicine) also fulfill the doctor's prescriptions for the provision of appropriate medical, diagnostic and preventive care at home to the population of the district. Nurses of surgeons, orthopedic traumatologists carry out dressings, application and removal of plaster, etc.

The first group includes most of the nursing positions of outpatient doctors. The normative ratio of middle and medical personnel in this group is, as a rule, 1: 1, that is, one position is planned for one doctor's position. nurse... 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 for one position of a doctor of these specialties, 0.5 positions of a nurse are established. It is difficult to find a logical explanation for such standards, and in the absence of appropriate recommendations at the sectoral level, the heads of health care institutions, on the basis of the rights granted to them to form the number of personnel in health care facilities, it is advisable to establish the number of posts of nursing staff in these specialties, corresponding to the medical one. 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 has been amended, and the positions of nurses in medical offices are established at the rate of 1 position for each position of a pediatric dentist, dentist-surgeon and orthodontist. This standard is quite consistent modern technologies treatment and diagnostic process in dentistry with the use of modern composite materials, "four-handed" work and ethical and legal standards for admitting a patient in a separate office.

In recent years, due to the introduction of mandatory health insurance in the territories where payment is made for individual medical services, classifiers of medical services are developed and approved, in which the appropriate time standards for a doctor and a nurse are established. The feasibility of such a separate establishment of time norms for those specialties where the norms define an equal number of doctors and nurses raises serious doubts. So, for example, in one of the classifiers for otolaryngology, where, according to the staffing standards, one position of a nurse for one position of a doctor is established, the time spent on anterior nasal tamponade (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 finished the procedure before a doctor, will provide assistance to another patient without an appropriate medical examination and prescriptions. The situation becomes more complicated when the indicated expenditure of a doctor's working time is less than that of a nurse. For example, to replace the cystostomy drainage, the urologist is set at 3.0 EVEN, i.e. 30 minutes, and for the nurse - 4.0 EVEN, i.e. 40 minutes. 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 provides joint work a doctor and a nurse, or wait within 10 minutes for the nurse to complete this labor operation.

Thus, the establishment of different norms of time for separate labor operations for a doctor and a nurse contradicts the sectoral labor standards that determine the ratio between the number of positions 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 be considered only as an intermediate stage for the formation of standard costs for a more consolidated indicator recorded in the reporting and accounting documentation of a healthcare facility, i.e. to visit.

The normative number of junior medical personnel positions is also differentiated according to the specialties of outpatient doctors. So, in city 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 physicians, allergists-immunologists; for every 3 positions of other outpatient doctors.

RATING OF LABOR OF SECONDARY AND JUNIOR MEDICAL PERSONNEL IN HOSPITAL INSTITUTIONS

The rationing of the work of middle and junior medical personnel in hospital institutions has certain features, which are listed below:
the need to provide round-the-clock service to patients in the hospital;
the indicator that serves as the basis for calculating the number of posts is the number of beds;
setting norms of load (service) for the day of the patient's stay in the hospital or shift.

The standards for the number of middle and junior medical personnel in hospital institutions are expressed in the number of beds per position, or per one round-the-clock post. Depending on this, the norms of time are set either for the day the position is open, or for the day.

The rationing of the work of medical personnel in hospital institutions is carried out in stages according to the scheme shown in Fig. 2.

Stage I. The standard costs of working time of medical personnel in hospital institutions 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:
day of admission;
day of treatment;
day of discharge.

The time spent is usually set on the basis of timing.

The calculation of the weighted average indicator of the costs of the working time of a nurse or nurse working daily on the day of the patient's stay in the hospital (Tday) is carried out according to the formula:

Tday = (tp + tl x 0.825 (m - 2) + tv) / (m x 0.825), (4)

Where tp is the time spent by a nurse or doctor per patient on the day of admission;

Tl is the time spent on a patient during the treatment period per 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 a reduction in the number of days of work of a nurse or a nurse 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 specified regime, that is, nurses are working daily, providing individual care for seriously ill patients, dressing room, procedural room, barmaid attendants, nurses.

Calculation example No. 2

The time spent by a nurse for the organization of individual care for seriously ill patients, calculated for 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 equal to 13 days, calculated according to formula 4, is 83.5 minutes.

(100 + 80 × 0.825 × (13 2) + 70) / (13 × 0.825) ≈ 8.4.

There are about 10% of seriously ill patients in the department, therefore, this indicator per one hospitalized person is 8.4 minutes (83.5: 10).

Most nurses and nurses in hospitals work around the clock. At the same time, a 2 or 3-stage service system is introduced.

The use of a 2-stage 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 sanitary cleaner 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 premises in the absence of an adequate number of nurses, undoubtedly worsens the quality of medical care and contradicts sanitary and hygienic requirements.

