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Rationing of labor timekeeping in a medical facility. Rationing of work in the reception departments of health care institutions

The issues of labor rationing in health care are given serious attention at the level of the Ministry of Health and social development.

For proper adaptation, effective use personnel, it was just an opportunity with new knowledge and experience to address the issues of labor rationing in budgetary institutions.

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Regulations on labor rationing

The main treatment group, which is directly related to the volume of planned government targets, should be revised or adapted to the conditions in each medical institution.

The Ministry of Health has issued several methodological recommendations related to the regulation of the work of subjects and state municipal medical institutions.

When preparing the regulation, we are guided by the concept of “planned function of a medical position”.

This is a given standard of time, output, load (depending on the specifics of the performance medical activities), which is brought to each performer and is a signal for his effective work.

! in the Chief Physician System.

Standards exist for all groups of doctors providing treatment and diagnostic services. These norms are approved for the entire paraclinic group.

However, the change in the organizational and economic conditions for the activities of state-owned, autonomous, budgetary institutions makes it necessary to make adjustments to the previously adopted labor standards in health care.

Firstly, planned volumes of activities are brought to medical organizations. Secondly, the main source of financing is the funds of compulsory medical insurance with its own approach to invoicing, with its own requirements for insurance coverage of medical activities.

Today, these requirements are strictly tied to the implementation of federal standards.

The rationing of the “paraclinic” service, along with the existing standards for the performance of certain labor operations, must be controlled and tied to real conditions in which the medical organization operates.

Often, the provision on labor rationing begins to be developed to make adjustments to the standards of the paraclinic group or establish new temporary standards related to medical and diagnostic services.

⏰ How to set part time mode
in System Chief Physician

Last year, in certain areas of work of specialists from the “paraclinic” group (for those providing services in outpatient clinics), the Ministry of Health issued Order No. 290n. It establishes approaches to determining the norm of time for a visit.

The text of the document contains recommendations, standards for the duration of the appointment for a number of specialists: an ophthalmologist, an otolaryngologist, a general practitioner, a pediatrician, etc. That is, not the entire group of paraclinic specialists is covered through the standard labor standards in health care adopted by the Ministry of Health.

Therefore, one should think about the internal establishment of norms in a local regulatory act - the "Regulations on labor rationing".

Labor rationing in health care: sources of guidelines

The methodological foundations for improving wages in the healthcare system of Russia are laid down by regulatory legal acts of the President of the Russian Federation and the Government of the Russian Federation, regulatory legal acts and recommendations of the Ministry of Labor and Social Development of the Russian Federation and the Ministry of Health of the Russian Federation.

A set of measures to ensure the health system Russian Federation medical personnel is based on the principles systems approach and is carried out in 3 strategic directions:

Improving the planning and use of human resources in the industry.
Improving the system of training specialists with medical and pharmaceutical education.
Formation and expansion of material and moral incentives for medical workers.

Labor regulation in a healthcare facility

According to paragraph 16 of the Guidelines, approved. By order of the Ministry of Labor of Russia dated September 30, 2013 No. 504, in the absence of standard labor standards, institutions can independently develop appropriate labor standards, taking into account the recommendations of the organization that performs the functions and powers of the founder, or with the involvement of relevant specialists in the prescribed manner.

The labor standards developed in a budgetary institution are fixed in the Regulations on the labor rationing system of the institution, which is either approved by the local normative act taking into account the opinion of the representative body of employees, or is included as a separate section in the collective agreement (Article 162 of the Labor Code of the Russian Federation, clause 20 of the Methodological Recommendations).

To be used as a basis for developing labor rationing systems medical personnel can be guided by the appropriate procedures for providing medical care.

So, for example, standard norms in health care regarding the workload of an obstetrician-gynecologist in a consultative-outpatient appointment are established in paragraph 2 of the note to Appendix No. 2 of the order of the Ministry of Health of Russia dated November 1, 2012 No. 572n.

To obtain the weighted average time spent by a doctor on a visit to a particular specialty, the following calculations were carried out:

The structure of visits by age groups was calculated;
Then, in accordance with this structure, the weighted average cost indicator was calculated.
The results of the calculations are presented in the table. Ready-to-download table of weighted average time costs
doctors of different specialties to visit in the "Chief Physician" System.

In addition, the norms for the workload of medical personnel in the constituent entities of the Russian Federation can be established by the relevant regional regulatory legal acts and the territorial program of state guarantees for the free provision of medical care to citizens.

Thus, in accordance with the letter of the Ministry of Health of Russia dated December 12, 2014 No. 11-9/10/2-9388, in order to determine the number of medical workers required to provide inpatient medical care under the territorial program, one should take into account the load standards proposed by this letter, as well as regulatory the values of the average terms of treatment of 1 patient in the hospital and the established standards for the volume of bed-days in the context of the specialized departments of hospitals, differentiated by the levels of medical care.

As a basis for the development of systems for rationing the work of non-medical personnel, one can be guided by the Orders of the USSR Ministry of Health of June 6, 1979 No. 600, of September 26, 1978 No. 900, of May 31, 1979 No. 560 (these orders have not been officially canceled and in accordance with order of the USSR Ministry of Health of August 31, 1989 No. 504 are advisory in nature) as well as by order of the Ministry of Health of the Russian Federation of June 9, 2003 No. 230, which establishes the dependence of the amount staff units working professions from the volume of work according to technically justified standards, and in their absence - according to the standards developed by the institution experimentally and statistically.

Labor rationing in health care: methods

It is necessary to decide by what method the institution will establish internal norms. Normative and advisory documents are offered to us a choice.

Analytical method. During the modernization program, new units of medical equipment were purchased for all services. This allows you to revise the labor standards of an employee working according to the “doctor-equipment-patient” scheme.

The equipment has changed, which means that the requirements for the time spent on the work of a physician must also be changed. The analytical method allows you to establish how it has developed in practice, in connection with changes in the organizational and technical conditions of work. On the basis of which we deduce the average norm, coordinate it with the trade union organization and, preferably, with the higher one.

The second method, which is just as good and often used, is working time photography. A specially created commission is approved by order of the chief physician and is guided in its work by the regulation on labor rationing and calendar plan holding events.

