Flexible working in hospitals: how to make it a success

Brecht Cardoen

By Brecht Cardoen

Professor of Operations Management

12 June 2018

Flexible working is all the rage these days, and hospitals can't escape the trend either. The white paper ‘Flexible working in hospitals: OM and HRM perspective’ by our MINOZ research centre is the fruit of last year's efforts. It examines what flexible working means for the organisation and the employee, how the two perspectives can be brought into balance and which forms of flexible working are relevant for hospitals. Illustrated with practical examples, it offers food for thought for organisations which would like to introduce flexible working themselves.

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A question of perspective

How can you ensure an optimal response to the growing demand for care, despite increasingly tight budgets and without overwhelming the care staff? By focusing on four dimensions: public health, patient experience, care costs and the wellbeing of the care staff – the so-called quadruple aim. Flexibility can help with this. From an operational management perspective (OM perspective), flexible working is used to improve the coordination of the care demand and supply. The HRM perspective also regards flexibility as a means of improving the work-life balance.

Measurement means management

In Belgian hospitals, each nurse looks after an average of 8 to 10 patients. Is this figure high? The workload is only higher in Spain, with 12 patients. In the rest of Europe, each nurse only takes care of an average of 7 to 8 patients. In order to coordinate the demand and supply as efficiently as possible, you need to be able to estimate the demand for care. And this is exactly where the problem lies: the demand displays major fluctuations, both daily (with a peak in the morning) and during the year (with a peak during the winter months). Although various care weighting models exist, they require a great deal of data. This data cannot always be recorded, however, partly because of a lack of time. And even though digital technology can offer the nursing staff a helping hand, data recording remains an extra stress factor. All the same, it is worth charting the daily workload as this makes it possible to distinguish quiet departments from busy ones and adjust the workload accordingly. The white paper includes two examples of workload measurement tools as developed and used by University Hospital Brussels and the Jan Yperman Ziekenhuis hospital. 

Operational flexibility

From an OM perspective, there are various ways of responding to the variability of the demand for care.

  • Flexible deployment
    A nursing department's regular team can be supplemented with flexible employees who can step in to cover unexpected absences, excessive workloads or long-term staff shortages. The mobile team is typically used to make up for short-term shortages or if specific expertise is required. All too often, however, this team is used for relatively long periods. The flex team consists of part-time employees who will voluntarily provide cover on the basis of a temporary contract which allows them to determine when and in which department(s) they would like to work extra hours. Temping agencies also offer support during peak times but few of the affiliated hospitals use them, as they are fairly expensive. The white paper provides an in-depth discussion of the advantages and disadvantages of these forms of flexible deployment and makes a few observations regarding the flexible deployment of specialist nursing staff.
  • Flexible division of tasks
    Patient care, administration, projects, induction, training etc. Depending on the workload, tasks can be rescheduled where possible. Administrative tasks can be shifted to quieter moments of the day or week; training and projects can take place during quieter times of the year.
  • Flexible personnel planning
    Shift work makes it easier for hospitals to coordinate the healthcare supply and demand. Most hospitals have day and night shifts and early or late shifts. Split shifts are less common these days. Shift work can also be beneficial for employees. A 12-hour shift system was introduced at University Hospital Brussels in response to staff demand, for example, as it allows employees to avoid rush hour. To stop people working too little or too much, minimum and maximum limits are set for each day, week and/or year. The annual hours system makes it possible to compensate for peaks and troughs in the workload more effectively and take the employee's personal situation into account.
  • Flexible location
    Depending on the operational requirements, care staff (and other staff) can work on different campuses of the same hospital, in various different hospitals within a network or in care institutions within an integrated network. This can offer benefits for both the organisations involved and for the employees. Combining hospital work and home care can prove a good solution for some employees, as it allows them to be employed more satisfactorily and for a longer period. For care staff, working from home is not generally possible.
  • Inherent flexibility
    Another option is to take no action in the face of staff shortages. In this case, the nursing staff who are present must take on the extra workload by shifting tasks around, looking after more patients (which does not benefit the quality of the care) or by doing overtime (which can lead to stress and even burnout in the longer term). Although not doing anything might seem the easiest solution, it certainly involves some risks.

The forms of flexibility described above fall under the heading of volume flexibility. The white paper also briefly discusses mix flexibility (offering different services) and the impact of network formation on this form of flexibility, delivery flexibility (the possibility of changing the place and time of the services provided; for hospitals, flexible examination times are virtually the only possible form of delivery flexibility) and product/service flexibility (the possibility of introducing new products or services), focusing on the advantages and disadvantages of technological progress.

