2/13/05njm

Q. What are the best staffing ratios for my clinic and / or my hospital?

A. The best ratios provide effective care with dignity for your
patients. See below

There is no single 'cookie cutter' answer to this question. Staffing
ratios need to be defined at your own facility and the ratios depend on
many parameters, including the acuity of your patient load and your
facility's physical layout, but there are a myriad of factors to
consider.

#1

In the meantime, your first goal should be highly effective care
provided with dignity. In women's health a very important aspect is
dignity. One basic requirement to ensure care with dignity, can be as
simple as providing a chaperone during every physical exam involving the
genitals or breast regions.

The Indian Health benchmark for use of chaperones is the following ACOG
statement:

**ACOG's Ethics in Gynecology: Sexual Misconduct in the Practice of
Obstetrics and Gynecology: Ethical Considerations**

\"....The request by either a patient or a physician to have a chaperone
present during a physical examination should be accommodated
irrespective of the physician\'s gender. Local practices and
expectations differ with regard to the use of chaperons, but the
presence of a third person in the examination room can confer benefits
for both patient and physician, regardless of the gender of the
chaperone...."

This issue has been discussed extensively at our Biennial Indian Women's
Health meetings and we continue to endorse the ACOG statement as our
national benchmark. We made a strong recommendation for the routine use
of chaperones to HQE in both instances, as it reflects on staffing
ratios. With elevated rates of sexual assault victims in some AI/AN
populations, a chaperone is a **MUST** in women's health. In addition to
honoring the patient's dignity and choice, proper use of chaperones may
also value in the medico-legal aspects of care. (see Other Resources
below)

#2

Staffing at your facility should be defined by your local tribal board's
definition of desirable access to care. In some settings that metric can
be a third next available appointment within 1-4 days, depending on the
type of care provided.

The 'third next available' appointment comes from the concept that it is
not practical to judge from your 'next available' appointment. If
patient **'X'** 'no shows' just minutes before patient **'Y'** calls,
and an appointment becomes available within a few minutes, it is not
practical for patient **'Y'** to drop everything, take her children to
day care, etc... and rush in for an appointment on such short notice.

The basic principle should be to perform 'today's work today'. One can
have great success using the principles utilized in the Institute for
Healthcare Improvement's Breakthrough series. Here is some background on
that approach.

Flow: Institute for Healthcare Improvement

<http://www.ihi.org/IHI/Topics/Flow/>

Institute for Healthcare Improvement Home page

<http://www.ihi.org/ihi>

Access to care is a science, and well beyond the scope of this FAQ. I
would be happy to share some of our experiences from Alaska Native
Medical Center with you as we moved from access in the range of 23 days
for a routine appointment, to same day access to care in some settings.
Please contact me directly at <nmurphy@SouthcentralFoundation.com>

#3

Lastly, the Indian Health system has defined basic minimum staffing
patterns. My suggestion is to work with your tribal board first to
outline their exact objectives, then to apply the 'open access to care'
principles.

If you are still an 'Indian Health Service' facility, e.g., not on a 638
contract or compact, then I suggest your facility change to 638 status
as soon as possible. '638' status will allow your facility more
adaptability in billings and collections, so you can develop more
resources to provide additional staff to the ratios outlined in the
minimum patterns below.

**Planning and Evaluation**

# Resource Requirements Methodology (RRM) Staffing Standards Reference Model

### INTRODUCTION

**A. Background**\
This Staffing Standards Reference Model documents the current staffing
criteria used in the Resource Requirements Methodology (RRM). These
criteria are used in concert with empirical data, such as workload or
service population, called driving variables, to estimate the staffing
requirements in full-time equivalents to provide comprehensive acute,
chronic, and preventative health care services to Indian people.

This manual was prepared after extensive discussion with IHS
professionals affiliated with the program discipline responsible for the
services of each particular RRM module. The proposed changes to each RRM
module were further reviewed by a RRM Technical Advisory Committee.