In a 3-degree system, a doctor, a nurse and a nurse are involved in patient care.

The calculation of the weighted average costs of the working time of a nurse or a nurse per day of hospital stay (Tsut) is calculated using a formula similar to formula 4, but without taking into account the coefficient 0.825:

Tsut = (tp + tl x (m - 2) + tv) / m, (5)

All designations correspond to formula 4, calculated not for a day, but for a day of the patient's stay in the hospital.

The weighted average cost of time is calculated separately for patients admitted as planned 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 a nurse per patient is determined. This method of calculation makes it possible to model an effective indicator of the average time spent per patient according to the department profile, 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 length of hospital stay, etc.

Calculation example No. 3

The costs of a nurse's working time per patient per day by periods of hospital stay, admitted for emergency indications and in a planned manner, are shown in Fig. 3.

Calculations of the time spent on one patient per day, carried out according to formula 5, show that for those admitted as planned, with an average length of stay equal to 12 days, they will amount to 40.8 minutes:

(73.8 + 34.6 (12 2) + 70.2) x 12 ≈ 40.8.

Rice. 3. The cost of working hours of the ward nurse

Working hours for patients admitted on an emergency basis, with an average hospital stay of 8 days, will amount to 107.4 minutes:

(396,6 + 60,8(8 2) + 97,8) / 8 ≈ 107,4.

The average time required for a 10 percent emergency hospitalization is 47.5 minutes:

(107.4 × 10 + 40.8 × 90) / 100 ≈ 47.5.

The average time required for a 30% emergency hospitalization is 61.8 minutes:

(107.4 × 30 + 40.8 × 70) / 100 ≈ 61.8.

Thus, an increase in the proportion of hospitalizations for emergency indications from 10 to 30% leads to an increase in the cost of a nurse's working time per patient per day from 47.5 to 61.8 minutes, i.e., by 30%.

Stage II. The calculated load (service) norms for medical personnel of hospital institutions are expressed in the number of patients served per day or per day according to the formula:

NB = (B x k) / T, (6)

Where Nb - norms of the load on the hospital staff;

B - daily work time medical personnel (on a six-day working week) or daily working hours;

K is the coefficient of using the working time of nursing staff for the main and auxiliary activities;

T is the average time spent per patient per day (from formula 5). The main activity of medical personnel is, as a rule, work carried out directly with the patient, that is, the time of direct contact of the personnel with the patient, namely, the performance of various kinds of procedures and manipulations. However, some categories of medical personnel do not have any contact with patients at all, for example, a cleaning nurse with a two-level service system, therefore, their main activity is to perform a direct production task.

All the preparatory work done to perform the main activity and carried out both in the presence and in the absence of the patient is an auxiliary activity: preparation and cleaning of the workplace, preparation for manipulation, procedure, transfer to another department, etc.

During the working day, the staff needs a short rest, eating, and carrying out sanitary and hygienic measures. These costs are related to the personal time required.

Interdisciplinary teaching materials recommend to devote about 10% of the working time to personal necessary time. The experience of labor rationing in health care shows that the coefficient of working time for main and auxiliary activities for most positions of medical personnel (except for auxiliary medical and diagnostic services) is 0.923, i.e., out of 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 No. 4

The calculated norms of the load of a nurse for the organization of individual care for seriously ill patients with the cost of working time per hospitalized person is 8.4 minutes (example of calculation No. 2). The load (service) rates, calculated according to formula 6, are 42 hospitalized:

(6.5 × 60 × 0.9) / 8.4 ≈ 42.

Calculation example No. 5

The calculated load norms for a nurse with a working time per patient per day equal to 47.5 minutes (calculation example No. 3), determined by formula 6, are 27 hospitalized:

(24 × 60 × 0.9) / 47.5 ≈ 27,

And at a cost equal to 61.8 minutes, 21 patients:

(24 × 60 × 0.9) / 61.8 ≈ 21.

Stage III. The standard for the position of medical personnel of a hospital institution, expressed in the number of beds per position, is calculated by the formula:

Nk = (Nb x 365) / R, (7)

Where Nk is the number of beds per position;

Nb - load in the number of patients per day (from formula 6);

R is the planned number of days the bed will work in a year.

The value of the indicator R in formula 7 is:
for city and 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 No. 6

The norm for the position of a nurse for the organization of individual care for critically ill patients of a department of a city hospital, calculated according to formula 7, with the time spent per patient per day equal to 8.4 minutes (example No. 2) and the number of patients served equal to 42 (example of calculation No. 4), is 45 beds ((42 x 365) / 340) per position.

