Workforce Constraints Research Articles

Outsourcing Expert Services by State Transportation Departments

Privatization has increasingly become a policy option for government agencies struggling to meet rising demands for services but with fewer resources. In the transportation arena, many state departments of transportation (DOTs) have privatized by outsourcing highway functions to the private sector. But the outsourcing of technical and expert services such as those related to the design and construction of highway infrastructure may result in a smaller or less knowledgeable DOT workforce that is unable to perform the necessary contract management to ensure the quality of the work done by contractors. We posit an outsourcing process in which DOTs respond to the combination of increased demand for highway services and growing workforce constraints by contracting out much of the work formerly performed by in-house personnel. This, in turn, can produce perceptions of quality problems regarding the outsourced work and a subsequent expansion of the workforce. We examine the extent to which different highway-related tasks are being outsourced, the effect of workforce and employment factors on outsourcing, the perceptions of highway officials regarding the impact of outsourcing on cost-effectiveness and the service quality of the outsourced work, and subsequent employment levels.

Predictors of adequate depression treatment among Medicaid-enrolled youth

To determine if Medicaid-enrolled youth with depressive symptoms receive adequate acute treatment, and to identify the characteristics of those receiving inadequate treatment. We used administrative claims data from a Medicaid-enrolled population in a large urban community to identify youth aged 6-24 years who started a new episode of treatment for a depressive disorder between August 2006 and February 2010. We examined rates and predictors of minimally adequate psychotherapy (four visits in first 12 weeks) and pharmacotherapy (filled antidepressant prescription for 84 of the first 144 days) among youth with a new treatment episode during the study period (n = 930). Fifty-nine percent of depressed youth received minimally adequate psychotherapy, but 13 % received minimally adequate pharmacotherapy. Youth who began their treatment episode with an inpatient psychiatric stay for depression and racial minorities were significantly less likely to receive minimally adequate pharmacotherapy and significantly more likely to receive inadequate overall treatment. While the majority of youth appear to be receiving minimally adequate acute care for depression, a substantial number are not. Given current child mental health workforce constraints, efforts to substantially improve the provision of adequate care to depressed youth are likely to require both quality improvement and system redesign efforts.

Integrating evidence into policy and sustainable disability services delivery in western New South Wales, Australia: the 'wobbly hub and double spokes' project

BackgroundPolicy that supports rural allied health service delivery is important given the shortage of services outside of Australian metropolitan centres. The shortage of allied health professionals means that rural clinicians work long hours and have little peer or service support. Service delivery to rural and remote communities is further complicated because relatively small numbers of clients are dispersed over large geographic areas. The aim of this five-year multi-stage project is to generate evidence to confirm and develop evidence-based policies and to evaluate their implementation in procedures that allow a regional allied health workforce to more expeditiously respond to disability service need in regional New South Wales, Australia.Methods/DesignThe project consists of four inter-related stages that together constitute a full policy cycle. It uses mixed quantitative and qualitative methods, guided by key policy concerns such as: access, complexity, cost, distribution of benefits, timeliness, effectiveness, equity, policy consistency, and community and political acceptability.Stage 1 adopts a policy analysis approach in which existing relevant policies and related documentation will be collected and reviewed. Policy-makers and senior managers within the region and in central offices will be interviewed about issues that influence policy development and implementation.Stage 2 uses a mixed methods approach to collecting information from allied health professionals, clients, and carers. Focus groups and interviews will explore issues related to providing and receiving allied health services. Discrete Choice Experiments will elicit staff and client/carer preferences.Stage 3 synthesises Stage 1 and 2 findings with reference to the key policy issues to develop and implement policies and procedures to establish several innovative regional workforce and service provision projects.Stage 4 uses mixed methods to monitor and evaluate the implementation and impact of new or adapted policies that arise from the preceding stages.DiscussionThe project will provide policy makers with research evidence to support consideration of the complex balance between: (i) the equitable allocation of scarce resources; (ii) the intent of current eligibility and prioritisation policies; (iii) workforce constraints (and strengths); and (iv) the most effective, evidence-based clinical practice.

Planning models for floriculture operations

This paper proposes planning models that will assist a flower grower with the land and flower variety allocation decisions in such a way that the revenues (or profits) are maximised over a given planning period. In particular, this paper presents models where the mix of flowers is modified throughout the planning horizon to accommodate market fluctuation such as changes in demand and price for the different varieties being planted and harvested. The problem considers capacity and workforce constraints and demand, yield, and price variability across time. The models developed are applied to a case study of flower growing in Ecuador. The results of these models are presented, including one based on a heuristic strategy that renders in most cases rapid and close to optimal solutions.