From the very beginning to the end of the working day, the commission monitors all the functions that this or that specialist performs. “Photographs” all its functions, fixes it in a special document.

The current stage of healthcare development raises questions of the quality of medical care provided to the population in a new way. The proper level of medical care can be achieved only with the appropriate staffing of health care institutions.

Service standards (providing medical services) are established for the work of medical personnel - in units of time - the average time for which a medical worker must carry out his activities. - speed of work - the average number of actions completed in a certain period of time.

Currently, staffing standards for the main types of healthcare institutions have a 25-30 year limitation period for their approval and, therefore, they do not correspond to the changed structure and level of morbidity in the population, new diagnostic and treatment technologies, new organizational forms of provision and mechanisms for paying for medical care.

In health care, the following standard labor indicators are used: Estimated time norms - the regulated duration of the performance of a unit of work by personnel or a group of personnel in standardized organizational and technical conditions. Time limits for outpatient physicians are expressed in minutes per visit. Load (service) norms - the established amount of work performed per unit of time by personnel or a group of personnel in certain organizational and technical conditions of activity. Load (service) rates are expressed for outpatient doctors in the number of visits per hour, year. Headcount standards - the required number of personnel to perform all the functions assigned to a particular institution (division) and a specific amount of work, determined by standard indicators and their combinations, calculated values.

Rationing methods The analytical, or element-by-element, method is based on the differentiation of the labor process into separate components, determining the standard time spent on them and the formation of labor standards, taking into account the rational organization of the labor process as a whole, the volume and quality of work performed. The total method does not provide for a change in labor costs for individual components of the labor process, while this method determines the labor costs for actually performed work according to the technology used in the institution. Comparative rationing is used if the technology for carrying out a particular work is similar to that for which there are already labor standards. With the expert (experimental) method of labor rationing, the indicators are set on the basis of the past experience of the developer of the standard. The statistical method is applied when there are statistical data on the volume of work, for example, the number of visits or certain procedures, examinations and the number of personnel actually performing this work.

Classification labor costs medical staff includes 7 types of activities: main auxiliary other activities work with documentation office conversations personal necessary time unloaded time

In healthcare, two types of timing are used: timing measurements photo timing observations To determine the time spent on specific view chronometric measurements are used to study activities, along with the time spent on the structure of the working day, possible unproductive costs, photochronometric observations are used.

Labor rationing must be applied in determining and planning the number of medical personnel. It has a direct impact on the remuneration of the main and auxiliary medical personnel of health care institutions.

In accordance with job descriptions the doctor of the admission department and the established practice of work in this state health institution, the doctor of the admission department performs the following work. medical work: collection of anamnesis and complaints in the pathology of various organs and systems; visual examination in the pathology of various organs and systems; palpation in the pathology of various organs and systems; percussion in the pathology of various organs and systems; auscultation in the pathology of various organs and systems; anthropometric research; function studies internal organs; the appointment of drug therapy for the pathology of various organs and systems; the appointment of dietary therapy for the pathology of various organs and systems; the appointment of a therapeutic regimen for the pathology of various organs and systems.

Patient care work by category (the number of patients is taken as an average per day, calculated from the total weekly number): those arriving urgently; released from among those delivered to the emergency department and from among those who applied for medical help on their own; provision of emergency consultations in hospital departments (5 persons per day).

Current work on duty in the hospital: on the days of hospital duty (2 days a week), the work of doctors in the admission department per shift in the amount of 2 pcs. units ; on ordinary days, the work of doctors in the admission department per shift in the amount of 1 pc. units

Household and managerial work: organization and coordination of activities at the level of a healthcare institution (organization); organization and coordination of activities at the level of a subdivision of an institution (organization) of health care; organization and coordination of activities at the level of individual employees of the unit of the institution (organization) of healthcare; control of activities at the level of individual employees of the unit; interaction with patients and their relatives on solving administrative issues; organization of activities in the conditions emergency, in wartime conditions and mass influx of victims.

. With the help of the methods used in the regulation of labor, losses and unproductive expenditures of working time are singled out. By studying labor movements the most economical, productive and least tiring methods of work are developed. This contributes to the growth of labor productivity. Further improvement of the organization of labor is impossible without improving its rationing.

Calculation example The cost of the nurse's time for organizing individual care for seriously ill patients per 1 day of the patient's stay is 100 minutes on the day of admission, 80 minutes daily during the treatment period and 70 minutes on the day of discharge. The weighted average with an average length of stay of a patient equal to 13 days, calculated according to formula 1, is 83.5 minutes.

(100 + 80 × 0.825 × (13 2) + 70) / (13 × 0.825) ≈ 8.4. There are approximately 10% of seriously ill patients in the department, therefore, this indicator per one hospitalized is 8.4 minutes (83.5:10). A coefficient of 0.825 has been introduced into the formula, showing a reduction in the number of days a nurse or nurse works during the entire period of stay due to holidays and weekends. When calculating the coefficient, 12 holidays and 52 days off are taken into account when working on a six-day working week: (36552 -12) / 365 ≈ 0, 825.

Formation of a socially oriented market economy and its development is impossible without developed labor relations. The material basis of any society is the labor activity of people. Labor is a condition of human existence independent of any social forms and constitutes his eternal natural necessity.

In healthcare organizations, work on labor rationing should be carried out in a timely manner in order to further reduce the time spent on providing medical services to the population, taking into account the use of new methods of work, best practices, as well as improving workplaces and equipment used.

The current stage of development of labor rationing in health care is characterized by two opposite trends.

The current stage of development of labor rationing in healthcare is characterized by two opposite trends:

at the intersectoral level, a number of decisions are made aimed at creating a system of labor rationing, including in healthcare institutions; in one of the research institutes of the Ministry of Health of Russia, a division for the regulation of the work of medical workers was opened;
The Ministry of Health of Russia approves legal documents on labor that contain a lot of erroneous provisions, both editorial and semantic in nature, and do not correspond to the theory and practice of labor rationing.

1. Organizational technologies of labor rationing

As positive measures to create a system of labor rationing, one should recognize the approval of the Orders of the Ministry of Labor of Russia: dated May 31, 2013 No. 235 “On approval of guidelines for federal executive authorities on the development of standard industry labor standards” and dated September 30, 2013 No. 504 “On approval of methodological recommendations on the development of labor rationing systems in state (municipal) institutions”.

