HERC Health Economics Seminar 1/18/2012 

Organizational Slack Resources and Quality of Primary Care 

Presented by: Mohr, David

My name is Ciaran Phibbs, I'm one of the economists at the Health Economics Resource Center part of the organization which hosts this presentation. Today we are pleased to have David Mohr present. He is an HSR&D investigator and a research assistant professor at Boston University school of Public Health. He received his Ph.D. in industrial organization psychology from Bowling Green State University. He directs his research activities towards understanding the role of team work and organizational climate in the healthcare settings with an emphasize in primary care services, and he is also involved in VA efforts to focus on measurement assessment of organizational health, including such programs as the all employee survey and the employee occupational health and safety. He's done some joint work with Mark Meterko and Gary Young, that has found a positive relation between teamwork culture and patient satisfaction, and today David is going to speak on Organizational Slack Resources And The Quality Of Primary Care. David. It's all yours. 

Okay. Well, thank you very much. I'm delighted to be here today, to be talking with you. Thank you for taking some time out of your busy schedule. I want to acknowledge the work I'll be talking about today comes from a manuscript that I authored with Gary Young. We are both with the Center for Organization Leadership and Management Research, at the HSR&D Center at Boston VA Medical Center and we have affiliations with Boston University School of Public Health for myself and Northeastern University for Gary. I also want to acknowledge this work was based on a grant funded by VA HRS&D, looking at teamwork and primary care, and also want to acknowledge some is people who have been helpful along the way in provide some ideas or insights and thoughts on this topic specifically. And, again, a standard disclaimer. These are my own views, and don't reflect the position or policy of the VA, and I have no conflicts of interest to declare. So to get started, I want to do a brief interaction question just to see who is on the line. I was wondering if you could tell me which category best describes to you being a researcher, investigator, programmer, administration, or policy maker, clinical, or some other category before we begin. 

Yes. Okay. Now I do see the results. Most people are in the researcher/investigator side, 25% administrator or policy maker, some 'others', and some programmers involved too.

So today's objective, audience members will become family with organizational slack. I'll talk about what it is, how it's been defined, some theory around it and how it's been used and research studies to be assessed. I'll talk about the debate around organizational slack, and whether it's a good thing, a bad thing, or something in between. I'll give a brief highlight of some selected findings from the literature on organizational slack. Fourth, I'll talk about the manuscript that I was involved with, and an application of the concept of organizational slack to VA primary care. And 5th is kind of considerations for extending your understanding on the topic and potential application of this concept to your own line of work. 

So to begin with, an overview, a definition. It is a concept from organizational theory and strategic management literatures. It may not be something we've come across that often in healthcare, so I think that's one reason it's caught a lot of attention, or there is some interest in having me discuss this topic, but it represents organizational slack, or those extra resources that are available to meet demands. So, you know, having a little bit extra than you need to get the job done basically. Is this is a classical dilemma for managers. They want to know how to balance efficient operations, and their extra resources, so they're not wasting too much, or they're not under resourced or understaffed, and they want to be able to respond to unexpected threats, demands, or changes, and the environment, and any new opportunities that they could, you know, potentially create that would lead to even better performance for the organization, be it profit or delivery of high-quality care, and expanding access opportunities. 

