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Cash inflow, as defined by Brideau (2004) is the measurement of the movement of cash into the organization, usually generated from operating, investing and financing activities. The components of cash flow must be visible on a planner so that it will be easily understood exactly what occur. Without cautious monitoring of the cash flow, the organization may not have the profit realization as they scheduled it (Donaldson & Gerard, 2005). Hence, by having the knowledge of how income flows into one’s organization is vital. So, corrective actions can be done to prevent incidents that may run the organization into economic failure.
The current clinical setting where I work in is conveniently located at the annex block of Mount Elizabeth hospital. The unit consists of 24 beds, involving a team of 32 healthcare workers, ranging from doctors, nurses, pharmacists and laboratory technicians. Our center is mainly specialized in haematological disorders such as anaemia, leukaemia, thalasemmia and so on. Majority of our patients are those who required blood transfusion, Bone Marrow Aspiration (BMA) and chemotherapy.
Primarily, the core income will be coming from the consultation fees generated by our team of haematologists. Beside consultation fees, procedural fees commonly involved are BMA, intra-thecal chemotherapy and insertion of Central Venous Catheter (CVC). On the nursing part, services provided for patients normally include blood taking, blood transfusion, performing dressing to CVC site and giving injections to post chemotherapy patients to boost their immunity.
Furthermore, our clinic is involved in the blood donation drive and counselling is mandatory for both the donors and recipients. All the above mentioned services delivered would drive income into our department. Currently, the nurses have the authority to recommend some of the topical skin moisturiser for patients undergoing chemotherapy, who will usually encounter dry skin conditions. Hence, this will further increase the income flow into the department.
A built in laboratory and a pharmacy are also available in our clinic, which provide blood test services and dispensing of medicines respectively. External funding and donations from other organisations also constitute part of the income flow into our department.
In general, our revenue is generated through a variety of means, along with billable patient services, investments and donations to the organization. Specific unit-based revenue is generated through billing for services such as invasive diagnostic or therapeutic procedures, physical therapy and so on. Revenues are also arising through the provision of multiple services overtime, such as hourly rates for chemotherapy administration or blood transfusion. Hence, nurses need to be informed and partner with the management team to generate revenue and control expenses in relation to patient care (McCue et al, 2003). Ultimately, these are the ranges of services available in the clinic that will be involved in the generating of income flow.
2. Critically evaluate the steps you would take when reviewing the skill mix in your own clinical setting. Discuss how you might balance the financial implications of your actions?
The challenge in healthcare is to ensure that quality of care and the calibre of the staffs are not comprised in this ever-changing, cost-controlled environment. Many healthcare organizations are looking into skill mix (SM) as a potential solution to healthcare service delivery problem. As stated by Adam et al (2003), SK is the percentage of registered nurses (RNs) to other direct care staffs such as enrolled nurses (ENs) and SM plays a critical role in improving organization effectiveness and the quality of care.
So what is the specific role of the RNs and ENs based on my current clinical setting? These questions need to be answered prior to the reviewing of the skill mix in the clinical setting.
Serrano & Slunecka (2006) stated that, the RNs are responsible for patient assessment, diagnosis, care planning and evaluation, whereas, the ENs are trained to perform bed-side duties such as bathing, feeding, toileting and ambulating patients.
In my current setting, our main issue is inadequate staffing due to inappropriate SM. As evidenced by Gillies (2003), insufficient staff is the most common contributing factor causing negligent of patients, thus, leading to poor quality of care. Hence, significant steps must be taken to efficiently establish a staffing pattern, a plan that articulates how many and what kind of staffs are required per shift to staff a unit of department (McCue et al, 2003).
We must first examine the following factors and take into consideration that a novice nurse takes longer to accomplish the same task than an experienced one. The acuity of patients, the capabilities of the staffs, the complexity of the nursing task, the amount of supervision a RN will be able to provide and the number of available staffs assigned to accomplish the unit workload are the key points when reviewing SM in a clinical setting (Adam et al, 2003). For illustration, in an intensive care unit, the RNs skill mix will be much higher than in a nursing home where the skills of RNs are required to much lesser degree.
Lastly, Hall et al (2004) stated that cost is associated with the nature of SM. In developing a staffing pattern that leads to a budget, it is important to benchmark against other organization with similar patients population. It is important to note that RNs hours of care are more costly than those of lesser skilled workers, hence, it is important to evaluate the patient care required and who can perform necessary functions (Hall et al, 2004). Allocating ENs appropriately and freeing RNs from uncalled for duties can assist in cost control. As evidenced by Rothberg et al (2005), it is cheaper to have ENs to perform supportive care than to have RNs to perform them.
Therefore, SM is accountable for the distribution and consumption of resources. It is essential that nurses need to be informed and collaborate with the management team so that appropriates decisions can be made regarding cost-effective practices (McCue et al, 2003). The key is to have the right number and skill level of caregiver available to ensure safe, effective and appropriate care.
3. Develop a system which would enable you to audit your staffing expenditure on a monthly basis. Give a detailed critical discussion of your rationale underpinning your system.
Table 1: Budgeting and spending of an individual staff
(1 year experience)
Staff Nurse II
(2 year experience)
Senior Staff Nurse
(5 year experience)
(1 year experience)
Enrolled Nurse II
(2 year experience)
Table 2 (12 month wages)
Late for work
Table 3 (monthly audit for staff)
Staffing expenditure (SE) generally accounts for the expenses associated with labours. According to Brambleby (2005), healthcare services are very labour intensive and it is estimated that salary and benefits accounts for 50% to 60% of an organization cost. As defined by Payne & Keep (2004), staffing expenditure is determined by identifying the expenses of every staffs in the organization.
SE is commonly broken down into monthly basic salary, staff benefits, allowances and lastly, annual increment and bonus. Besides the above listed, it is compulsory for every organization in Singapore to contribute 13% of total gross income to Central Provident Fund.
In an organization, the first most common expense is the basic salary of every individual staff. However, the amount of salary a particular staff will be eligible to depend on their individual experience. Medical fees entitlement, staff allowances and benefits would include meal allowances and shift allowances, which would fluctuate every month within an individual pending on numbers of working years. Whereas, annual bonus and increment will depends on individual performance.
Looking at Table 1, it keeps a record on the spending and budgeting of an individual staff based on their wages, meal allowance, shift allowance, medical fees and the total wages draw by the individual staff in the month of January.
As for Table 2, in this table showed the collection data of the total wages each individual staff draw from January to December over a period of 12 month. Zooming in at the month of December in Table 2, all the staffs are drawing a higher wages as compare to all the other month. This is the amount of the annual bonus given to the individual staff.
According to Kanji (2004), staff performance can be benchmarked by the number of utilized medical leave, the number of compliments from patients and the punctuality of the employees. By keeping a record of staff performance, it will reduce instance of bogus sickness, hence increase work productivity and increased job satisfaction of staffs (Murray & Frenk, 2004). The system ensures that expenses are kept within the budgeted amount, revenue generated is consistent with projected productivity and standards and necessary corrective actions are carried out.
You are required to give a detailed discussion how you would audit non-staff expenditure on a monthly basis in your clinical setting. What reasonable cost effective strategy would you implement in order to maintain best practice?
As stated by Payne & Keep (2004), non-staff expenditure can be subdivided into direct expenses and indirect expenses. Direct expenses are associated with the patients, such as medical and surgical supplies and drugs. Whereas, indirect expenses are expenses for items such as utilities, comprising of gas, electricity, maintenance and support functions.
Referring to Table 1, it displayed the number of consumables being utilized and its balance stock in a month. This stock inventory system is being performed on a monthly basis. On top of that, a “First in first out” system is being imposed, meaning those with the nearest expiry items should be placed at the outer shelf and to be used first.
All these system will help to monitor the amount of usage of the items, preventing the wastage of unnecessary items which resulted from overstock or under-stock. Hence, by saving resources, it will enhance cost-effectiveness. While searching for a supplier, key points to look for will be an item of good quality and with the lowest cost. By exploring new products with vendor representatives and networks with colleagues, discussing the quality and cost differences of supplies with other staffs and management, who had tried both new and modified products, cost wastage can be reduced. Usually, bulk ordering will take place for frequently used consumables, thus, saving cost.
Budget monitoring is generally carried out on a monthly basis, to ensure that revenue generated is consistent with projected productivity and standards. Staffs are encouraged to discuss the implementation or reinforcement of strategies that can positively affect the budget. For example, they should learn to plan for supplies needed for every patient encounter and consciously eliminate unnecessary items.
Typically, budgets are monitored monthly because if deficiencies arise throughout the year, financial improvement plans can be instituted early. Corrective action is often initiated to prevent long-term effects in a particular area, such as wastage or loss of supply items. Therefore, by acquiring a working knowledge of how a department monitors financial and quality indicators, and participate in the development of actions is vital (McCue, 2003). It helps to increase patients’ satisfaction or to create the “best patient experience”. All these strategies act as a tool to foster collaboration with an organization because individuals must work together to achieve cost-effectiveness by utilizing consumables appropriately.
You are required to describe in detail essential information which would enable you to successfully manage your staff and non-staff budget. From your information, what do you consider to be key issues in terms of successful management?
An effective management encompassed the ability to develop a budgeting plan that would provide the necessary for staffs and effective nursing care. Only through effective planning can a balanced relationship between quality services and cost of services begin to be achieved. As Donaldson & Gerard (2005) had stated, budgeting is an ongoing activity in which revenues and expenses care managed to maintain responsibility and health.
A basic management plan through which all expenditures and revenues from all sources maybe projected and controlled is critical, so that excellent and cost-effective healthcare services can be delivered. Certain elements are necessary to establish an effective budgeting system.
Firstly, according to Mitton & Donaldson (2004), commitment to strategic planning is a basic requirement, where well-defined and objectives are developed. The budget should be an outcome of discussions at all levels and departments within the company related to priority setting in accordance with the company’s goal, acknowledgement of achievements, responses to new demands and looking beyond the time frame of the ensuing year.
Secondly, effective organizational structure and chart, presenting with clear and direct lines of authority is essential. As supported by Dixon (2005), it is only when authority is clearly defined, than an individual can be held responsible for the activities of the department. Hence, major objectives of the budget can be more easily accomplished. For example, the manager has the responsibility and accountability for managing the nursing budget; they are required to make all the decision on adjusting the nursing budget to manage the program and cost. This will include adding and removing programs, expanding and controlling the program and modification of revenues and expenses within the nursing department.
Lastly, an uniform budget reporting system is required, so as to facilitate program monitoring and aids in strategic planning, ensuring that plan is updated by periodically and allowing the evaluation of the progress of the organization. An important factor is ensuring that the time period within which a service development must be achieved, the projected budget is able to balance against the complexity and defining area of scale of change required and the existing resources envelope (Fine, 2006).
Overall, the process of setting and monitoring budgets should be an important part of both the planning and performance management cycle. It should always be remembered that within the resource package are included staff (clinical and non-clinical), equipments and building as well as money. An essential part of management planning process is to assess the ability of current resources to be used in new and different ways to meet changing needs and to increase the productivity of existing resources, while acquiring new resources (Murray & Frenk 2000). By having a well-conceived budget in place, it is possible to foresee the results of quality standard of care; best practice in the organization.
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