Order No. 235 contains:

conditions and terms for the revision of standard industry labor standards;
normative factors;
methods of labor rationing;
labor intensity;
stages of normative research work.

The appendix to the order provides statistical tools for the development of standard industry labor standards.

The main provisions of the order coincide with the methodological materials on labor rationing in the healthcare sector [ Shipova V.M. Fundamentals of labor rationing in health care ( tutorial) Under the editorship of Academician of the Russian Academy of Medical Sciences O P. Shchepin: - M .: GRANT Publishing House, 1998. - 320 p.; Labor rationing in health care, lectures No. 1-No. 10 M .: RIO FGBU "TsNIIOIZ", 2013-2017. ]. However, when applying Order No. 235, the specifics of the work of medical workers should be taken into account. Recently, there has been an increased interest of the heads of medical organizations in the development of local labor standards, including timing. In the process of timing, an examination of the volume and quality of work is carried out, an assessment of the compliance of medical and diagnostic measures with the diagnosis and state of health of the patient, and medical prescriptions. This work can only be carried out by an appropriate specialist who knows the technology of the diagnostic and treatment process well. It is a mistake to involve economists, personnel department employees, commissions in timing the activities of medical workers, since, firstly, these workers not only cannot expert assessment, but even to accurately determine the name of the labor operation, and, secondly, the presence of persons who do not have a medical education is unacceptable when contacting a medical worker and a patient.

Order No. 504 defines the types of labor standards and establishes a connection between them. These provisions are of great importance to healthcare organizers and to all healthcare professionals. The fact is that the issues of labor rationing are still not included in the program of diploma and postgraduate training of doctors and paramedical workers, these issues are not considered in textbooks on public health.

Order No. 504 contains certain innovations in organizational technologies for labor rationing. The document provides recommendations for state (municipal) institutions on the development of the Regulations on the labor rationing system, which is either approved by the local regulatory act of the institution, taking into account the opinion of the representative body of workers, or included as a separate section in the collective agreement.

labor standards applied in the institution;
the procedure for implementing labor standards;
the procedure for organizing the replacement and revision of labor standards;
measures aimed at compliance with established labor standards.

The most important for medical organizations, taking into account the existing regulatory framework for labor in the healthcare sector, is the first section, in the annexes to which the following data is indicated:

references to standard labor standards used in determining labor standards;
the applied methods for determining the population rate based on the typical time rate, the number rate based on the typical service rate and the service rate based on the typical time rate (if calculations were made);
calculation of the correction of standard labor standards, taking into account the organizational and technical conditions for the implementation of technological (labor) processes in the institution (if a correction was carried out);
methods and means of establishing labor standards for individual positions (professions of workers), types of work (functions) for which there are no standard labor standards.

Order No. 504 also defines the circle of persons who should be involved in the development of a labor rationing system in an institution.

Taking into account the number of employees and the specifics of the activities of the institution for the performance of work related to labor rationing, it is recommended to create a specialized structural unit (service) for labor rationing in the institution. In its absence, the performance of work related to the regulation of labor may be assigned to a structural unit (employee), which is in charge of staffing the activities of the institution, organization of labor and wages.

The implementation of these recommendations in medical organizations should be addressed, in our opinion, as follows. Given that health professionals do not have, as noted, necessary knowledge and skills in labor rationing, the deputy chief physician for economic issues should be responsible for organizing labor rationing in medical organizations. In the absence of this position, the organization of labor rationing can be entrusted to the personnel department, accounting staff, while it should be emphasized that it is organization regulation of labor.

The direct development and establishment of labor standards on the basis of standard norms approved at the federal level, or in the absence of such, is carried out by the heads of structural medical and diagnostic units, chief and senior nurses, taking into account the specifics of the specific conditions of labor organization.

2. Analysis of the modern regulatory framework for labor in the healthcare sector

The labor standards of medical workers have been set out in recent years in the following departmental legal documents:

orders of the Ministry of Health of Russia on the procedures for the provision of medical care;
letters from the Ministry of Health of Russia on the formation and economic justification of the territorial program of state guarantees of free provision of medical care to citizens for the corresponding financial year and planning period (hereinafter referred to as the territorial program);
letters of the Ministry of Health of Russia, FFOMS "On guidelines on methods of payment for medical care at the expense of compulsory medical insurance” (labor standards for dentistry).

Mass approval of orders of the Ministry of Health of Russia on the procedures for providing medical care, integral part which are the recommended staffing standards, began in 2009 and, after a short break in 2014, continues to this day. To date, there are 67 orders. Unfortunately, the erroneous provisions of the labor standards given in these documents, as a rule, are not corrected during the revision, and in some cases new errors are added to them.

The systemic erroneous provisions of modern legal documents on labor are as follows.

2.1. Erroneous application of different types of labor standards

In health care, the following types of labor standards are used: norms of time, workload (service), number. The values of these indicators are presented in the methodological materials on labor rationing in health care and, as indicated, in Order No. 504 of the Ministry of Labor.

Time standards in health care are expressed in minutes, conventional units, conventional units of labor input (UUT), load (service) norms - in the number of visits per hour, year, patients per day, number of examinations, procedures per day, year or for any other period of time .

The size standards are presented in terms of the population or its contingents, the number of beds or round-the-clock posts per 1 medical position, the volume of a particular work.

In the orders for the procedures approved before 2012, the norms of time for visits in certain specialties were cited, erroneously called the norms of workload or workload. When reviewing such orders, these data are not indicated. However, in the current order for coloproctology (dated April 2, 2010 No. 206n), the time standards for a diagnostic and treatment appointment are given, called the load rate.

In the territorial programs, starting from 2008 and up to the present, a table is provided, the title of which indicates “the load indicator for 1 position of a doctor (middle medical worker)”, and the content of the table shows the number of beds per 1 medical position and the number of beds per 1 post of nurses, i.e. population standards.