See also Table of Contents below

<http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-index.asp>

# RRM Category: AMBULATORY CLINIC

## RRM Module: Ambulatory Nursing

(please add a chaperone in each encounter to the figures below)

The RRM Ambulatory Nursing staffing module estimates the requirements
for nurses that provide comprehensive health care and education to the
individual and family in the ambulatory setting. The workload parameter
that is the key variable in the staffing estimation for Ambulatory Care
Facilities is Primary Care Patient Visits (PCPVs). For Out Patient
Departments in hospitals supervisory and their clerical support is based
on ambulatory clinics. This module estimates the need for Nurse
Managers, Registered Nurses, Licensed Practical Nurses, and Clerical
Support for ambulatory.

Ambulatory Nursing provides comprehensive health care and education to
the individual and family in the ambulatory setting, through provision
of nursing care and/or services utilizing the nursing process, and in
coordination with the medical plan of care and other health care
providers. Continuity of care is accomplished through coordination of
services with inpatient and community health programs and utilization of
community resources in the promotion/maintenance of health.

Ambulatory Nursing services are directed towards meeting the needs of
individuals, families, and the community during times of health and
illness. Within the Indian Health Service, the ambulatory care nursing
staff services people of all ages. Ambulatory care nurses apply their
skills in, and knowledge of, clinical nursing, administration, public
health, epidemiology, counseling, and education to provide direct and
indirect services such as: therapeutic, emergency, health promotion,
disease prevention, and advocacy services.

1.00 FTE [Nurse Supervisor]{.underline} for every ambulatory care clinic
with a staff of at least 3.00 registered nurses and the clinic is
located within a hospital.

1.00 FTE [Medical Clerk]{.underline} for every ambulatory clinic with a
staff of at least 3.00 registered nurses and the clinic is located with
in a hospital.

1.00 FTE [Nurse Manager]{.underline} for every 10,400 PCPVs up to 10,400
PCPVs, plus 1.00 FTE [Nurse Manager]{.underline} for every 16,000 PCPVs
above 10,400 PCPVs.

Fixed [Registered Nurse]{.underline} staff of 1.43 FTEs for each
facility with at least 4,400 PCPVs, plus 1.00 FTE [Registered
Nurse]{.underline} for every 3,200 PCPVs above 4,400 PCPVs.

Fixed 0.35 FTEs [Licensed Practical Nurse]{.underline} for every
facility with at least 4,400 PCPVs, plus 0.35 FTE [Licensed Practical
Nurse]{.underline} for every 3,200 PCPVs above 4,400 PCPVs.

Fixed 0.33 FTEs [Clerical Support]{.underline} for every facility with
at least 4,400 PCPVs, plus 0.33 FTEs [Clerical Support]{.underline} for
every 3,200 PCPVs above 4,400 PCPVs.

Nurse Supervisor\
Medical Clerk\
Nurse Manager\
Registered Nurse (RN)\
Licensed Practical Nurse (LPN)\
Clerical Support

More information

<http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ac-ambulatory-nursing.asp>

# RRM Category: INPATIENT CARE

## RRM Module: Obstetrics/Gynecology

The RRM Obstetrics/Gynecology staffing module estimates the requirements
for OB/GYNs and Certified nurse midwives to provide full service
obstetrics, gynecology, and gynecological surgery services,
operating/recovery room services, and primary care for women. The
workload parameters that are the key variables in the staffing
estimation are the number of deliveries and the number of OB/GYN surgery
cases. The minimum workload for Obstetrics/Gynecology is 200 deliveries
plus OB/GYN surgery cases. Nursing services for OB/GYN are covered in
the Inpatient Nursing modules.

The Obstetrics/Gynecology staff provides:

 Full Service Obstetrics, Gynecology, and Gynecological Surgery
Services

 Operating/Recovery Room Primary Care Service

 Primary Care for Women

NOTE: Nursing services for Obstetrics/Gynecology are covered as part of
Inpatient Nursing

[OB/GYN Surgeon]{.underline} staff of 1.5 FTEs for each facility with at
least 200 OB/GYN deliveries plus surgical cases, plus 1.0 FTE [OB/GYN
Surgeon]{.underline} for every 210 OB/GYN deliveries plus surgical cases
above 200.