Calculation example No. 7

To ensure the activities of the ward nurse of the department in the conditions of a city hospital with a working time per patient per day equal to 47.5 minutes (example of calculation No. 3), and the calculated load norms of 27 patients (example of calculation No. 5), a 24-hour post is required for 29 beds ((27 x 365) / 340), and at a cost of 61.8 minutes and a load rate of 21 patients, there is a 24-hour post for 23 beds ((21 x 365) / 340).

The calculation of the number of posts to ensure the work of a round-the-clock post is carried out according to the formula:

Dpost = (24 × 60 × 365) / B, (8)

Where Dpost is 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 budget of working time (B in formula 8) is calculated according to formula 3, presented in the Methodological Recommendations "Development of technology for labor rationing in health care."

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 special conditions For a number of categories of medical personnel, a reduced working week has been established, amounting to 24, 30, 33 and 36 hours.

In accordance with the clarification of the Ministry of Labor of Russia dated December 29, 1992 No. 5, approved by Resolution No. 65 of December 29, 1992, the daily working time is calculated according to the estimated 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 working hours by 5 days.

In accordance with Art. 95 of the Labor Code of the Russian Federation, the duration of a working day or shift immediately preceding a non-working holiday is reduced by 1 hour.

If a day off 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 of weekends and non-working days by employees, the Government of the Russian Federation has the right to postpone weekends to other days. As a rule, as a result of such transfers during the year there are 7 or 8 pre-holiday days. Currently, the number of non-working holidays in the 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":
January 1, 2, 3, 4 and 5 - New Year's holidays;
January 7 - Nativity of Christ;
February 23 - Defender of the Fatherland Day;
March 8 - International Women's Day;
May 1 - Spring and Labor Day;
May 9 - Victory Day;
June 12 - Day of Russia;
November 4 - National Unity Day.

When calculating the number of working days, holidays, non-working days and pre-holidays in a year, it is advisable to use the Production calendar.

In 2008 - 250 working days in 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), but the duration of the vacation remained the same. In calculating the annual budget, it is advisable to determine the vacation time as the product of the weekly working time by the number of weeks.

Calculation example No. 8

The annual budget of the working time of the position of a nurse in a city hospital with a 39-hour working week, 28-day leave (in the number of calendar days), calculated for 2008 according to formula 3, is 1787 hours: (39/5) × 250 - 7 - 4 × 39 = 1787 h, or 107 220 min (60.0 × 1787).

Table 2 presents the final data for calculating the annual budget of the working time of the positions of medical personnel for different modes of work and rest.
table 2

The annual budget of the working time of medical personnel positions in 2008 for different modes of work and rest
Working week duration, h
Annual budget (h) for vacation duration (in calendar days)

28
35
42
49
56

24
1097
1073
1049
1025
1001

30
1373
1343
1313
1283
1253

33
1511
1478
1445
1412
1379

36
1649
1613
1577
1541
1505

39
1787
1748
1709
1670
1631

Calculation example No. 9

The number of nursing posts to ensure the work of a 24-hour post with an annual budget of working hours equal to 1787 hours (example calculation No. 8), calculated according to formula 8, is 4,916 posts ((24 x 366) / 1787)

Table 3 shows the final data for calculating the number of positions of medical personnel for different modes of work and rest to ensure the work of a round-the-clock post in 2008.

Table 3

The number of positions of medical personnel with different modes of work and rest to ensure the work of a round-the-clock post in 2008
Length of the working week (h)
The number of posts per post with the duration of the vacation (in calendar days)

28
35
42
49
56

24
8,007
8,186
8,374
8,570
8,775

30
6,398
6,541
6,690
6,847
7,010

33
5,813
5,943
6,079
6,221
6,370

36
5,327
5,446
5,570
5,700
5,837

39
4,916
5,025
5,140
5,260
5,386

The calculation of the number of posts in a particular department is carried out according to the formula:

Dotd = (Dp × K) / P, (9)

Where Dotd is the number of posts in the department;

Дп - the number of posts per 1 post;

K is the number of beds in the department;

P is the number of beds per 1 post (according to the standard).

Calculation example No. 10

In a department with 30 beds, with a standard indicator of 20 beds per 1 post, and the number of positions of a nurse (ward) to ensure the operation of one round-the-clock post, equal to 4.916 positions (with a 39-hour working week and 28-day leave), 7.374 ward nurse positions:

(4.916 × 30) / 20 = 7.374.

The calculation was carried out according to formula 9.

SPECIFIC FEATURES OF LABOR RATING OF SECONDARY AND JUNIOR MEDICAL PERSONNEL IN DAY HOSPITALS

In recent years, hospital-substituting types of care have been significantly developed. The staffing standards of the 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 in accordance with 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 the day hospital are determined depending on the specific local conditions and range from 5 to 9 hours daily. In some cases, two-shift work of the day hospital is practiced. When calculating, it is necessary to take into account the number of days of work of the day hospital in a year: on a five-day or six-day working week, without days off and holidays, etc.