Slack can be seen as a cushion of actual or potential resources within the organization. And so what it does, it allows organizations through their work units to adapt to internal stress, things that are happening within the organization, or to react strategically or proactively to external changes, such as new regulations, new systems, such as health information technology changes, the new guidelines that come about, and slack theoretically should allow for two different types of -- two different classes of behaviors. One would be kind of an internal maintenance factor. So preserving the existing coalitions or work groups within an organization, so not having to make a lot of changes or shuffling people around, or different groups around without breaking things up too dramatically. It can serve as a resource for conflict resolution. For example, if you have a lot of extra, you know, cash for improvement projects, you won't have a lot of people fighting over which is the best one, or how should people be assigned, or enabled to attend professional conferences. You know, can reduce some of the conflict in those situations, and it also helps to be a buffer or help to protect employees or the organization from being overwhelmed by too much demand, or too much workload. The second class of actions that it allows is it facilitates strategic behavior. So things like innovation, or satisfaction, doing something just adequate but not really excelling, and potential political management aspects, all can be kind of improved, or you have greater degrees of flexibility how you might carry on any of these actions with additional resources and it's probably the most closely related to the concept of efficiency among different performance models. The IOM 6 Aims models has efficiency as one of its key aims. So I think that fits into this concept of efficiency. And I'll talk a little bit later about different views in healthcare, or different research perspectives from healthcare. But right now, I wanted to talk a little bit more about defining it further. And so it's been further classified into different types of slack. Based on how easy it is to recover or obtain slack. The first class is available slack. This is the easiest one to recover. It's liquid. Resources are not being used in the organization. So think about, you know, cash. You have extra cash, you can, you know, willingly spend it in different areas without a lot of restrictions. Or it could be underutilized employees, so someone who just comes on to the organization, has extra time, or people that, you know, through job changes have, you know, extra time to work on different projects, or different areas of the organization. The second class of slack is recoverable. So this is slack that can be recovered with a little bit of effort, more so than the available slack. It requires some kind of redesign or reconfiguration within the work unit, or the organization. So traditionally this includes things like inventory, sales expenses, or overhead expenses. So these are things that you move around a little bit, but it takes a little bit of permission, or a little bit of maneuvering to be able to do so effectively. And the third is potential slack. And this is as -- this has the longest time frame, and it also requires the greatest amount of effort to recover. So this can be used to, you know, generate additional capital or debt, such as, you know, requesting more funds from the public, if you're a big stock, if you are a publicly trading company on the stock market, or plans to add new staff or space. So things that take a lot of effort, and they don't happen very quickly or easily. So it's been measured primarily through financial means, but there are some other nonfinancial forums that have been used for organizational slack, and those things include unused staffing, space, capital, cash, and other assets, and also the company's reputation is also considered part of slack. For example, if a big pharmaceutical company has to issue a recall on a product, you know, that may hurt their image a little bit, that may hurt their profits a little bit, but they can still recover. It's not going to be the game-ender for that company, per say. And a lot of the management research that use financial instruments, things such as debt to equity, long-term debt to assets, research and development of sales, administrative expenses to sales, working capital to sales. So usually it’s some kind of ratio estimate. Okay. In healthcare, a couple of things that have been used, one would be the ratio of employees per adjusted patient day. That was used in one healthcare specific study. More recently, there's been the Alberta context tool, which is a nine item instrument that asks employees about things around slack, such as staffing, space, and time, around those three dimensions. So an employee might be asked if there's adequate space to provide patient care, if they have enough staff to get the work done, or to provide high-quality care, or if there's enough time to do something extra for patients, or to look something up, or to learn about new clinical knowledge. So those are the kinds of things that are asked about in this kind of instrument, and slack time has also been used in another study by a single item, which asks about employees having time to choose what they want to work on. So the other thing that is important to note is that it can be considered as either an outcome, a predictor variable, or a control variable. And typically, it's been used mostly as a predictor variable, and sometimes as a moderator variable. So coming in between two things, such as organizational size, and innovation, and they look to see the extent that slack may moderate or improve the relationship between size and innovation. Before we go into the debate, I want to get a sense of where the audience stands on their views of organizational slack. Whether you think of it as something good, a cushion, or something bad, as being inefficient or wasteful, maybe it depends, or if they're unsure. So take a moment to provide your responses. 

Okay. Responses are coming in. I'll just wait for it to slow down a little bit before closing it. 

Okay. 

And there's your results. 

Okay. So the majority are showing that it depends. Okay. So a few people saying good, bad, or unsure, but about the same amount. So let me talk next about the debate. On why people would see this as good or bad, or some place in between. So I think I've talked a little bit about some of this briefly, but go into a little more detail here about why slack is a beneficial resource. It allows facilities to be more innovative, take risk, try to enhance their performance. It allows hiring maybe more employees than are needed to meet or address upgrades or increasing demand. Something that would allow expanded hospital services, expanding campuses, or CBOCs, partnering with other agencies, such as the Department of Defense for example on some of the work VA has been doing. Slack would allow hospitals to seek prestigious affiliations such as the Magnet and Carey Award. Also helps to improve employee working conditions and also benefits. It's useful for conflict resolution, because it allows powerful organizational groups, who have different or maybe conflicting goals, to resolve differences, so that these, you know, groups, say marketing and human resources, may have very different goals or different needs. Having that slack, you know, provides some way to kind of satisfy both groups, so that they don't compete and cause harm to the overall functioning on the organization. 

And you may be able to think of cases in Primary Care especially or a tradeoff that this may apply as well. And primarily in a knowledge-based organization, it allows for thinking time, for people to just think about new clinical ideas, or new procedures that might be valuable. 

Okay. This also has not only a facilitative effect, but a protective effect. So it's going to protect the organization against environmental changes. For example, any environmental shocks or surprises, like a sudden change in the economy may lead to greater patient demand, any types of internal changes around guidelines being introduced, or new information technology adoptions being implemented, because it allows extra time to respond or integrate those changes into the organization. Organizations that have greater slack are less likely to be worried about failing or, you know, having one -- having one idea go wrong, and so they'll be more likely to develop into an innovative culture. So it allows a little bit more freedom to think and take some risks. And without slack, organizations and work groups are probably more likely to focus just on the immediate or short-term performance, maybe kind of not think so much about what happens in the long run. So people who think slack is inefficient or a bad thing, that it should be eliminated, come from this perspective thinking that it's too much money, or too much -- too many resources were being spent to provide the product or the service, or that the product and the service exceeds what is needed. So, you know, putting too much time into something that isn't necessary, or trying to develop the A-plus product may not be as important as developing the B-plus product. And some economic theories would define the slack as inefficiency, and that’s really a bad thing, it implies resources and demands are not in equilibrium. So think about some of the year-end spending models you have, spend a million dollars, and you have, at the end of the year, 200,000 left to spend, that might be inefficient, and in some systems you might get penalized for having this extra income or cash on hand before the year ends. As you may not get that same amount next year. Slack as inefficiency is also seen as something that may lead to bad decision making. If you have too much freedom, through agency perspective, they believe that managers may begin to pursue self-serving procedures or selfish behaviors that may maximize profit, such as with holding up a shareholder investments or dividend distribution, in financial terms, focusing on pet projects, or splitting the company into new areas or growing into new areas that may not be very valuable, or having personal preferences about organizational structure that may not make sense on a business perspective. So trying out too many things may lead to too many things going wrong. The IOM in their report also suggests that reducing quality waste and administrative and production costs were, you know, an area of concern, as they take care away from patients. So if you have slack, as money or time or staffing matter being spent on noncare activities, that takes away from delivering care to the patient. And there's also a book from the '90s that talked about the ICARUS paradox, where success of an organization or manager can lead to overconfidence, a situational blindness, and you're not paying attention to what's happening outside of the workplace, or outside of the internal organization, and things are happening, but you're not being very responsive to them, because maybe it's a tradition that things always work the way that they have, and we've got along fine, so why change? Things such as disruptive innovations may come along that really radically change the playing field, that may hurt the performance in the long run. And there's also a perspective from organizational theory of the resource constraint theory, that says that firms with few fewer resources will find a way to use them more efficiently. So if you take away, you know, $10,000, from organizations, some department is going to find a way to make up for that difference by maybe motivating staff to work harder, or an extra hour, or moving some resources around, or collaborating with other departments within the organization to be able to meet their goal. So the compromise view, which I think many of you said it kind of depends, shows a curve linear relationship between slack and organizational success. So slack is good up to a point, but beyond that, too much slack will lead to negative outcomes. Some pursuit of innovation can lead to better organizational performance, and that surplus of resources is helpful for unforeseen threats or opportunities, but it should be limited to prevent people from behaving irresponsibly. And there's also a YERKES-Dodson law, a concept from psychology that I think kind of nicely illustrates this point, where it's looking at performance, and physical or mental arousal, and the best performance usually happens sometime between the high and the low arousal. So you don't want too much mental anxiety. That will hurt performance, but you don't want to be not paying attention, because they won't lead to best performance either. So we'll talk about the past research. Wanting to ask an interaction question. How often do you use organizational or clinical level variables as a means to influence your research or policy thinking and decision making? 

Okay. Responses are coming in. We'll give it a few more seconds here. And there's your results. 

Okay. So like a third said most of the time, and more than half said some of the time, and a small percent said hardly ever. Okay. So next I want to talk about some of the past research on this topic, before I get to talking about the example in primary care. I'll go through this somewhat briefly. But it's been a concept that's been well-studied in the organizational behavior and strategic management literature, mostly looking at financial measures, a recent 2004 meta analysis looked at slack and performance or profitability. It did show a positive relationship between the two. And they theorized that firms use -- or appear to use slack to improve performance. In healthcare, it's not been researched as well, but there's been a couple of articles in health services research that have happened, or have been cited, that do address this topic in detail, through either an essay or empirical study. Slack has been known to influence organizational behavior and performance, such as innovation and adoption. This has probably been one of the most researched areas outside of profitability as to how well slack contributes to innovation. And slack can also help learn from patient safety failure events and differences in care quality and efficiency may be due to slack in one study from hospitals. A few other studies have looked at knowledge slack relating to organizational learning innovation and performance, corporate social responsibility, Medicare mortality rate, risky business decisions and R&D investments.

So you can look at each study in a bit more detail if you're interested. So the primary care example, the rationale for the study is that clinics with greater slack should allow for greater provider and support staff flexibility and provide appropriate preventive tests and procedures. 

So this should lead to more positive perceptions of the overall care experience for the patient. And to the extent there’s too much or too little organizational slack, organizational practices may continue inefficiently and that could lead to lower care delivery quality. The one study theory we looked at 568 primary care clinics, in VA, had two independent samples of patients. We used a patient satisfaction survey, the SHEP. Many of you may be familiar with this. We looked at the overall quality of care, and continuity of care. And we also looked at the technical quality of care, such as the influenza vaccination. These are examples of different process or preventive care measure. So, it's not meant to be an exhaustive study, but more representative of care practices. So for organizational slack resources, we used the VA primary care management module. There are a number of references in VA describing this. VA has developed some standard staffing guidelines for primary care. They've been extensive reviews, benchmarking, and internal testing. Stefos and colleagues also have a paper published within the last six months detailing this model that may be worth looking at, as well, if you're interested in this PCMM module. So the two variables I used for organizational slack included the panel size for clinic capacity, as a measure that indicated if the percent of the clinic was above or below the VA guideline. So the panel size is the number of patients assigned to each provider, typically about 1200 for physicians, or 900 for a nurse practitioner, or physicians assistant, and based on how many available provider -- how much capacity could the providers in that clinic see. So the clinic level measure was created at individual per level, but aggregated to the clinic. A score of zero would indicate that the clinic is at the guidelines, so they don't have any additional slack, a .1 value, and the clinic has about 10% slack, or a value of negative .1 may indicate some deficiency in slack, or limited resources. And we also looked at support staff per provider, and both of these are collected and reported on a routine basis, with some of the primary care management module reports. The support staff is basically the number of extra support staff per provider beyond the guideline recommended. For our outcome variables, we looked at influenza. We chose that because providers usually accept the guidelines, but they're not always followed in compliance due to the higher demand during that seasonal period, patient preferences. But once they show that organizational change interventions were among the most effective classes of interventions, leading to improvement of vaccinations. So if changing the configuration or the job design, or the staff allocation may lead to better improvement in vaccination and organizational slack may have something to do with that. And we looked at patients seen from September to March of 2007, and we matched EPRP data set to the SE data set to make sure these were patients with primary care visits that happened during that period, and were at least 50 years old to meet the influenza criterion guideline. From the SHEP survey, this is administered routinely in VA to patients who make specialty care visits or primary care visits of new and established patients. We only included patients whose survey results matched the primary care visit during that same time period, and that survey had a response rate of about 54 percent nationally and a 54% clinic wide response rate. Continuity of care was selected because patients with regular care providers were more likely to get preventive care services at a busy clinic without a lot of slack, patients may not be able to get their own appointments with their provider. And we had about 50,000 responses to that question that we matched to our sample. And these are all quality of care items, something that's widely used to look at quality perception, and it should be sensitive to organizational resources. So, again, the correlation between the overall quality of care item and the continuity of care item was about .28 from the same survey, so there's not too much overlap between these measures, and, again, also wanted to emphasize patients in the SHEP, and with the patient satisfaction survey, and the influenza sample were different patients. In the model, we included patient level variables for age, sex, marital status, visit frequency, and quality of life per the SHEP survey respondents. For the clinic level, we included a few more than might typically be used. We included traditional ones of census regions, urban or rural clinic location, whether the hospital was a community -- whether the clinic was community-based, or hospital-based, teaching affiliation, and also looked at whether the clinic had been operating for at least five years, as this may indicate some type of clinic maturity. New clinics may have trouble getting everything fully staffed, or running the systems, and interacting with VA. We felt that night be a critical factor, and whether the clinic had won a Carey award, as this is indicative of some type of quality improvement activities that may have happened, or be happening with primary care. We considered support staff mixing. As mentioned, we have a support staff provider variable, but we wanted to look at it more as a mix of personnel, as how care is being construed, so we had a variable for RNs, and total support staff as well; clinic size, in terms of the total FTEE of the clinic. Provider type index, mixing of physicians to nurse practitioners or physician assistants. A full time provider index to get a sense of how often these providers are in the clinic, so that could be 40 hours if everyone is full time, or maybe 20 hours if a clinic is staffed mostly by part-time employees, and we also used a group oriented organizational culture from the all employee survey. We used SAS PROX GLIMMIX with patient variable entered in level 1 and clinic variables in Level 2 

We looked at organizational slack as both a linear and quadratic term. Here are the odds ratios. You can see for each of the models where the organizational slack variable was significant, or the square term was significant. So for influenza vaccination, we have three of the four variables significant. Continuity of care the support staff per provider linear and quadratic term was significant. For overall quality of care, the panel size per capacity squared was significant. And the next few slides, I show what that relationship looks like, if we were to plot it. The point zero indicates the bottom of -- the middle of the slide indicates the clinic has a has an equal balance, so they're at the guideline, and you can see as the -- down here is a deficiency, or fewer staff than needed to meet the demand, up and here is a surplus, and so as the clinic, you can see with a 10% reduction, or less staff than the guideline would suggest or recommend, you'll see the score is about right here, maybe about .68 or so. As you move up this curve, the likelihood of a patient getting the influenza vaccination increases. And then it kind of tapers off around here, where it doesn't ascend as quickly. And the next few graphs also show something similar, both support staff for influenza vaccination, overall quality of care with panel size, support staff, and continuity of care. So we also looked at the marginal effects, so at what point would adding additional resources contribute to no additional improvement. That seems to happen around 1 to 1.5FTE beyond staffing guidelines. At that point, you're increasing up to that point, but beyond then, you start to slightly decrease, in terms of performance. So that's about right here. This is when you begin to start to not gain as much from adding additional staff. And for the panel size measures, panel size per capacity, that happens at -- you see improvements at 4% and 7% beyond the guidelines. So beyond that amount the probability of a good patient outcome starts to waver or decline. They’re not going to benefit that much. The patient seen in that clinic is not likely to benefit much from having more staff. So based on the graphics, we also tested whether there is a logarithmic function that would fit but we didn’t find great support for that. We found the geographic region was significant for all the variables, teaching affiliation, group oriented organization culture, clinic size, and provider type index were significant in two out of the three models. So to kind of summarize what we found, having insufficient resources was far worse than having too many in this study. Additional staffing contributed to higher levels of quality, but only up to a certain point. And more staff only led to minimal contributions in quality, and may slightly decrease quality if you continue to add staff beyond a certain level. 

So I wanted to talk a little bit about the impact of limited resources. There are types of barriers that can happen that may lead to lower performance. If you're lacking resources, you may have a barrier to capability, so staff are unable to perform their successful work strategies, because they have or are missing something resource, and also there is also a barrier of will when staffers are less motivated because they have fewer job resources. So both of these are things of consideration when thinking about why limited resources may impact the relationships we've seen. There's also an impact of having too many resources that might have seen at the further end of the graph. Having too many staff can create coordination problems. People are kind of bumping into one another. It can also reduce collective effort. This is known as a concept as social psychology of social loafing, where people are less likely to put in their 100% effort when they know they have other team members who can pick up the slack. So take into account accountability for testing, providing services may decrease, or may get back for more detail. In terms of the implications, you know, having the right mix of staffing, resources, is becoming a greater challenge in VA, and other healthcare, and non-healthcare settings. VA has some new models of regular care and specialty care, delivery after implementing, so things like organizational slack may be a key thing to consider when it relates to these types of innovation, and whether they'll be fully implemented, and the success they'll have. And the mix of resources can be detrimental, or beneficial to performance based upon how many you have, and the right amount. Findings provide some support for the VA guidelines, something we found consistent with what we might have expected using the VA guidelines, kind of the cut point for slack. Considering, you know, the incremental improvement in adding staff, does a .5 FTE lead to a big difference? It may not a lead to a big difference in quality in terms of this study, but there are other factors such as adding personnel or making changes. Limitations, only VA was used, other staffing measures were not considered. Clinic level scores rather that provider level scores were used. It was a cross-sectional study. It did not distinguish among different types of slack. So a number of other areas for consideration of expanding this research include looking at more financial measures, looking at staff perceptions, at how outside influence impact on implementation and quality improvement practices within the VA initiatives, applying to other settings with staffing guidelines. You know, further research could also assess ease of recovering or acquiring slack among those different dimensions that were mentioned. Think about what management may do to actually maintain or use slack, or obtain additional resources to meet their goals, and the impact of organizational slack and its role in workplace routine design are also areas of further thought for consideration. So just wanted to... we’re almost to that point of take something questions. I just wanted to get a sense of, you know, this presentation, if it went through too much detail in some places, or not enough in some others, but hope if you saw anything about organizational slack that sparked your interest, how you might kind of think about using this opinion your own work place. And I'll turn it over to the Q&A. 

Thank you. In the past, I know that we've had a white board we've been able to use for questions -- excuse me -- for questions like this, but we don't have that functionality in go to Webinar, so we're asking you to use your Q & A screen to submit your responses to this question. And I don't think there's... – Kirin?

This is KIRAN. While people are writing questions, I’ll ask a question. This relates to some stuff I've been doing with nurse staffing, where, you know, there is a law called quality of employment employee affect, that in addition to numbers of bodies, it's the composition of the bodies, and how long they've been working on the unit also matter. Have you considered that type of -- that, or has anybody actually looked at that with respect to how this organizational slack and productivity matters? 

Good question. I think nursing is a prime area. They have -- and some states have mandatory nurse to patient ratios. I know VA has done a lot of work on assessing hours per patient day. Not aware of anything that specifically looked at this issue of nursing slack, but I would think, you know, something similar may be found where, you know, having fewer nurses than needed is going to be much more detrimental to the quality of care than having too many nurses. Yeah, I looked a little bit at the staffing mix, by looking at RNs, the total support staff, so that was significant, and one of the models around influenza vaccination may be due to or having a greater scope of practice to be able to provide vaccinations at some clinics. I'm not really sure. But I think the staffing does matter. We didn't look at tenure, per se, but I think we looked at the clinic age of whether the clinic had been operating for five years or more, and so that was not significant, but it did show a positive [indesc] of clinics that were open or operating for a longer period of time are more likely to deliver the high quality care compared to clinics that were younger, but this was not a statistically significant difference. So I think all of those things are, you know, very important, like considering who is on the team, and their -- you know, there are things beyond just basic demographics and occupational things that can influence quality of care, but I think that's one of those key team structure components that will have an influence on how well other things within the clinic or the nursing unit will happen to be central to communication or, you know, psychological safety, which can then, in turn, impact the patient quality of care. 

There's a question that's come up, but I'm not sure how to negotiate this. I really can't read it. If you can repeat it, please. 

That's fine. I'm happy to read it here. We have two that have been sent in. So the first one we received. How useful would an organizational slack dashboard to be a clinic manager to optimize performance? If so, what would a reasonable example look like? 

Okay. That's a good question. So the slack dashboard, I know the VA has a number of dashboards on different topics, but they've not been referring to look at, you know, is the organization above or below a certain minimum threshold. So I think first defining those variables of interest would be important, and a lot of the management studies, it's easy to look at sales, or sales expenses, and capital, and may not be as easy to do that in VA, but, you know, there are some things, such as mandatory guidelines. I chose the primary care management module, because this was something that was based on extensive study. So it seemed like it would lend itself well to be able to look at organizational slack in that way. Now, there may be other measures that are useful to VA, such as the hours per patient day, but probably would need to know which ones are mandatory, or which ones are recommended. So it's not probably an easy thing to do on a, you know, very quickly, but I think it may be worthwhile in the long run. I think it's also important to think about how managers may use this information, and, you know, if there is a deficiency, you know, what are the unattended consequences of having a deficiency, or having a surplus. If you have too many staff, is that going to be a risk that your staff may get pulled to another unit, or you have too few staff, will it be a bargaining chip that you can use and say, look at -- you know, look at our clinic. We don't have enough resources based on the model. We need more help. So, you know, it's not a, you know, easy thing to implement, certainly politically or tricky one I think to actually implement into practice. But I do think that – at least  some initial exploration of this topic may be worth doing, just to, you know, first and whether these things are actually -- whether the variables actually lend themselves to be easily identified and categorized in such a way. 

Okay. Thank you. Next I have a comment here. I'll wait to see if you have a response to it. Seems need for slack due to knowledge business applies to nursing staff question about long-term versus short-term staff on the job. 

Right. So in terms of the knowledge slack, that's something that's been looked at in a couple of studies. So thank you for that comment, and so I think that, you know, especially if you’re new nurses, having that type of orientation, or learning on the job is important. You know, it's probably not ideal to be in a clinic that's very busy, overwhelmed, and may make it harder for the person doing the training to introduce all of the concepts in full detail. It may be much easier to just show someone what was done, and maybe explain it, or not really have as much time to explain it as ideal, but, I mean, having the extra time for discussion, this is something that was assessed through the Alberta, Canada, or slack measure index that I mentioned earlier, and asked about questions like having adequate time to talk about new clinical knowledge, or having time to look something up. So things like that may make a difference on the nursing unit, and other units, as well. Especially for nurses who spend less time. And, additionally, I'm not sure in this goes back to your question, but there is also a lot of work around knowledge management, and people who have been within the organization a lot longer have developed greater knowledge capital, or human capital, and are sometimes seen as the experts, or the people to go to for questions. So knowing who best to contact, or who is, you know, the educational leader within the unit, can be very helpful for some of the newer staff, or even some of the staff who have been there a fair amount of time. 

Okay. Thank you. 

I'll just interject, because I raised this, is that we have pretty strong evidence that tenure matters in addition to number of nurses in terms of patient outcomes for outpatient care, that's a paper under review, and that's part of why I raised the issue. 

Great. Thanks. The next question that we have here, what do you think of a nursing pool, as a slack resource to address nursing needs in primary care clinics? 

Yeah, so I think in terms of the... you know -- so, I think that's a good example that's been used for some of the inpatient setting studies, you know, for example if there's an emergency that requires... a catastrophic emergency that requires staff to be called in, this is for some of the emergency management systems concepts may have a particular interest in this concept, but even if there's maybe a period of high -- greater demand, maybe the flu season, or something going around where the clinic is busy that day, it is helpful to have this available slack where the number of groups of people that you can easily call into the clinic that can kind of serve as reinforcements to kind of bolster and help meet, you know, the nursing unit, or the nursing -- or the primary care clinics demands for that day. So it is something that, you know, would be considered available slack, if you can just make a phone call and get a few additional nursing staff to come over, that would be, you know, in terms of the theory, a beneficial idea. 

Great. Thank you. That's all that we have received at this point. 

Okay. Great. Thank you. Great questions. 

All right. Well, if there are no other questions, would like to thank David for an interesting presentation.  Heidi, are these also archived? 

Yes, I am -- yep, I am recording this session right now. We will be posting it on-line, and we will be sending the link to the archive recording out to everyone. It will go out in an e-mail tomorrow, so everyone will have that link tomorrow afternoon. 

Okay. Well, thank you very much for inviting me. It was a great honor to be able to talk with everyone today. 

Fantastic. Thank you so much for taking the time to put together and present this cyber seminar. We very much appreciate all of the time and effort that you put into this. For our attendees, our next session in the HERC Healthcare Economics Series is scheduled for February 15th, and John Zeber will be presenting Medication Adherence in Chronically Ill Veterans: Copayments, Other Potential Barriers, and Health System Factors to Potentially Mitigate Cost Burdens. I sent out a registration link earlier today and you will be seeing another one in a couple of weeks if you are interested in joining us for that session. Once again, thank all of you. We hope to see you at a future session. 

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