1.  FTE [Certified Nurse Midwife]{.underline} for every 200 OB/GYN
    deliveries plus surgical cases for each facility with at least 125
    deliveries

More information

<http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ic-obstetrics-gynecology.asp>

# RRM Category: INPATIENT CARE

## RRM Module: Inpatient Physicians

The RRM Inpatient Physicians staffing module estimates the requirements
for physicians to provide all medical inpatient services other than
surgery and delivery services. The workload parameter that is the key
variable in the staffing estimation is Average Daily Patient Load
(ADPL). This module estimates the need for Chief of Service, General
Medicine Physicians, Pediatrics Physicians, OB/GYN Physicians and
Clerical Support for inpatient care. The staffing needs for surgery and
OB/GYN deliveries are estimated in other inpatient care modules.

The Inpatient Physicians staff provides the following types of service:

 General Medicine

 Pediatric

 Obstetrical/Gynecological

 Other Non-Surgery Type Service

The Inpatient Physicians staff provides the following types of service:

 General Medicine

 Pediatric

 Obstetrical/Gynecological

 Other Non-Surgery Type Service

More information

<http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ic-inpatient-physicians.asp>

**[Other Resources]{.underline}**

**MCH web site Frequently Asked Question (FAQ) page**

**Q. What is the Indian Health policy on use of chaperones?**

A. There is no official IHS policy yet, but we strive to honor our
patients' dignity and choice.

The Indian Health benchmark for use of chaperones is the following ACOG
statement:

**ACOG's Ethics in Gynecology: Sexual Misconduct in the Practice of
Obstetrics and Gynecology: Ethical Considerations**

\"....The request by either a patient or a physician to have a chaperon
present during a physical examination should be accommodated
irrespective of the physician\'s gender. Local practices and
expectations differ with regard to the use of chaperons, but the
presence of a third person in the examination room can confer benefits
for both patient and physician, regardless of the gender of the
chaperone...."

This issue has discussed extensively at each of our last 2 Biennial
Indian Women's Health meetings and we continue to use the ACOG statement
as our national benchmark. We made a strong recommendation for the
routine use of chaperones to HQE in both instances, as it reflects on
staffing ratios. With elevated rates of sexual assault victims in some
AI/AN populations, a chaperone is a MUST in women's health. In addition
to honoring the patient's dignity and choice, proper use of chaperones
may also value in the medico-legal aspects of care.

**[Resources:]{.underline}**

**ACOG's Ethics in Gynecology: Sexual Misconduct in the Practice of
Obstetrics and Gynecology: Ethical Considerations**

[[https://www.acog.com/from_home/publications/ethics/ethics89.cfm]{.underline}](https://www.acog.com/from_home/publications/ethics/ethics89.cfm)

**Chaperone Use by Family Physicians During the Collection of a Pap
Smear**

The use of chaperones during gynecologic examinations remains a
controversial issue with no formal guidelines or legal mandates. The
topic is poorly addressed by the medical literature and by our current
medical education system. No consensus is found among state medical and
osteopathic boards on the use of a chaperone. From the legal
perspective, the recommendations are nearly unanimous in strongly
supporting the use of chaperones. Many questions related to this issue
are unanswered. Does chaperone use decrease malpractice claims? Does
chaperone use have an impact on clinical efficiency, as the inverse
relationship with the volume of Pap smears performed suggests? What are
the regional influences contributing to the geographic variation in
reported use of a chaperone? We believe the question with highest
priority is...What is the perspective of patients?

**[OB/GYN CCC Editorial comment]{.underline}**

After the 2002 Biennial OB/GYN Meeting there should be no controversy in
the Indian Health System about the use of chaperones during examinations
of the breasts or genitals.

It is the standard of care.

If your current staffing does not encourage this practice, then your
staffing needs to modified accordingly. Please also see the ACOG
benchmark statement below.