From ‘public health’ to ‘safeguarding children’: British health visiting in policy, practice and research

This study examines the location of British health visiting in contemporary policy discourses concerned with public health and safeguarding children. It argues that professional identity and orientation can be understood through health visiting’s long history of public health work with children and families, which has included an engagement with protecting children. The expansive safeguarding children agenda, which includes the requirement to undertake a progressive universal approach to service provision and which incorporates a broad concept of risk and requires early intervention, has created tensions, particularly given current workforce constraints. The location and visibility of British health visiting in the academic and practice worlds also shape how the profession is understood.

Bamboo Ceilings in the Federal Service

This article is an update to the 2006 AAPI Nexus Journal article about Asian American and Pacific Islander (AAPI) senior executives in the federal government. Despite notable progress in recent years, AAPIs remain underrepresented in the Senior Executive Service (SES). Although recent administration initiatives have been beneficial for increasing diversity in the civil service, budget pressures and workforce constraints still hinder further advancements in executive diversity.

Bamboo Ceilings in the Federal Service

This article is an update to the 2006 AAPI Nexus Journal article about Asian American and Pacific Islander (AAPI) senior executives in the federal government. Despite notable progress in recent years, AAPIs remain underrepresented in the Senior Executive Service (SES). Although recent administration initiatives have been beneficial for increasing diversity in the civil service, budget pressures and workforce constraints still hinder further advancements in executive diversity.

Pharmacy services at admission and discharge in adult, acute, public hospitals in Ireland

to describe hospital pharmacy involvement in medication management in Ireland, both generally and at points of transfer of care, and to gain a broad perspective of the hospital pharmacy workforce. a survey of all adult, acute, public hospitals with an accident and emergency (A&E) department (n = 36), using a semi-structured telephone interview. there was a 97% (n = 35) response rate. The majority (n = 25, 71.4%) of hospitals reported delivery of a clinical pharmacy service. On admission, pharmacists were involved in taking or verifying medication histories in a minority (n = 15, 42.9%) of hospitals, while few (n = 6,17.1%) deployed staff to the A&E/acute medical admissions unit. On discharge, the majority (n = 30,85.7%) did not supply any take-out medication, a minority (n =5,14.3%) checked the discharge prescription, 51.4% (n = 18) counselled patients, 42.9% (n = 15) provided medication compliance charts and one hospital (2.9%) communicated with the patient's community pharmacy. The number of staff employed in the pharmacy department in each hospital was not proportionate to the number of inpatient beds, nor the volume of admissions from A&E. There were differences identified in service delivery between hospitals of different type: urban hospitals with a high volume of admissions from A&E were more likely to deliver clinical pharmacy. the frequency and consistency of delivering pharmacy services to facilitate medication reconciliation at admission and discharge could be improved. Workforce constraints may inhibit service expansion. Development of national standards of practice may help to eliminate variation between hospitals and support service development.

Secondary care and changing the face of emergency care

The delivery of emergency care has changed significantly over the last decade, driven by several factors which include better disease understanding, improved access to diagnostics, emergency care access targets and...

Care and compromise: developing a conceptual framework for work-related stress

In this paper we argue that in the current global healthcare climate, practitioners’ ability to provide compassionate and high quality care is undermined on a daily basis, not least by the organisational priorities of cost containment, of science and technology and, paradoxically, innovations experienced as demands such as specialisation. It is not surprising that the financial and workforce constraints of the global healthcare system, now more than ever, affect the practitioners’ capacity to deliver the optimum level of care, care that is positively influenced by patient satisfaction, a current indicator of quality. Whilst the notions of quality and standards have increasingly become the concern of healthcare organizations, quality cannot be considered in isolation from the healthcare management and occupational health of the workforce. In this paper we argue that healthcare practitioners are especially vulnerable to stress because the very nature of caring as a profession demands high levels of emotional engagement and compromise. It is clear that at a time when healthcare systems are under-resourced and over-stretched, practitioners may experience additional stress, ironically at a time when services need to increase retention, recruitment and job satisfaction. We propose a conceptual framework of stress and compromise in relation to caring and a methodology for developing an intervention that would consider how compromise itself may be utilised and adapted to both alleviate stress and inform individual and professional development.