The calculation of the number of nursing and junior medical personnel in day hospitals can be performed based on the data of photo-timing observations. However, given the laboriousness of photo-timing observations to determine the norms of time in health care institutions, it can be recommended to use the existing normative base for labor for these groups of personnel in hospital institutions, but taking into account the working hours of the day hospital.

Headcount planning ward nurses, junior nurses 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 personnel, the load (service) rates in the daytime, as a rule, increase, at night - they decrease. For example, when planning one post for 20 beds in the daytime, you can set the load to 15 beds, and at night - 40-50 beds.

However, the differences in the composition of patients in the day hospital as compared to the conventional hospital department, the mobility of patients and the ability to self-service make it possible to take the total value of the indicator of the number of beds per post as the basis for planning the number of nursing and junior medical personnel in the day hospital.

The calculation of the number of positions of ward nurses, ward nurses in the day hospital is carried out according to the formula:

Ddays = Dpost x (T / W) x (K / N), (10)

Where Ddnevn is the number of positions of ward nurses and nurses in the 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 work of the day hospital during the year;

W is the number of hours of operation of the round-the-clock post per year;

K is the number of beds in the day hospital;

N is the standard number of hospital beds with round-the-clock stay for 1 post.

Calculation example No. 11

Inpatient day stay therapeutic profile for 25 beds works from 10 am to 6 pm, i.e. 8 hours daily for 303 days (for a six-day working week). Therefore, T = 2424 h (8 × 303). A 24-hour post of a ward nurse in the therapeutic department of a city hospital is installed for 20 beds, cleaning attendants - for 30 beds (with a two-stage service system). According to table 3, 4,916 positions are required to ensure the work of a 24-hour post (with a 39-hour work week and 28-day leave). Calculations according to formula 10 show that in this day hospital in 2008, 1,696 positions of nurses and 1,131 positions of nurses are needed.

In accordance with the procedure for rounding off posts, 1.75 posts of a ward nurse and 1.25 posts of a ward nurse-cleaner can be introduced into the staffing table.

RATING OF LABOR OF THE MIDDLE AND JUNIOR MEDICAL PERSONNEL OF AUXILIARY THERAPEUTIC DIAGNOSTIC SERVICE

Labor rationing for middle and junior medical personnel of the auxiliary medical and diagnostic service is carried out mainly in the same stages as for other personnel, but it has certain features.

Stage I consists in determining the estimated time norms for individual studies, manipulations, and procedures.

The currently valid normative documents defining these indicators for labor, as a rule, were approved 15-20 years ago. A list of normative documents is given in the appendix to this publication. The development of a regulatory document before its approval takes about 3-5 years, therefore, the data presented in them correspond to the equipment used in health care institutions more than 20 years ago. At the same time, in a number of services there is a rather intensive replacement of equipment, especially in recent years in connection with the implementation of the national project "Health." changes in the labor costs of personnel for their implementation, and these changes can be in the direction of both increasing and decreasing the norms of time.All this determines the necessity and urgency of carrying out normative research work on the development of norms of time for diagnostic studies on modern equipment.

Unfortunately, such work at the federal level is currently not being carried out.

Stage II. The norms of workload (service) of the medical personnel of the auxiliary medical and diagnostic service are expressed in the number of examinations or in the time budget for which it is possible to carry out the normative number of examinations, procedures, manipulations per job change, month, quarter, year. Typically, an annual time frame is used.

The load (service) norms for nursing staff, for whom the time norms for individual studies, the procedures of the auxiliary medical and diagnostic service, are determined by the formula:

N load auxiliary = B × k, (11)

Where N load auxiliary is the load norm of the auxiliary medical and diagnostic service;

B - the annual budget of the working time of the position;

K is the coefficient of using the working time of the position.

These positions include laboratory assistant, laboratory assistant, massage nurse, physiotherapy nurse, functional research department nurse.

The annual budget (B in formula 11) can be expressed both in time units (min, h), and in conventional units.

The coefficient k in formula 11 has different meanings for each service and is directly dependent on the structure of the estimated time norms and the ratio of different components of this indicator. For example, only the main activity is included in the estimated norms of time for laboratory research, while 20% of the working time is allocated to the laboratory assistant for other types of work. The value of the coefficient k is presented in table 1.

Calculation example No. 12

The annual budget for the working time of the position of a massage nurse with a 39-hour working week and 28 calendar days of vacation is 107,220 minutes, or 10,722 conventional massage units (1 conventional massage unit = 10 minutes). The load (service) rate, calculated according to formula 11, is 8256 conv. units (10,722 x 0.77).

