Skill mix in healthcare: An international update for the management debate

Purpose: The interest in health workforce redesign has been growing internationally and over one decade of practice and research resulted in a variety of literature on the impact of the different approaches to staffing on patient and services' outcomes. The purpose of this review is to produce an update on the knowledge developed on this topic of interest to the international healthcare management community and to policy makers involved in reforming healthcare systems and organizations. Methods: A systematic review on healthcare skill-mix literature was conducted in a 4-month period through the Pubmed, BioMed Central, and Medline databases. Fourteen articles published between 1995 and 2011 were selected according to inclusion and exclusion criteria. Findings: A total of 14 studies undertaken between 1998 and 2011 were selected for our discussion. The review identified a methodological weakness preventing the results of individual studies from being considered together to produce concrete findings and structured knowledge on the effectiveness of skill-mix experiments. Most studies describing the implementation of skill-mix models were undertaken in the USA and Australia in specific care settings and were mostly focused on doctors-nurses mixes. We found no evidence of a wider impact from a skill mix on health systems nor on the variables that determine its success. Most studies did not explain why a particular approach to skill mix was chosen, nor gave enough information about the context in which decisions were made. There were few appropriate evaluations of outcomes, quality, and costs that enable for effective skill-mix evaluation. Conclusion: This review showed that despite the widely acknowledged interest on skill-mix initiatives there is a lack of evidence on skill-mix implications, constraints, outcomes, and quality impact that would allow policy makers to take sustained and evidence-based decisions. There is a need to examine closely the methodological rigor of skill-mix reviews and to be aware of the motivation driving them. Being able to recognize differences between countries and contexts will also allow a better comprehension of the effectiveness of the initiatives and ways to implement them.