2.2. Unjustified change in the format of presentation of labor standards

The norms for the number of personnel in health care institutions are determined by the staffing standards used for medical workers, and the standard staffs used to standardize the work of employees and workers. medical organization. The difference between these documents is that staffing standards are set based on some indicator, for example, at the rate of 1 position of a general practitioner for 25 beds. The overwhelming majority of typical states do not require such a calculation, and one or another position is established for the presence or a certain capacity of an institution, unit, for example, the position of deputy chief physician for economic issues is established in a medical facility with 100 or more beds and including outpatient clinics. divisions.

The recommended staffing standards given in the orders on procedures are modeled on model staffing that do not provide for calculation and are used for non-medical personnel. With the transition to this new form of population norms, i.e. the use of model states instead of staff standards, the words so necessary for staff standards have also disappeared: “the position is established on the basis of ...”, which can lead to different workloads for medical workers with the same amount of work. For example, if the position of a doctor is set as “1 for 20 beds”, this leads to the fact that only one position can be established for 20 beds, and for 30, and for 35 beds, which obviously leads to a different workload for the doctor. If the position was established “based on 20 beds”, as is customary in staffing standards, then 1.5 positions can be installed for 30 beds (30: 20 = 1.5), and 1.75 positions for 35 beds ( 35:20=1.75).

Only in two orders (dated November 15, 2012 No. 923n “Procedure for the provision of medical care in the field of neurosurgery” and dated November 15, 2012 No. 918n “Procedure for the provision of medical care to patients with cardiovascular diseases”) and only in hospital departments of the position of medical workers are set “based on 30 beds”.

2.3. Violations of the nomenclature of medical organizations, specialties and positions of medical workers, hospital beds

Currently, the following legal documents on nomenclatures are in force:

Order of the Ministry of Health of Russia dated 08/06/2013 No. 529n "Nomenclature of medical organizations";
Order of the Ministry of Health of Russia dated 07.10.2015 No. 700n "Nomenclature of specialties of specialists with higher medical and pharmaceutical education" with additions made by order of the Ministry of Health of Russia dated 11.10.2016 No. 771n;
Order of the Ministry of Health and Social Development of the Russian Federation of April 16, 2008 No. 176n with subsequent additions “Nomenclature of specialties for specialists with secondary medical and pharmaceutical education in the healthcare sector of the Russian Federation”;
Order of the Ministry of Health of Russia dated December 20, 2012 No. 1183n “Nomenclature of positions of medical and pharmaceutical workers”;
Order of the Ministry of Health of Russia dated October 08, 2015 No. 707n “Qualification requirements for medical and pharmaceutical workers with higher education in the direction of preparation “Health care and medical sciences””;
Order of the Ministry of Health of Russia dated 10.02. 2016 No. 83n "Qualification requirements for medical and pharmaceutical workers with secondary medical and pharmaceutical education";
Order of the Ministry of Health and Social Development of the Russian Federation of May 17, 2012 No. 555n "Nomenclature of the bed fund according to the profiles of medical care."

Compliance with these nomenclatures is mandatory for medical organizations. Incorrect names of positions and specialties in the staffing tables of medical organizations lead to complications in the provision of pensions for employees, the establishment of a work and rest regime, wages, and so on. Moreover, such violations are unacceptable in legal documents. However, in almost every order on orders there are names of positions and specialties that do not correspond to the current nomenclatures. So, for example, in orders on orders, the positions of a gynecologist are given instead of the position of an obstetrician-gynecologist, a dermatologist instead of a dermatovenereologist, a traumatologist instead of an orthopedic traumatologist, a neuropathologist instead of a neurologist, a laboratory assistant instead of a clinical laboratory diagnostics doctor, a ward nurse instead of a ward nurse (guard), a bacteriologist instead of a bacteriologist, a massage therapist instead of a massage nurse, etc., as well as positions that are not in the nomenclature, for example, a microbiologist, a senior laboratory assistant, a senior radiologist, etc.

When applying orders on the nomenclature, one should keep in mind a number of existing contradictions between the nomenclature of positions, the nomenclature of specialties and qualification requirements. A number of medical positions indicated in the nomenclature of positions are not included in the nomenclature of specialties. These positions include: a diabetes doctor, a medical prevention doctor, a clinical mycologist, a laboratory mycologist, a palliative care doctor, a medical rehabilitation doctor. These positions are also absent in order No. 707n on qualification requirements, although for most of these positions there are labor standards defined in the relevant orders on procedures.

His "mite" in the incompatibility of orders on the nomenclature of specialties, positions and qualification requirements introduced the order of the Ministry of Health of Russia dated October 11, 2016 No. 771n, which included a number of specialties as an addition to the nomenclature of specialties of specialists with higher medical and pharmaceutical education.

These changes in the nomenclature of specialties are not accompanied by changes in either the nomenclature of positions or in the document on qualification requirements.

2.4. Erroneous data on the number of posts to ensure round-the-clock work

The organization of the activities of medical organizations involves different modes of operation of units and relevant positions for their functioning. So, for example, an ambulance station (department) operates around the clock; in a hospital to ensure round-the-clock provision of medical and diagnostic medical care, round-the-clock posts of middle and junior medical workers, a number of positions of doctors are established. The orders on procedures indicate the specific number of posts to ensure round-the-clock work: from 1 to 5.7 posts.

The number of posts to ensure round-the-clock work depends on two main groups of data:

the number of workers, and pre-holiday days in the year in which there are reductions in working hours;
mode of work and rest positions.

The number of working and pre-holiday days in which there is a reduction in working hours changes annually.

The regime of work and rest differs not only in the names of positions, but even in the same position, but working in medical organizations in different regions of the country, for example, in an institution in the Central Strip of Russia and in the regions of the Far North due to different vacation duration.

Therefore, it is not a different number of posts to ensure round-the-clock work, specified in orders on procedures, that is erroneous, but the very indication in the normative record of this number of posts. The normative record on the staffing of round-the-clock work should contain only the number of beds for organizing this mode of operation, or a certain amount of work, for example, the number of emergency calls and, consequently, the number of teams. The specific number of positions must be calculated in a medical organization annually, depending on the mode of work and rest of the position and the number of working and pre-holiday days in the year in which there is a reduction in working time.