A workable working situation

From an HRM perspective, flexible working offers a method of providing employees with sustainable employment by focusing on workable work and a pleasant working environment. The white paper discusses various forms of flexibility which contribute to this.

  • Flexible skills
    Nurses are frequently given administrative and logistical tasks too. Some nurses regard this as an enhancement, and for others these tasks are a good alternative if the care function becomes too physically demanding. Not only do regular courses and training allow nursing staff to keep their knowledge up to date, they also encourage them to keep learning.
  • Flexible remuneration and holiday arrangements
    Various leave and compensation arrangements (reduction in working hours, time credits, unpaid leave etc.) allow employees to coordinate their schedule with their personal life more effectively. For hospitals, these arrangements constitute an extra challenge in terms of administration, continuity of care and expertise.
  • Functional flexibility
    Most of the affiliated hospitals have an internal change policy which gives employees the opportunity to progress within various services and departments. Employees who are no longer physically capable of carrying out their job require extra attention. Wherever possible, integration projects are used to try to switch them to other roles.
  • Flexible working arrangements
    Part-time, full-time, 4/5, 24 or 30-hour shifts… numerous working arrangements exist. Despite the operational challenges, most of the affiliated hospitals would like their own employees to decide how to fill their own schedules in concrete terms. Various affiliated hospitals are putting self-scheduling to the test. The Jessa Ziekenhuis hospital has been using this system for the past 20 years. The white paper provides more information about their experiences.

Proper leadership, motivation and mindset

Sustainable staff deployment involves keeping work pressure under control in order to limit the risk of depression, burnout and absence through illness. Work pressure – the relationship between the workload and the capacity of the employee – cannot be measured objectively, unlike the workload. After all, the capacity depends on numerous personal factors which determine the amount of stress an individual can handle. Although OM and HRM have different starting points, the two perspectives are not necessarily incompatible or contradictory. However, good communication and collaboration between all the parties concerned are essential in order to ensure a good balance between the workload and capacity of the employee. A significant role is played by the managers here.

Motivation is an important factor which determines whether or not employees are prepared to go along with flexible working. Motivation is achieved not so much through financial means as by giving employees autonomy, providing them with the opportunity for personal and/or professional development and by ensuring that they are familiar with the aims of the organisation, so that they understand how their work fits into the bigger picture.   

However, motivation alone is not enough. Flexible working also demands a certain mindset from employees – a mindset which focuses on growth and change. All the same, everyone has a limit when it comes to flexibility. People need stability in order to feel competent. It is therefore important to create the right context first, before communicating about what will and will not change. This also avoids emotional reactions gaining the upper hand.

Impact on the quality and safety of care

When focusing on flexible working and its impact on the employee and organisation, we must not lose sight of the patient. When attempting to achieve multidisciplinary, integrated care which revolves around the patient, communication between the various parties is essential in order to optimise the patient experience.

Between dream and deed...

Between dream and deed, as the Belgian poet Willem Elsschot wrote, are laws that bar the way and problems stark and plain. There is no lack of creative ideas when it comes to flexible working, as is evident from the affiliated hospitals' contributions to the white paper. Unfortunately, financial and/or legal restrictions mean that not all ideas are equally feasible. Finally, the paper focuses on the consequences of network formation: the way in which the financing of hospital networks is organised will affect employment and flexible working options.

Getting started with flexible working

Better operational efficiency and sustainable employment? The examples from the white paper show that it's perfectly possible. Conditions for success: good communication, coaching managers, a pleasant working atmosphere and an organisational culture which gives employees freedom and a voice.

About the white paper
The white paper ‘Flexible working in hospitals: OM and HRM perspective’ was written in collaboration with the affiliated hospitals which formed part of the MINOZ research network in 2017: AZ Alma, Jan Yperman Ziekenhuis, AZ Sint-Maria, Jessa Ziekenhuis, AZ Sint-Lucas, AZ Sint-Maarten, Algemeen Stedelijk Ziekenhuis, AZ Maria Middelares and AZ Nikolaas. University Hospital Brussels also made an active contribution. The Zorgnet-Icuro network for healthcare organisations served as a sounding board for the legal and financial framework. 

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Brecht Cardoen

Brecht Cardoen

Professor & Director DBA Programme