The role of self‐management in designing care for people with osteoarthritis of the hip and knee

Osteoarthritis of the hip and knee is an increasingly common condition that is managed principally with lifestyle behaviour changes. Osteoarthritis management can be complex, as it typically affects older patients with multiple comorbidities. There is evidence that opportunities exist to improve uptake of evidence-based recommendations for care, especially for non-pharmacological interventions. The National Chronic Disease Strategy (NCDS) defines key components of programs designed to meet the needs of people with chronic conditions; one component is patient self-management. NCDS principles have been effectively integrated into chronic disease management programs for other conditions, but there is limited evidence of effectiveness for osteoarthritis programs. A comprehensive osteoarthritis management model that reflects NCDS policy is needed. Barriers to implementing such a model include poor integration of decision support, a lack of national infrastructure, workforce constraints and limited funding.

Technical Feasibility and Relative Productivity of Alternate NASA Robotic Missions to a Lunar Dark Crater

Two concepts for large-scale, complex, robotic missions to search for frozen water at the lunar south pole are systematically analyzed to determine their relative productivity and investment requirements. A concurrent design team, a technology-assessment tool, and a sensitivity model are integrated to search a large, complex trade space. Performance goals for a broad portfolio of missions comprising NASA's lunar exploration program are optimized subject to budget, workforce, and other nontechnical constraints. Explicit distinction is made between enabling and enhancing technologies. Uncertainties and dependencies are included within the optimization framework. Given the constraints used in this analysis, the study determines that the longer mission [using a radioisotope thermoelectric generator (RTG)] would return 14 times the value of the shorter mission (using a methanol-oxygen fuel cell) for roughly a 17% increase in cost, and would be enabled with the recommended temporal technology portfolio. To assess the robustness of the investment recommendations, other potential fuel-cell chemistries are evaluated along with potential improvements in rover speed and autonomy, and a reduced activity profile. Results indicate that a lithium-oxygen fuel cell would enable the highest level of productivity among the three fuel cells studied, though not as high as that permitted by an RTG. For the shorter duration mission concepts, it was found that productivity could be enhanced by reducing the number of activities from the baseline 15 to 4, thereby permitting time for each activity to be more fully accomplished.

Developing recommendations for implementing the Australian Pain Society's pain management strategies in residential aged care

This study aimed to develop recommendations and a related implementation resource 'toolkit' to facilitate implementation of pain management strategies in Australian Residential Aged Care Facilities (RACFs). This qualitative study used written materials, focus groups and individual interviews to gather data from participants. Thirty-four health-care professionals with experience in the aged care sector were recruited from five Western Australian RACFs. General practitioners who had an interest in aged care were contacted via local general practice networks. Findings indicated that focused education sessions were needed to support implementation. A tailored toolkit was developed to assist the process. Funding and workforce constraints were found to be threats to complete implementation in some facilities. A multifaceted approach is needed to promote the implementation of pain management strategies in RACFs. In particular, unlicensed care workers, who may have responsibility for recognising and reporting signs of pain, require further education to support their role in the pain management process.

Book Prescriptions — A Strategy for Delivering Psychological Treatment in the Primary Care Setting