2.5. Unreasonable introduction of new indicators for labor rationing

When choosing an indicator for labor rationing, the following requirements must be observed:

taking into account the current level of development and organization of medical care, labor organization, equipment, compliance with the relevant technologies of the treatment and diagnostic process;
compliance with the degree of integration of the indicator to the conditions and nature of the work of a particular type of institution, ensuring the necessary accuracy in setting staffing standards; the influence of the main norm-forming factors and the need to take them into account in the normative indicator;
coverage of the most common options for performing work, convenience for calculating staffing standards;
the specific content of normative indicators, the possibility of establishing their quantitative value.

The following indicators meet these requirements:

the number of the population or its individual contingents to establish the positions of outpatient doctors;
the number of beds to establish the positions of medical workers in hospitals;
the number of outpatient doctors and the number of beds or the amount of work to establish the positions of medical personnel of the auxiliary medical diagnostic service, most of the positions of middle and junior medical workers.

An unreasonable change in these indicators for the normalization of labor in the absence of their value fixed by statistics makes these data very manageable and leads to the possibility of an unjustified increase or decrease in the number of employees. An example of the erroneous introduction of a new labor indicator is the establishment in orders of orders of the position of an anesthesiologist-resuscitator for the number of workplaces of operating tables.

It is quite obvious that the number of workplaces, operating tables does not indicate the volume of work of the personnel, in this case it is necessary to determine at least the number of surgical interventions on one operating table, or the operating hours of the operating table, and so on. According to earlier orders of the USSR Ministry of Health, the standard number of these doctors was set to the number of surgical beds, and, in our opinion, there are no grounds for changing this indicator.

Another example of changing the indicator for labor rationing is to establish the standard number of nurse positions per office. In fact, the number of offices, as premises for the work of a doctor, is not in the statistics, and the indicator for the standard for the number of positions of a nurse should be the number of positions of a doctor of a particular specialty.

Another "novelty" of orders on orders is the change in the normative indicator for the position of chief physician, head of the department. Thus, the number of these positions in the children's polyclinic, according to the relevant order (dated April 16, 2012 No. 363n), is set for 10 thousand attached population. If you follow the "letter" of this order, then in a children's polyclinic serving 20 thousand children, you can establish 2 positions of chief doctor, and 30 thousand - 3 chief doctors, which is contrary to public health practice.

2.6. Lack of regulatory support for a number of departments of healthcare facilities, individual positions

In a number of modern legal documents, positions or entire divisions are “missing”. So, the order on the order in the inpatient department of traumatology and orthopedics (dated March 31, 2010 No. 201n) did not provide for the positions of a dressing and operating room nurse. When this document was revised (No. 901n dated November 12, 2012), the position of a dressing nurse was introduced into the structure of this unit, and the position of an operating room nurse is still missing. In the staffing standards of the dermatovenerologic dispensary, there is no staffing of medical workers in the admissions department, in the staffing standards of the children's polyclinic - the security of the registry, etc.

2.7. Erroneous wording of the standard for the position of the head of the department

IN staffing in a medical organization, the position of head can be established only in the form of one position, although the procedure for establishing this position may be different: instead of the whole or part of the position of a doctor or in addition to medical positions. At the same time, the position of the head in outpatient departments is established by the number of positions of outpatient doctors of the corresponding specialty, in hospital departments - by the number of beds. In orders on orders, in some cases it is recommended to establish a fractional number of posts: 0.25; 0.5 or 0.75 posts.

The position of the head of the hospital department in a number of cases is established, as indicated, "based on 30 beds." Such a record is quite acceptable for most positions, but these positions include the head of the department. At the same time, the question of the number of positions of managers in a department of a different capacity, for example, in a department with 45 or 50 beds, remains open. Following the specified standard, in a department with 45 beds, 1.5 positions of the head can be established (45:30 = 1.5), and in a department with 50 beds - 1.75 (50:30 = 1.667, rounded 1.75). Thus, the presented establishment of the positions of heads of departments is contrary to public health practice.

2.8. Inconsistency in the values of labor standards in different, simultaneously valid documents

In simultaneously acting orders on orders, a different standard is indicated for the same position. For example, the position of a surgeon, according to one of the orders, is set as 1 position per 10.0 thousand of the adult population, according to another - 0.65 positions. It is quite characteristic that both of these orders were approved in 2012 and entered into force almost simultaneously - in November-December 2012. The standard for the position of a pediatric urologist-andrologist has a two-fold difference: according to one of the orders on orders, this position is established for 10.0 thousand of the attached child population, according to another - for 20.0 thousand.

In addition to orders on orders, labor standards are also indicated in territorial programs, while for a number of profiles there is a discrepancy between these values and orders on orders. So, for otorhinolaryngology, according to the territorial program for 2016, a standard is set equal to 12 beds per 1 doctor's position, and according to the order on order - for 20 beds, for nephrology - for 12 and 15 beds, respectively, and so on.

There are no coincidences indicated in the territorial program and in the orders of the Ministry of Health, in terms of the standard labor costs for a visit: according to the order approved in mid-2015, the following standard time standards for a visit were established: for a district general practitioner - 15 minutes, for a general practitioner (family doctor) - 18 min. The territorial program for 2016 states the following: “The recommended time limit for 1 visit to a district therapist, general practitioner, district pediatrician is an average of 20 minutes.”

Such conflicting data on the value of standard labor indicators specified in simultaneously valid legal documents approved by the same department require urgent action at the federal level of healthcare management.

2.9. Recommendations for the use of one indicator out of several given in the standard

In staff standards, the establishment of a particular position is possible for several indicators. In these cases, the number of posts is calculated for each indicator, and then the calculated number of posts is summed up. In the orders on procedures approved in 2016 (dated March 1, 2016 No. 134n, dated March 24, 2016 No. 179n), the union “or” is included in the normative record. This union is used in Russian to connect two or more sentences, as well as homogeneous members of a sentence that exclude each other. Thus, the normative record with the union "or" suggests that you need to choose only one of the given indicators. However, the logic and practice of applying labor standards suggests that if a position in one of the medical organizations is set for one of the indicated indicators, for example, in one of the medical and physical education clinics for the number of people involved in sports, and in another - for another indicator, for example, on the urban population living on the territory of the dispensary, this will lead to a different standard number of positions that does not reflect the full scope of work and the load on servicing all the contingents of the population and athletes indicated in the document.