Stage III. The calculation of the number of posts by the volume of work is carried out according to the formula:

D = T / N load auxiliary, (12)

Where D is the number of posts;

T - the cost of working time for research, procedures for a certain period of time, as a rule, for a year;

N load auxiliary - calculated norms of load (service) from formula 11.

The expenditure of working time for a particular position of the support service for a particular period of time (T in formula 12) is determined by summing the products of the time spent on each study by the number of these studies, carried out, as a rule, during the year. The number of studies is established by copying necessary information from primary documentation or in the course of current accounting. Such a methodological technique is due to the fact that the reporting documentation contains a grouping of studies, procedures, manipulations, and standard indicators for labor are set for each specified unit.

Calculation example No. 13

The massage nurse performed 1000 procedures of segmental massage of the cervicothoracic spine, 500 - hand and forearm massage, 8000 - neck massage during the year. The time spent on the first of these types is 3.0 conventional massage units, for the second and third - 1.0 conventional massage units. The total cost is 11,500 conventional massage units (3.0 × 1000 + 1.0 × 500 + 1.0 × 8000). The calculation carried out according to formula 12 shows that in order to perform this volume of work, 1,393 positions of massage nurses (11,500: 8256) must be entered into the staffing table, rounded - 1.5 positions.

The indicators for planning the number of posts of nursing staff of the auxiliary treatment and diagnostic service in accordance with the staffing standards are:
the number of positions of outpatient doctors or the number of beds (for calculating the positions of laboratory assistants, paramedics, laboratory assistants, massage nurses, physical therapy instructors); the number of positions of doctors of the auxiliary service of the corresponding specialty (for calculating the positions of X-ray technicians, nurses of ultrasound diagnostics);
amount of work (for calculating the positions of massage nurses, physical therapy instructors);
population size (for calculating the positions of nurses in the functional diagnostics room during medical examination of the population);
the presence of an appropriate office (to establish the position of a nurse in a functional diagnostics office); institution (to establish the position of a laboratory assistant in the center of general medical (family) practice);
job change to calculate the positions of X-ray technicians.

The indicators for establishing the number of positions of junior medical personnel of the auxiliary medical and diagnostic service are:
the number of medical and (or) paramedical personnel of the relevant unit; for example, the position of a laboratory nurse is established at the rate of 1 position for 4 positions of doctors and laboratory assistants, a nurse of an X-ray room - according to the positions of radiologists; nurses of the physiotherapy department (office) - at the rate of 1 position for 2 positions of physiotherapy nurses (for most types of institutions);
number of beds; for example, the positions of the nurse of the X-ray room (department) of regional, regional hospitals are established at the rate of 1 position for 300 beds;
availability of a corresponding office; for example, the position of a nurse in a functional diagnostics room at a local hospital is established at the rate of 1 position for each office;
job change; for example, the position of a nurse in the X-ray room of a city polyclinic is assigned to the X-ray room on a shift.

Thus, the application of the outlined methodological approaches to the standardization of work of middle and junior medical personnel makes it possible to scientifically substantiate sectoral labor standards, to calculate the number of personnel in health care institutions in accordance with specific local conditions, forms and methods of organizing medical care for the population and will contribute to a rational arrangement and use of frames.

Who establishes the labor rationing system in health care institutions?

The system of labor standards in health care institutions is established by the employer on the basis of standard labor standards. By virtue of Art. 161 of the Labor Code of the Russian Federation, standard labor standards are developed and approved in the manner established by the federal executive body authorized by the Government of the Russian Federation. In the field of health care, such a body is the Ministry of Health of Russia. So, by order of the Ministry of Health of Russia dated 06/02/2015 No. 290n, standard industry norms time to complete work related to a visit by one patient to a district pediatrician, district general practitioner, general practitioner (family doctor), neurologist, otorhinolaryngologist, ophthalmologist and obstetrician-gynecologist. These standard norms are the basis for calculating workload norms, standards for the number and other labor standards of doctors of medical organizations providing primary medical and primary specialized health care on an outpatient basis.

In turn, according to Art. 163 of the Labor Code of the Russian Federation, 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 workers.

The main local regulatory legal act in this case is the staffing table of the institution.

What are the requirements for the staffing table medical organization and the calculation of staffing standards?

Currently, when calculating staffing standards, first of all, it is necessary to be guided by the Decree of the President of the Russian Federation of 05/07/2012 No. 597 and the order of the Government of the Russian Federation of 11/26/2012
No. 2190-r, which approved the Program for the phased improvement of the remuneration system in state (municipal) institutions for 2012-2018.