Chaperone Use by Family Physicians During the Collection of a Pap Smear

Pamela Rockwell, DO, Terrence E. Steyer, MD and Mack T. Ruffin, IV, MD,
MPH

*Annals of Family Medicine* 1:218-220 (2003)

[[http://www.annfammed.org/cgi/content/full/1/4/218]{.underline}](http://www.annfammed.org/cgi/content/full/1/4/218)

**Discussion in the December 2003 CCC Corner**

[[http://www.ihs.gov/medicalprograms/mch/m/mchdownloads/ccccorner12103b.doc]{.underline}](http://www.ihs.gov/medicalprograms/mch/m/mchdownloads/ccccorner12103b.doc)

**Discussion in the July 2005 CCC Corner**

[[http://www.ihs.gov/MedicalPrograms/MCH/M/mchdownloads/CCCCorner71803.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/mchdownloads/CCCCorner71803.doc)

**Chapter 13: IHS Manual**

<http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part3/pt3chapt13/pt3chpt13.htm>

# Resource Requirements Methodology (RRM) Staffing Standards Reference Model

### Table of Contents\*

(please add a chaperone in each encounter to the figures below)

**INPATIENT CARE**\
» [Inpatient
Physicians](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ic-inpatient-physicians.asp)\
» [Surgery and
Anesthesia](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ic-surgery-anesthesia.asp)\
» [Obstetrics and
Gynecology](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ic-obstetrics-gynecology.asp)\
» [Inpatient
Nursing](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ic-inpatient-nursing.asp)

**ANCILLARY SERVICES**\
» [Laboratory](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-as-laboratory.asp)\
» [Pharmacy](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-as-pharmacy.asp)\
» [Imaging](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-as-imaging.asp)\
» [Medical
Records](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-as-medical-records.asp)\
» [Respiratory
Therapy](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-as-respiratory-therapy.asp)

**AMBULATORY CLINICS**\
» [Ambulatory
Physicians](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ac-ambulatory-physicians.asp)\
» [Ambulatory
Surgery](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ac-ambulatory-surgery.asp)\
» [Ambulatory
Nursing](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ac-ambulatory-nursing.asp)\
» [Emergency Room/Urgent
Care](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ac-emercency-room-urgent-care.asp)\
» [Eye
Care](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ac-eye-care.asp)\
» [Audiology](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ac-audiology.asp)\
» [Physical
Therapy](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ac-physical-therapy.asp)\
» [Dental](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ac-dental.asp)

**COMMUNITY HEALTH**\
» [Public Health
Nutrition](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ch-public-health-nutrition.asp)\
» [Public Health
Nursing](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ch-public-health-nursing.asp)\
» [Health
Education](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ch-health-education.asp)

**BEHAVIORAL HEALTH SERVICES**\
» [Mental
Health](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-bhs-mental-health.asp)\
» [Social
Service](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-bhs-social-service.asp)

**GENERAL SERVICES AND PLANT OPERATIONS**\
» [Housekeeping](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-gsfo-house-keeping.asp)\
» [Facility
Maintenance](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-gsfo-facility-maintenance.asp)\
» [Clinical
Engineering](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-gsfo-clinical-engineering.asp)\
» [Laundry](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-gsfo-laundry.asp)\
» [Food
Services](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-gsfo-food-services.asp)\
» [Materials
Management](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-gsfo-materials-management.asp)\
» [Staff
Health](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-gsfo-staff-health.asp)\
» [Security](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-gs-security.asp)

**ADMINISTRATION & PROGRAM MANAGEMENT**\
» [Administration](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-apm-administration.asp)\
» [Financial
Management](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-apm-financial-management.asp)\
» [Office
Services](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-apm-offices-services.asp)\
» [Contract Health
Services](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-apm-contract-health-services.asp)\
» [Business
Office](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-apm-business-office.asp)\
» [IMS/IRM](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-apm-ims-irm.asp)\
» [Quality
Management](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-apm-quality-management.asp)\
» [Central
Supply](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-apm-central-supply.asp)\
» [Interpreters](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-apm-interpreters.asp)\
» [Drivers](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-apm-drivers.asp)

**EMERGENCY MEDICAL SERVICES**\
» [EMS
Methodology](http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-ems-methodology.asp)

\* Link:
<http://www.ihs.gov/NonMedicalPrograms/PlanningEvaluation/rrm-index.asp>