2.10. Economic groundlessness of new labor standards

All the shortcomings of legal documents indicated in the previous paragraphs can be considered as editorial, although they are unacceptable in documents of this kind. If desired, erroneous provisions can be corrected: you can introduce a calculation method for the formation of labor standards, bring the names of positions, specialties into line with the nomenclatures, change the regulatory records for establishing the positions of heads of departments, set the required indicator for round-the-clock work, eliminate contradictions in simultaneously existing regulatory and legal documents and so on.

The medical and economic assessment of modern labor standards was carried out according to the methodology of labor rationing in healthcare. Within the framework of this publication, it is not possible to describe all the methodological approaches used, they are presented in sufficient detail in the relevant literature and are used in medical organizations in the economic analysis of the activities of medical workers and departments.

Carrying out calculations of the normative number of medical positions only according to orders approved over the past two years (except for order No. 134n), showed that over 30 thousand additional positions are needed for their implementation, including the need to increase the positions of narcologists by more than 3 times compared to their actual number, geriatricians - 10 times and so on. Moreover, the calculations were carried out only on those indicators that have statistical security.

A striking example of the economic unreasonability of labor standards is Order No. 134n “On approval of the procedure for organizing the provision of medical care to persons involved in physical culture and sports (including the preparation and conduct of physical culture and sports events), including the procedure medical examination people who want to go sports training, engage in physical culture and sports in organizations and (or) fulfill the standards of tests (tests) of the All-Russian Physical Culture and Sports Complex "Ready for Labor and Defense".

If, when calculating the normative number of medical positions, only one indicator is used: the number of people involved in sports and health clubs, organizations and groups, which is currently 39071.4 thousand people [ Healthcare in Russia, 2015: Stat. Collection / Rosstat. - M., 2015. - 174 p.], i.e., contrary to common sense, to use the word “or” indicated in the regulatory record, it turns out that in order to implement only this provision of the order, the number of medical positions is required, exceeding the actual number of all doctors in the country. For comparison, we note that the previous order (dated August 9, 2010 No. 613n) established the standard number of doctors in sports medicine and physiotherapy equal to more than 25 thousand positions, and the actual number of these doctors is 3.9 thousand positions. Moreover, these positions include not only doctors working in medical and physical education dispensaries, but also in hospitals, sanatoriums, and clinics. Under these conditions, with such a lack of staffing standards of the current order, the very decision to revise the regulatory document is erroneous.

With regard to the normative number of middle and junior medical workers, a different trend is revealed: a decrease in the number of middle medical personnel and the disappearance of the norm for the number of junior medical workers. In accordance with the new order (dated 05.05.2016 No. 279n), the standard for the positions of paramedical workers in sanatorium-and-spa organizations has been reduced tenfold compared to those previously in force, and the standard for the position of a ward nurse (according to the nomenclature in force during the period of approval of this standard) or the standard for junior there is no nurse to care for the sick (according to the current nomenclature) at all.

The introduction of order No. 279n of the Ministry of Health of Russia into healthcare practice does not allow organizing the work of a sanatorium for children with less than 250 beds and a sanatorium for adults with less than 500 beds, primarily because of such a reduction in the standard number of middle and junior medical workers and the impossibility of their round-the-clock work. In sanatoriums more power reduction in the number of round-the-clock posts of ward nurses (guards) and complete absence normative provision with junior medical workers will lead to significant difficulties in organizing the provision of medical care.

There are no standards for the positions of orderlies in the recommended staffing standards for the department (office) of medical prevention for adults (dated September 30, 2015 No. 683n), the audiology room (dated April 9, 2015 No. 178n), the geriatric department and the geriatric office (order No. 38 dated January 29, 2016 ) and so on.

The reduction in the actual number of junior medical personnel in medical organizations is due to an attempt in this way to fulfill the May 2012 decrees of the President of Russia. In medical organizations, the positions of nurses are being transferred to the positions of cleaners, i.e., these positions are being excluded from the number of medical workers, and in a few months of 2016, according to Rosstat, about 50 thousand nurses quit [ Chief nurse, 2016. - No. 10. - P.8.]. It should be noted that such a transfer is not always justified, since in a number of cases the nurse performs not only the functions of a cleaner, but also takes part in providing medical care to the patient to a certain extent, i.e., performs the functions of a junior nurse to care for the sick, especially in the provision of hospital and sanatorium care. But in this case, we are talking about the standard provision of junior medical personnel, and in order to transfer the positions of nurses to the positions of cleaners, it is necessary to have a standard for the position of a nurse. In this regard, we consider it erroneous to exclude the positions of junior medical personnel from staff standards.

Conclusion

The current stage in the development of labor rationing can be viewed as a transition to the creation of a system of labor rationing. The measures taken to create this system are apparently not enough, since legal documents containing such obvious errors are still being approved.

The critical mass of erroneous provisions of orders on procedures in terms of labor standards, the main of which is economic unreasonableness, determines the need to revise these legal documents. IN modern conditions organization of labor rationing and functioning in one of the research institutes of the Ministry of Health of Russia of the labor rationing unit, all documents of this kind should be developed jointly with specialists in labor rationing, or at least undergo an appropriate peer review before they are approved. Such work is partially carried out, but, in our opinion, it should be extended to all draft legal documents on labor standards.

In order to improve the development of labor standards, it is necessary to include labor rationing issues in the training program for doctors and nurses and postgraduate training in the specialty "Organization of health care and public health", "Organization of nursing", holding seminars, lectures on this topic, and, first turn, for the developers of labor standards and specialists who approve these standards.

For chief physicians, heads of departments of medical organizations, representatives of ministries and departments in the field of healthcare: we suggest that you familiarize yourself with the program of the symposium, which will be held on August 21-25, 2017 "Management of a medical institution in modern conditions" .

We invite you to take part in the International Conference for Private Clinics , where you will get the tools to create a positive image of your clinic, which will increase the demand for medical services and increase profits. Take the first step towards the development of your clinic.