According to said Program gradual improvement of the remuneration system, the formation of the staffing of institutions should be carried out using labor rationing systems, taking into account the need for high-quality provision of state (municipal) services, the implementation of the volume of medical care established by the Program of State Guarantees of Free Provision of Medical Care to Citizens and the corresponding territorial program.

In accordance with Art. 159 of the Labor Code of the Russian Federation, labor rationing systems are determined by the employer taking into account the opinion of the representative body of workers or are established collective agreement... Institutions can independently develop appropriate labor standards, taking into account the recommendations of the organization performing the functions and powers of the founder, or with the involvement of relevant specialists in the prescribed manner (clause 16 of the Methodological Recommendations, approved by order of the Ministry of Labor of Russia dated September 30, 2013 No. 504).

It should be noted that in accordance with sub. "G" p. 39 sec. X Unified Recommendations, approved by by the decision of the Russian Trilateral Commission of December 24, 2014 (Protocol No. 11), the formation of the staffing tables of health care institutions must be carried out taking into account the Nomenclature of positions of medical workers and pharmaceutical workers, approved. by order of the Ministry of Health of Russia dated 20.12.2012 No. 1183n.

Regarding the staffing standards of the organizational and methodological departments of medical organizations in Soviet time the following orders were developed.

Order of the Ministry of Health of the USSR dated 06.06.1979 No. 600 (with amendments and additions).
Order of the Ministry of Health of the USSR of 09/26/1978 No. 900 (with amendments and additions).
Order of the USSR Ministry of Health dated 05/31/1979 No. 560.

These documents have not been officially canceled by the Ministry of Health of Russia and, in accordance with the order of the Ministry of Health of the USSR No. 504 dated 31.08.1989, are recommendatory in nature. In this connection, they can be used as a basis for the development of labor rationing systems installed in medical organizations. When applying these documents, it should be borne in mind that the names of the positions of medical and other personnel of healthcare institutions must comply with the Nomenclature of positions of medical workers and pharmaceutical workers (approved by order of the Ministry of Health of Russia dated 20.12.2012 No. 1183n).

Regarding the determination of the standard of staffing of employees and workers of state and municipal healthcare institutions, one can be guided by the order of the Ministry of Health of Russia dated 09.06.2003 No. 230, which establishes the dependence of the number of staff units of blue-collar occupations on the amount of work according to technically sound standards, and in their absence - according to the norms, developed by the institution in an experimental and statistical way.

Thus, the staffing table of a medical organization is established by the medical organization itself on the basis of reasonable labor standards and is approved by its head (subparagraph "d", clause 33, Section VIII of the Unified Recommendations, approved by the decision of the Russian Trilateral Commission of 12/25/2013, Protocol No. 11) ...

It should be especially noted that the staffing table should be uniform and take into account all personnel involved in the implementation of the state assignment and in the provision of paid services.

The staffing table is used to formalize the structure, staffing and staffing of the organization in accordance with its charter (statute). The staffing table contains a list structural units, job titles, specialties, professions with qualifications, information on the number of staff (Instructions on the use and filling out of primary accounting forms, approved by the decree of the State Statistics Committee of Russia dated 05.01.2004 No. 1).

According to sub. "In" p. 35 of the Unified Recommendations, approved. By the decision of the Russian Tripartite Commission of 12.24.2014 (Minutes No. 11), the formation of a unified staffing table in the institution is carried out regardless of what types of economic activity the structural divisions of the institution belong to.

In turn, in accordance with clause 10 of the Regulation on the establishment of salary systems for employees of federal budgetary, autonomous and state institutions (approved by the Government of the Russian Federation of 05.08.2008 No. 583), the staffing table should include all positions (professions) of this institution ... At the same time, the wage fund for employees of a federal budgetary institution is formed based on the amount of funds received in accordance with the established procedure by the federal budgetary institution from the federal budget, and funds received from income-generating activities (clause 11 of Regulation No. 583).

It follows from these provisions of the legislation that institutions make up a single staffing table, which includes all positions (professions) of this institution, regardless of what funds are used to finance a particular position.

Speaking about the form of the staffing table, it should be said that direct explanations of the federal authorities on this issue no. However, since the departmental normative act (order of the Ministry of Healthcare of Russia dated 01.18.1996 No. 16) approved its own form of staffing for health care institutions, in my opinion, it should be used.

So, for example, the relevant departmental regulations approved schedule forms for subordinate institutions: staffing, approved. by order of the Federal Agency for Special Construction dated 03.12.2010 No. 540, staffing, approved. by order of the Federal Agency for state reserves from 09.09.2010 No. 180, staffing, approved. by order of the Federal Customs Service of 18.10.2005 No. 970, staffing, approved. Methodological recommendations for working with documents in educational institutions(letter from the Ministry of Education of Russia dated 20.12.2000 No. 03-51 / 64), and others.