ost people who are treated for mental health problems receive their treatment from their GP. A quarter of all consultations in primary care have a significant mental health component and depression is now the third most common reason for consultation in UK general practice (Effective Health Care Bulletin, 2002). The fact that 90% of people treated for mental health problems are treated solely at the primary care level makes it crucial that a range of appropriate and effective treatments is available to patients in this setting. Traditionally, primary care-based treatment for depression, panic disorder, obsessive-compulsive conditions, agoraphobia and other mild or moderate mental health problems has been exclusively pharmacological. Antidepressants and other types of psychotropic medication have benefited millions of patients and continue to be prescribed in large quantities. However, the past decade has seen a growing awareness of the desirability of providing additional psychological therapies in the primary care setting. The ‘talking therapies’, including counselling and various types of psychological intervention, are well established and there is now impressive evidence of their effectiveness for a range of the common emotional problems. In particular, there is very strong evidence for the effectiveness of cognitive-behaviour therapy (CBT), which helps people to examine and change the dysfunctional beliefs and thinking patterns that may underlie their anxiety or depression. Broadly, the evidence suggests that CBT based approaches are M at least as effective as drug therapy (NICE, 2004a; 2004b; 2004c). One advantage of cognitive therapy is that, because it has a strong educational component (teaching the patient positive thinking skills, perspective-taking, etc), it may not only ameliorate the present condition but may also prevent later relapse (Frude, 2004a). While patient surveys and government policy documents point to the need for primary care-based psychological treatment, drug treatment continues to predominate (although a recent expansion of primary care counselling provision is to be warmly welcomed). The continued pre-eminence of pharmacological treatment is easy to explain in terms of logistics. It is simply much easier, in practical terms, to provide pharmacological help by writing a prescription than to arrange for the delivery of psychological help. And whereas there is generally a waiting list for ‘the talking therapies’, the prescription of a drug – if not always the effects of a drug – can be immediate. Psychological therapies tend to be comparatively expensive and, as well as the financial constraints, there are also workforce constraints, with few suitably trained professionals available for employment. Thus it seems inevitable that the current low level of provision will persist for psychological treatments delivered by conventional means. After a career in academic psychology, during which I had long taught students about the highly effective cognitive behavioural methods, I moved to a post as research director of a clinical psychology training course. This also allowed me to practise as a clinician again after many years. Working within a community mental health team, it didn’t take me long

Vertical-horizontal synergy of the health workforce

Health systems are made up of a “hori-zontal system” of general services, pro-viding prevention and care for prevailing health problems, and of “vertical pro-grammes” for specific health conditions. Not surprisingly, vertical programmes are found more frequently where poverty prevails and epidemics flourish; general health services are weakly developed under such conditions. This theme issue deals with health workforce limitations in developing countries (1) that hinder vertical programmes in reaching their targets.Vertical programmes have three components: intervention strategy, moni-toring and evaluation, and intervention delivery. The first two are inherently vertical in nature. The intervention strategy sets out in detail how best to handle the health problem at hand. The monitoring and evaluation component follows the impact of the interven-tion strategy at population level and is essential to improve it continuously. In contrast, intervention delivery does not usually occur in a vertical manner. Depending on the health system of a country and the disease or condi-tion targeted, this component is more or less integrated in the horizontal system. When less integrated, as with polio eradication (268–273), health workers may, depending on incentives, move across from the general services. When more integrated, adding new initiatives such as “3 by 5” for the extended delivery of antiretrovirals (2) may increase health workers’ motivation and pride in their work, but may also overburden them and thus weaken the general services.Intervention delivery therefore con-stitutes the vertical–horizontal interface linking the health workforce constraints of system and programmes. A construc-tive collaboration between responsible officers of both is urgent, because the delivery of interventions requires by far the largest portion of the health work-force that programmes require to reach their targets, and is the most difficult to resolve.Vertical programmes possess two strategies to enhance vertical–horizontal collaboration: making better use of the workforce that is potentially available, and promoting workforce growth in quantity and quality. Private sector providers can also contribute more. In sub-Saharan Africa, private providers deliver at least 50% of the services and are an inherent part of the health system operating under full govern-mental stewardship of their markets and services. Governments must put incen-tives in place to engage private sector providers in the delivery of interven-tions for public good. Standardization in quality and procedures of services, as achieved by franchising (274–279), is a powerful tool to increase the involve-ment of private providers.The second option to increase vertical–horizontal collaboration, pro-moting substantial workforce growth in quantity and quality, can usually only be achieved through the regular policy, planning and implementation mechanisms. A focus on task analysis, estimations of the time needed per intervention component, skill sets and support functions is useful, but more is needed to connect effectively with health system and workforce planning mechanisms in countries.Workforce growth requires that programmes quantify their needs in variables that can guide planning, supply and deployment of personnel within the general services. These variables should capture, from the perspective of the user, the availability of the required cadres of health worker, their accessibility, and the affordability of their services.Planning for personnel and their supply and deployment within the general services cannot be based on the needs of a single programme, nor by simply adding up the needs of all the programmes. Approaching health workforce strengthening jointly, com-bining the requirements of programmes that use similar cadres of health worker for the delivery of their interventions, optimizes the chances that programme limitations will be overcome while simultaneously strengthening general health services. This dual goal can be reached because combining the needs of various programmes will significantly broaden the skill sets of the health workers delivering the interventions.It will be difficult for national programmes to move rapidly towards collaboration in intervention delivery if global views do not move accordingly. International agencies and donors have to rethink their health workforce strategies in view of the reality that this most costly component of a prior-ity programme can only be solved in vertical–horizontal synergy. O

Comparative approaches to equipment scheduling in high volume factories

Mail processing and distribution centers (P&DCs) are large factories that accept, sort, and sequence mail in preparation for delivery. A central problem in these facilities is how to schedule the equipment over the day to ensure batch production under tight equipment and workforce constraints. The problem falls into the general category of multi-level lot sizing and is notoriously difficult to solve. No exact algorithms exist that are efficient and can consistently provide high-quality solutions. In the paper, we investigate two specialized approaches for solving this problem. The first is a piece-by-piece LP-based heuristic and the second is a Benders decomposition. The heuristic uses the LP fractional solution as a target and attempts to find an integer solution that is as close to it as possible by minimizing the L 1 -norm. The procedure consists of solving the LP relaxation of the original model and two reduced mixed-integer programs. The process is similar to what has been called ‘piece-by-piece decomposition’ in nonlinear programming. While the goal there is to find better initial starting points for the nonlinear code, our goal is to improve solution quality. Computational testing using data provided by the Dallas P&DC confirmed the superiority of the piece-by-piece LP-based heuristic with respect to branch and bound, which proved to be computational expensive, and the Benders algorithm which took several hours to find feasible solutions. In general, the LP-based heuristic was an order of magnitude faster than branch and bound and provided solutions that were able to process more than 99.75% of the daily volume.

The challenge to balloon science

A thorough review of the NASA balloon program in 1995 confirmed both the inherent importance of balloon science investigations and their value for developing technology for future space missions. A follow-on study in 1996 looked into restructuring the entire suborbital program, in order to find more efficient and effective ways of doing business. These studies were mandated by the adverse impact of NASA's declining budgets and work force constraints on all aspects of space research. The challenge is to accomplish more with less. The balloon program began stepping up to this challenge several years ago with the advent of 10 – 20 day long-duration flights in Antarctica. We must now push ahead with enhanced flight capabilities and with new science instrument technologies, as we forge alliances with other modes of low-cost access to space. Specifically, the development of sealed superpressure balloons could extend flight duration by another order of magnitude, to about 100 days, making ballooning even more competitive with space missions.

Maximizing the Effectiveness of a Preventive Maintenance System: An Adaptive Modeling Approach

The dynamic nature of an operating environment, such as machine utilization and breakdown frequency results in changing preventive maintenance (PM) needs for manufacturing equipment. In this paper, we present an approach to generate an adaptive PM schedule which maximizes the net savings from PM subject to workforce constraints. The approach consists of two components: (a) task prioritization based on a multi-logit regression model for each type of PM task, and (b) task rescheduling based on a binary integer programming (BIP) model with constraints on single-skilled and multi-skilled workforce availability. The task prioritization component develops a multi-logit regression for machine failure probability associated with each type of PM task at the beginning of the year, using historical data on machine utilization, PM, and machine breakdowns. At the start of each PM time-bucket (e.g., a month), we use the updated machine failure probability for each candidate PM task to compute its current contribution to net PM savings, which indicates its current priority. The task rescheduling BIP model incorporates the priorities in selecting tasks for the current bucket to maximize PM effectiveness subject to workforce availability, yielding an adaptive and effective PM schedule for each time-bucket of the master PM schedule. We examine the effect of using multi-skilled workforce on the overall PM effectiveness, and also provide an illustration from a newspaper publishing environment to explain the use of the approach. We have developed four heuristic algorithms to yield good solutions to large scale versions of this scheduling problem. The heuristics perform extremely well, and the best heuristic solution is within 1.4% of optimality on an average.

An HMMS Type Interactive Model for Aggregate Planning

For purposes of aggregate production smoothing, quadratic functions often produce good fits to data on some of the relevant incremental costs, such as inventory and overtime costs. However, when costs of hiring and laying off workers are described by smooth quadratic functions, the model solutions tend to involve very frequent minor workforce adjustments. Production managers are often unwilling to actually implement such decisions because changing workforce levels involves a great many intangible costs, many of which seem to defy meaningful analytic representation. In this paper an interactive model is developed where, through parametric analysis of a set of workforce constraints, a manager can establish the appropriate trade-offs between his judgmental estimates of hiring and firing costs and other more tangible production costs.