Service standards - in units of time - - in units of time - the average time for which a medical worker must carry out his activities. - speed of work - - speed of work - the average number of actions completed in a certain period of time. (providing medical services) are established for the work of medical personnel

Standards of care For example, the standards of care for an antenatal health center with a midwife can be reflected in terms of unit time: 10 minutes for each pregnant woman or examination speed: 18 pregnant women were seen during a three-hour consultation. A unit of time is measured from the start of one activity to the start of another similar activity. The time estimate must include the time required to complete all work related to the job, including the time to complete medical documents. It is worth noting that the work according to the standard is carried out taking into account existing local conditions work. It is assumed that the work according to the standard is performed by well-trained, qualified and motivated employees. The time a health worker spends on a particular activity is thus correlated with the quality of the services provided.

1 by specialty (CAS) Must be performed by all employees of this specialty. The norm of standards is adopted to support and supplement the standards 2 individual norms of standards Calculated by how much time it takes for additional work for employees. The norm of the standard can be expressed either as actual working time or as a percentage of working time. For example, compliance with the norm of the standard "accounting and reporting" can be shown as either "one hour during the working day" or as "14% of the working time". (One hour is equal to 14% of the 7.2 hours average workday for a midwife at a Wisnela health center.) To do this, make a list additional species activity, the number of employees performing that activity, and the time it takes to complete each activity. Then the number of employees is multiplied by the annual time requirement. After adding up the results, you will find out how many hours it takes to additional work some employees.

Number of consultations per doctor per year Countries Number of doctors Number of paramedical personnel Workload of GPs Labor rationing Per 10,000 population Population per GP % of GPs using fixed appointment times Average duration of one appointment (min.) Number of consultations per doctor per year USA Germany UK France Israel

Country Population per GP Number of patients per day Fixed appointment times % of GPs with patients waiting more than 2 days In the office By phone Home visits per week % of GPs using a fixed appointment time Average duration of 1 appointment (min.) Fee per visit Austria Belgium France Germany Luxembourg Norway Switzerland Fee per capita/combined Denmark Ireland Italy Netherlands United Kingdom different countries in the context of payment methods by general practitioners (GPs)

GP admission rate Country Percentage of GPs using fixed appointment times Duration of appointment (minutes) Austria 3415 Belgium 6319 Bulgaria 2913 Croatia 1512 Czech Republic 1918 Denmark 9213 Germany 6613 Estonia 2716 Finland 8918 France 6920 Greece 1521 Hungary 914 Iceland 9017 Ireland 5014 Israel 6311 Italy 2022 Latvia 1421 Lithuania 2717 Luxembourg 6118 Netherlands 9310 Norway 8219 Poland 2221 Portugal 5816 Romania 2319 Slovakia 287 Slovenia 2113 Spain 5410 Sweden 7124 Switzerland 7815 Turkey 419 Ukraine 915 UK 858 Average 46.2515.88

Data for general practitioners Influenced by the composition of patients at the site (or attached): The number of patients that can be served by 1 general practitioner during the year depends on the composition of patients at the site (or attached) and on average in EU countries ranges from 1800 to 1500 Human. For example, the more patients under 1 year old or older than 70 years old, the more visits they make. On average, the likelihood of a visit (or need) is 6.5 visits per person per year (OECD average). Next, the average time of the number of consultations that a doctor provides per day is taken into account (for example, 20 consultations) and the number of working days of this doctor per year (240 days - on average for the EU countries) and the optimal volume of the attached population is calculated (20 x 240 / 6, 5) = 738 people. method proposed by the American Society of General Practitioners - Family Practice Management Web site at Copyright©2007 American Academy of Family Physicians.

For each country, these indicators are different based on: 6.5 The population's need for medical care (measured in the number of visits per 1 person per year, (in OECD countries - 6.5) 55 hours The established maximum doctor's work time per week (on average (OECD countries - 55 hours) 15 min Time spent on seeing 1 patient (OECD average - 15 min.) days Established number of days a doctor works per year (days in OECD countries) Population density of the population, i.e. must be taken into account the time it takes the patient to get to the doctor (and the doctor to the patient) Therefore, in areas with low population density, doctors must serve a smaller population.

This system included: By the beginning of the 80s, a certain system of labor rationing had been formed in the healthcare of the Russian Federation. This system included: unified methodological support for the development of all labor standards; involvement in the development of evidence-based labor standards of highly qualified specialists, as a rule, employees of specialized research institutes who are well aware of modern and promising technologies of the treatment and diagnostic process; creation of pilot sites in different economic and geographical areas of the country to collect the necessary information in the development of standards and approbation normative documents by labor. During the creation and development of this system of labor rationing, more than 50 normative documents on labor were developed and approved.

At present, staffing standards for the main types of healthcare institutions have a summer limitation period for their approval and, therefore, they do not correspond to the changed structure and level of morbidity in the population, new diagnostic and treatment technologies, new organizational forms of provision and mechanisms for paying for medical care.

Rationing methods The analytical, or element-by-element, method is based on the differentiation of the labor process into separate components, determining the standard time spent on them and the formation of labor standards, taking into account the rational organization of the labor process as a whole, the volume and quality of work performed. The analytical method is subdivided into analytical-research and analytical-calculative. In the first method, labor costs are measured for all the constituent elements of the labor process in optimal organizational and technical conditions corresponding to modern technology medical diagnostic process. The method is time-consuming, but allows you to adjust the resulting data as the technology of individual components changes. The analytical and calculation method uses previously developed indicators of labor costs for a particular type of activity and, based on a specific amount of work, the required number of personnel is calculated.

Rationing methods The total method does not provide for changes in labor costs for individual components of the labor process, while this method determines labor costs for actually performed work according to the technology used in the institution. The method is simple and accessible, which allows it to be widely used in health care institutions to analyze labor standards and establish new standards in an expeditious manner, which are subsequently subject to replacement with indicators established using the analytical method. Comparative rationing is used if the technology for carrying out a particular work is similar to that for which there are already labor standards. With the expert (experimental) method of labor rationing, the indicators are set on the basis of the past experience of the developer of the standard. The statistical method is applied when there are statistical data on the volume of work, for example, the number of visits or certain procedures, examinations and the number of personnel actually performing this work.

In healthcare, two types of timing are used: timing measurements photo timing observations The choice of one or another type of timing depends on the purpose and objectives of the study. Timing measurements are used to determine the time spent on a specific type of activity; photochronometric observations are used to study, along with the time spent on the structure of the working day, possible unproductive costs.

Results of chronometric studies. Norms of the time of admission of one patient in a medical organization (in minutes) Position Initial appointment Repeated appointment Average time of GP 27.2±3 20±3 23.6±3 District physician 19.1±117.0±118.3±1 District pediatrician 19.0±313.6±316.3±3

Results of chronometric studies. Norms of time for receiving one patient at home (in minutes) Position Initial appointment Repeated appointment Average time for GP45.0±240.0±242.5±2 District general practitioner 35.0±230.0±232.5±2 Doctor – district pediatrician 33.0±230.0±231.5±2

Distribution of the time of work with the documentation of the district pediatrician by elements of labor operations (%).

Organizational science (scientific management) in different periods solved the problems of rationalization and optimization labor activity to increase productivity, reduce physical and material costs, combat unemployment, etc. Now these problems are becoming increasingly important. Therefore, more attention should be paid to the problems of labor rationing, which will allow rationalizing and optimizing various areas labor activity.

Processes taking place in the modern economy, characterized by different dynamics market relations, represent new stage in the history of the formation of social and labor relations. However social and labor relations As the experience of developed countries shows, they can be effective only when a strong and stable state acts as a guarantor, the main parameters of which are: a constant growth rate of the gross national product, state controllability is unconditional, and the effectiveness of the current economic course is confirmed by visible results for citizens. For a federal state, the most significant indicator is the socio-economic development of its subjects and municipalities which determines the quality of life of the population of the country.

And one of the main areas affecting the quality of life of the population is health care, the level of development of which is largely determined by the indicators of the efficiency of the use of the country's labor resources.

In healthcare, technologies for the provision of medical services are constantly developing, the structures of the pathology of diseases are changing, which requires constant improvement of methodologies in the field of labor regulation of personnel in medical healthcare institutions.

Quite a lot of attention was paid to the study of labor regulation problems, in particular, intersectoral, sectoral and local regulatory materials were developed on time standards for work performed, workload standards and headcount standards, and studies were carried out to establish and consolidate the scope of work in the form of qualification reference books.

Improving the organization of work in healthcare institutions requires further development of a methodology for determining the norms of time for medical services, methods for calculating the norms of the workload of medical personnel, approaches to determining and planning the number of medical personnel.

To achieve the above goal, it is necessary to solve the following tasks:

formation of a new system of regulation of the work of medical personnel using world standards for technologies for the provision of medical services;
development of modern methods for the development of time standards (labor intensity of work) for the provision of simple and complex medical services;
formation of a methodology for calculating the load norms for medical personnel of health care institutions in three areas (outpatient visits, diagnostic services, hospitals), taking into account the priorities for the development of health care in the Russian Federation;
development of new approaches to determining and planning the number of medical personnel of health care institutions.

It should be noted that the basis of the functioning of medical institutions are labor resources Therefore, a special role should be assigned to the organization of labor, which should be based on the management of the personnel of medical institutions on the basis of scientific and rational (regulatory) activities. At present, a high organization of labor gives better results, which will certainly lead to a higher dedication of the employee, an increase in the productivity of his labor, self-realization under organized leadership, designed by management means to motivate and stimulate the employee and, most importantly, ensures the necessary quality of medical services provided.

Obviously, only management organized on scientific basis, will allow finding optimal solutions for many social problems concerning the standard of living not only of medical personnel of health care institutions, but also of potential employees.

The relationship of labor rationing with the general standard of living

In recent years, studies have been carried out by the Federal State Unitary Enterprise "NII TSS" of the Ministry of Health and Social Development of Russia, intended for healthcare institutions of the Russian Federation.

Based on a volumetric analysis of the functioning of medical institutions, collected materials and expected prospects, it was revealed that with the help of labor rationing, it is possible to solve many problems related to the standard of living of medical workers, both at the micro and macro levels.

A health care institution, using a scientifically based labor organization, manages to increase the effectiveness of all its activities, increase the productivity of its employees, and achieve an increase in the efficiency of medical personnel in fulfilling their duties. In turn, this leads to higher remuneration for the work done in the form of wages and thus to an increase in purchasing power. A efficient operation, organized as a whole for the health care institution and the quality functioning of this institution as a whole lead to the improvement of its activities at the state level. Thus, the possibility of a comprehensive influence on the standard of living of the population of the country is achieved.

Rationing and efficiency

This direction now plays a key role in shaping the strategy for the development of healthcare institutions. The effectiveness of the work of the entire healthcare institution as a whole depends on how optimally the composition of the medical staff is formed. Unfortunately, the current period of development is characterized by an acute problem of both the quality and the composition of the medical personnel of health care institutions.

One of the most actual problems For public institutions healthcare is the lack of materials approved at the industry level on labor standards for admission departments, covering the full scope of medical functions performed. In this regard, the following uncertainties arise in the process of setting wages and the number of staff in admission departments:

lack of labor standards for the personnel of the reception departments of public health institutions;
lack of labor standards for support staff (nurses, nurses) in the reception departments of public health institutions;
the need to determine the intensity of work of the personnel of the reception departments of public health institutions;
standard criteria for the work of admission departments by types of healthcare institutions have not been developed.

Currently, there are no regulatory documents on the workload of doctors, middle and junior medical staff of emergency departments (with the exception of the Order of the Ministry of Health of the USSR No. 560 dated May 31, 1979, which is currently advisory in nature, is significantly outdated, and therefore not applicable in practice).

All of the above problems make it difficult to develop an adequate system of remuneration, taking into account the intensity of work of the main and auxiliary personnel of the reception departments of public health institutions. As a result, all this affects the quality of medical services provided to the population.

Methodology for calculating labor rationing

Almost every medical institution faces the above difficulties. Separate rates already exist simply because they have always existed, even if the load on them falls. There are no rates for other work and loads, because the management of the institution, with their obvious demand, is not always able to justify and calculate their need.

For a detailed analysis of the described problems and as a way to solve, we give an example of calculating the necessary rates based on the actual work performed and the time spent by the doctor of the admission department of the State Healthcare Institution.