Page 43 - ACCCN's Critical Care Nursing

20 S C O P E O F C R I T I C A L C A R E

Ethico-economic analyses of services like critical care and the hourly rate of pay and any penalties that are to be
expensive treatments like organ transplantation are the attributed to work done during the after-business-hours
new consideration of this century and are as important period. Non-productive hours include sick leave, holiday
to good governance as are discussions of medico-legal leave, paid education hours, paid maternity leave and any
considerations. Sound ethical principles to inform and other paid time away from the actual job that staff are
guide human and material resource management and employed to do.
budgets ought to prevail in the management of critical Personnel budgets tend to be fixed costs, in that the
care resources. 2
majority of staff are employed permanently, based on an
BUDGET expected or forecast demand. Prudent managers tend to
employ 5–10% less than the actual forecast demand and
This section provides information on types of budget, the use casual staff to ‘flex-up’ the available FTE staff esta-
budgeting process, and how to analyse costs and expen- blishment in periods of increasing demand, hence con-
diture to ensure that resources are utilised appropriately. tributing a small but variable component to the personnel
As noted by one author, ‘Nothing is so terrifying for clini- budget. 22
cians accustomed to daily issues of life and death as to
be given responsibility for the financial affairs of their Operational Budget
hospital division!’. Yet, in essence, developing and man- All other non-personnel costs (except major capital
3
aging a budget for a critical care unit follows many of the equipment) tend to be allocated to the operational
same principles as managing a family budget. Consider- budget. This includes fixed costs such as minor equip-
ation of value for money, prioritising needs and wants, ment, maintenance contracts, utility costs (e.g. electric-
and living within a relatively fixed income is common to ity), and variable costs that fluctuate with patient type
all. This section in no way undermines the skill and preci- and number (e.g. pharmaceuticals, meals, consumable
sion provided by the accounting profession, nor will it supplies such as gloves and dressings, laundry).
enable clinicians to usurp the role of hospital business
managers. Rather, the aim is to provide the requisite Compared with personnel costs, operational costs in criti-
knowledge to empower clinicians to manage the key cal care tend to be relatively small, but they can be
components of budget development and budget setting, managed and rationed with the help of good information
and to know what questions to ask when confronted by and cooperation. For example, there is a range of dressing
this most daunting responsibility of managing a unit’s or materials available on the market, and a simple dressing
service’s budget. that requires less expensive materials should always be
used unless a more expensive product is indicated and a
TYPES OF BUDGET protocol exists to inform staff of this clinical need.
There are essentially three types of budget that a manager Fixed costs can also be turned into variable costs and
must consider: personnel, operational and capital. Within hence encourage efficient usage. For example, pressure-
these budget types, there are two basic cost types: fixed reduction mattresses, traditionally purchased as a fixed
and variable. Fixed costs are those essential to the service asset with variable (and unpredictable) repair and main-
and are relatively constant, regardless of the fluctuations tenance costs, can now be leased on a per-day or per-week
in workload or throughput (e.g. nurse unit manager basis, with no need for storage, cleaning or maintenance
salary, security, ventilators). Variable costs change with costs. Further, critical care managers can work with other
changing throughput (e.g. nurse agency usage or staff hospital managers to create ‘purchasing power’ by coop-
overtime), especially if used in response to influx of erating to standardise the range of products used to obtain
demand and resulting consumables such as linen, dress- a better price for a product that will benefit all users.
ings and drugs.
Capital Budget
Personnel Budget Capital budget items are generally expensive and/or large
Healthcare is a labour-intensive service, and critical care fixed assets that are considered long-term investments,
epitomises this fact with personnel costs, the most expen- such as building extensions, renovations and large equip-
sive component of the unit’s budget. The staffing require- ment purchases. Capital budget items tend to be con-
ment for critical care generally follows a formula of x sidered as assets that are depreciated over time. Most
nurses per open (funded) bed. This figure is expressed hospitals consider these items as a global asset – that is,
in full time equivalents (FTEs): in Australia, the equiva- as a group of investment items and activities for the hos-
lent of a person working a 38-hour week. This equates pital – rather than attributing these costs to an individual
to 5 × 8-hour shifts per week with an 8-hour accrued unit or department.
day off every 4 weeks, or 19 × 12-hour shifts in a
6-week period. To request a capital budget item, a written proposal is
required describing the item, its expected benefits,
Personnel costs include productive and non-productive whether it replaces an existing item’s service or function,
hours. Productive hours are those utilised to provide the cost, possible revenue and cost-mitigating benefits.
direct work. A manager will determine the minimum or This analysis does not always have to demonstrate a
optimum number of nurses to be rostered per shift and profit, although the value and benefit of the service would
then calculate the nursing hours per day, multiplied by need to be established.