From January 1, 2013 in connection with the entry into force of the provisions of the Federal Law of December 6, 2011
No. 402-FZ "On accounting", unified forms for accounting for labor and its payment, approved by the decree of the State Statistics Committee of Russia dated 05.01.2004 No. 1 "On approval of unified forms of primary accounting documentation for accounting for labor and its payment", are not mandatory. At the same time, the information of the Ministry of Finance of Russia dated 04.12.2012 No. PZ-10/2012 explains that the forms of documents used as primary accounting documents established by authorized bodies in accordance with and on the basis of other federal laws (for example, cash documents ).

Who should approve the staffing table of a medical organization?

Such a duty is legally assigned to the head of a medical organization.

So, the right of the head of a medical organization to approve the staffing table is enshrined in the following regulatory legal acts:

by order of the Ministry of Health and Medical Industry of the Russian Federation of January 18, 1996 No. 16 "On the introduction of staffing forms for health care institutions";
Unified recommendations for the establishment at the federal, regional and local levels of remuneration systems for employees of state and municipal institutions for 2015, which were approved by the decision of the Russian Tripartite Commission for the Regulation of Social and Labor Relations dated December 24, 2014, Protocol No. 11 (sub. p. 33).

In addition, according to sub. "E" clause 8 of the standard form employment contract with the head of a state (municipal) institution, approved. Decree of the Government of the Russian Federation of 12.04.2013 No. 329, the head has the right to approve the structure and staffing of the institution in accordance with the established procedure. It should be noted that by virtue of Part 3 of Art. 275 of the Labor Code of the Russian Federation, an employment contract with the head of a state (municipal) institution is concluded on the basis of a standard form of an employment contract approved by the Government of the Russian Federation, taking into account the opinion of the Russian tripartite commission for the regulation of social and labor relations.

It should also be said that by virtue of the direct indication of the law, namely part 2 of Art. 13 of the Federal Law of 03.11.2006 No. 174-FZ, head autonomous institution independently approves the staffing table.

Should the head of a medical organization agree on the staffing table with higher authorities?

In accordance with clause 19 of the Unified Recommendations for the Establishment at the federal, regional and local levels of salary systems for employees of state and municipal institutions for 2015, approved by the decision of the Russian Tripartite Commission for the Regulation of Social and Labor Relations dated December 24, 2014, Protocol No. 11, the staffing table is approved by the head of the institution and includes all positions of employees (workers' professions) of this institution. In turn, the obligation of the head of a budgetary institution to coordinate the staffing table, including information on the number of staff units, is not established by federal legislation with the founder.

At the same time, this obligation can be established for certain types of institutions in the legal act of the founder or fixed in other agreements regulating the issues of remuneration of employees.

According to clause 11 of Regulation No. 583, the wage fund for employees of a federal budgetary institution is formed based on the amount of subsidies received in accordance with the established procedure by the federal budgetary institution from the federal budget, and funds received from income-generating activities.

Consequently, the procedure for approving the staffing table does not depend on the sources of funding for the remuneration of employees of the institution.

Thus, if the obligation to agree on the staffing table is not established in the legal act of the founder or in other agreements regulating the issues of remuneration of employees, then state-financed organization develops and approves the staffing table independently. Additional approval is not required in this case.

It is especially worth noting that in practice there are also quite often requirements from the territorial compulsory health insurance funds to agree on the staffing table directly with them. It should be said that federal legislation also does not provide for such a duty for the heads of a medical organization. In turn, the letter of FFOMS dated 06.04.2015 No. 1726 / 30-4 "On the procedure for forming staffing tables" explicitly explains that the structure and staffing are set by the head of the medical organization based on the volume of medical diagnostic work and the number of the population served, taking into account recommended staffing standards stipulated by the procedures for the provision of medical care. Thus, the coordination of the staffing table approved by the head of the medical organization with the TFOMI is not required.

What should the head of a medical organization be guided by when calculating staffing standards? Is it possible to apply orders, for example, the order of the Ministry of Health of Russia dated 09.06.2003 No. 230?

The staffing standards established by order of the Ministry of Health of Russia dated 06/09/2003 No. 230 are recommended, they must be followed when drawing up the staffing table along with the procedures for the provision of medical care, but the medical organization is not obliged to strictly comply with them.

In accordance with the letter of the Ministry of Health of Russia dated 08.01.2004 No. 14-04 / 9846, the order of the Ministry of Health of Russia dated 09.06.2003 No. 230 was recognized by the Ministry of Justice of Russia (letter dated 26.06.2003 No. 07/6476-ЮД) not needing state registration, since it is organizational in nature and does not contain legal regulations... Accordingly, as follows from the above letters, the order of the Ministry of Health of Russia dated 09.06.2003 No. 230 is of a recommendatory nature, since it does not contain binding legal norms.

In addition, in accordance with clause I of the current order of the USSR Ministry of Health of 02/10/1988 No. 90, the heads of health care institutions, based on production needs, are allowed to strengthen individual structural divisions or introduce positions that are not provided for them by the current staffing standards, at the expense of positions of other structural subdivisions within the established institution number of posts and the payroll. At the same time, it is allowed to replace posts in any order. The changes made are made to the staffing tables without the consent of the higher health authority.

It should also be noted that the business case is not prioritized in modern approach to the establishment of staffing standards:

In accordance with section IV of the Program for the phased improvement of the remuneration system in state (municipal) institutions for 2012-2018. (approved by the order of the Government of the Russian Federation of November 26, 2012 No. 2190-r) the formation of the staffing of institutions should be carried out using labor rationing systems, taking into account the need for high-quality provision of state (municipal) services (performance of work).
In accordance with the order of the Ministry of Health of Russia dated June 26, 2014 No. 322, when determining the need for medical personnel, the following are taken into account:

peculiarities of morbidity, taking into account the sex and age of the population in the constituent entity of the Russian Federation;
territorial features of the constituent entities of the Russian Federation (location of the constituent entity in the regions of the Far North and equivalent areas, population density, specific gravity rural population);
the volume of medical care provided within the territorial program of state guarantees of free provision of medical care to citizens (TPGG);
presence in the constituent entity of the Russian Federation settlements, remote (more than 400 km) from medical organizations where specialized medical care is provided.

In addition, in accordance with sub. 7 p. 2 of Art. 7 of Federal Law No. 174 of 03.11.2006, the charter of an autonomous institution must necessarily reflect the structure and competence of the bodies of an autonomous institution. Thus, if the authority to approve the number of employees of this institution is not attributed to the competence of the founder or supervisory board, then they refer to the powers of the head of the autonomous institution, along with the approval of the staffing table (clause 2 of article 13 of the Federal Law of 03.11.2006 No. 174).

Judicial practice is also of the opinion that the establishment of staffing standards is the right of the head of the institution. So, in the appeal ruling of the Tomsk Regional Court dated February 14, 2014 in case No. 33-140/2014, the judicial board ruled: “In realizing the rights enshrined in the Constitution of the Russian Federation (part 1 of article 34 and part 2 of article 35), the employer, in order to exercise effective economic activity and rational property management have the right to independently, under their own responsibility, make the necessary personnel decisions, while ensuring, in accordance with the requirements of Art. 37 of the Constitution of the Russian Federation, guarantees enshrined in labor legislation labor rights workers ".

It is especially worth noting that at present, the procedures for the provision of medical care, which, according to the current legislation, are mandatory, contain the recommended staffing standards for the number of medical personnel. The very fact that these staffing standards are recommended does not oblige the head of a medical organization to strictly adhere to them when drawing up a staffing table. It should also be noted that if in the Unified Recommendations for the Establishment of Remuneration Systems for Employees of State and Municipal Institutions for 2014 at the federal, regional and local levels, there was an indication of the formation of the staffing table in accordance with the procedures for the provision of medical care, then in similar recommendations on 2015, there is no such indication. Thus, the legislation does not establish a strict obligation to use the recommended staffing standards established by the procedures for the provision of medical care when drawing up the staffing table.

Can the head of a medical organization increase staffing standards, for example, in order to organize income-generating activities?

Yes, the manager has the right to do this. In addition, in a letter from the Ministry of Health of Russia dated 10/25/2012
No. 16-5 / 10 / 2-3238 "On the direction of methodological recommendations" Determination of the optimal ratio of medical / paramedical / other personnel in state and municipal health care institutions of the general medical network and specialized services»Contains clarifications that when determining the optimal ratio of medical / paramedical / other personnel in state and municipal health care institutions of the general medical network and institutions of specialized services, it is advisable to take into account such factors as the presence of full-time and occupied positions held at the expense of income-generating activities ( paid services). This activity is self-sustaining, and there is no need to monitor the availability and ratio of positions funded by paid medical services and other areas of income-generating activities. For example, additional positions of other personnel help to improve the quality of patient care in the provision of paid medical services.

Should a medical organization introduce separate staffing tables by funding source (for example, compulsory medical insurance and income-generating activities)?

No, the creation of separate staffing tables is not required in this case. This is directly indicated by the FFOMS in a letter dated 06.04.2015 No. 1726 / 30-4, explaining that a separate establishment of the staffing table within the framework of activities in the field of compulsory health insurance is not provided and is not required.

It might be helpful to read: