Tracking HPPD helps to ensure each of the units in a hospital are meeting financial targets in order to remain financially healthy. Administrators, charge nurses, and clinicians can share the common goal of working toward a financially secure hospital. Knowing how HPPD is calculated will help nurses use multiple types of benchmark data to influence decision making within their unit clinical practice committees. Tracking changes in benchmarks will provide a uniform method of sharing strategies that improve productivity, while simultaneously measuring quality using other measures such as patient satisfaction surveys.
Health care is rapidly changing from fee-for-service to contracted service, and is now focused on value-added pricing and reimbursement. Every aspect of patient and nonpatient expenditures must be continually scrutinized to ensure the highest level of efficiency. Not all measures of efficiency are reported in the research literature as thoroughly as other aspects of care are. Some measures are developed by private vendors, such as specifics of episodes of care, while other measures are more familiar: length of stay and outputs such as hospital discharges statistics.
HPPD includes the total number of nursing hours in a unit in a 24-hour period. (See Calculating HPPD). Although only clinical staff should be included in the HPPD calculation, some agencies include all clinical staff. According to Habasevich (2012) there is no single standard to calculate HPPD. When staff members are first informed about HPPD and how it is calculated, it is important that they understand the specifics of how an individual unit’s HPPD is calculated. Clinicians and practice committees can request that the chief financial officer or chief nursing officer disclose information about how HPPD is calculated so that all involved understand agency-specific procedures for documenting nursing productivity.
Potential limitations of HPPD
The unit HPPD is considered a budget-based staffing model that provides a snapshot of the overall day and shift, without concern for changes in patient census within a shift. One concern often expressed by nurses is the calculation of time required for admissions and discharges. Once a patient is discharged, it is usually likely that a new patient will be admitted, requiring intense care to assess and develop an individualized plan of care. However, reluctance to speed the discharge and admission process can bring a short-term gain but compromise the long-term financial health of a unit or hospital by increasing the HPPD beyond that which is budgeted, thus creating a deficit.
While some nurses may be able to influence patient census turnover, many other situations are beyond the control of a single staff member. Another common issue for many hospitals is overcrowding of patients in the emergency department (ED) partly because of the lack of available beds or staff in critical care or other units.
The following two case studies illustrate potential limitations with calculation of HPPD in certain situations:
Case study 1: patient with sepsis in the ED
A 65-year-old woman is brought to the ED by ambulance with presenting symptoms of lethargy (but she is arousable), cyanosis to hands and feet, and skin cool to the touch. Her systemic blood pressure is 80/50 mm Hg and heart rate is 130 beats/minute. The patient’s husband states that she has been complaining about abdominal pain. Upon examination the patient’s abdomen is distended. The ED physician will be ordering other tests but suspects sepsis. Therefore, there is no time to lose because the Surviving Sepsis Campaign Bundle protocol must be implemented within a limited time frame (www.survivingsepsis.org/bundles/Pages/default.aspx). It is therefore determined that the best place for the patient is in the critical care unit.
Analysis. The ED staff continues to provide the best care possible, but the ED staffing levels are not part of the budgeted critical care HPPD. There are many issues related to a patient remaining in the ED beyond what is appropriate. (For the purposes of this discussion, the focus is the financial consequences of inaccurate staffing expenditures. However, tracking patient care quality is always important.) Including information on financial expenditures provides clinicians with a more holistic view of unit function. These variables also provide a common language for discussing areas of concern with fiscal leaders at a hospital.
Case study 2: identifying possible causes of low patient satisfaction
A patient was admitted 9 hours ago from the ED and remains on a gurney awaiting transfer to the intensive care unit. The patient’s family complained about their loved one being confined to an uncomfortable gurney, the noise level, and limited visitations while waiting for a transfer. Some of the patient care was administered in the hallway with little privacy. Confining a patient to a less-than-satisfactory environment may result in lower patient satisfaction scores.
Analysis. If this patient is selected to receive a satisfaction survey upon discharge, her perceptions about quality of care will begin with the entry into the hospital. Every effort to discharge patients from units in a timely manner supports quality patient care and enhances patient satisfaction by ensuring that the patient’s dignity and comfort is maintained when they are in a room that allows privacy and the ability to have their family present.
One of the functions of the clinical practice committee is to review patient care issues, including patient satisfaction scores. For example, bottlenecks in discharges have been addressed with programs such as Wertheimer et al.’s Discharge before noon and may be helpful in improving both patient and financial outcomes. When there are higher ratios of patients to nurses, staff dissatisfaction may increase. Patients and families are sensitive to staff emotions, alterations in workflow and longer waits. Phone calls from family members asking for updates on their loved ones, delays in obtaining medication or being discharged in a timely way can be tracked, in part, to higher levels of patients to nurses. HPPD is a tool designed to track these ratios.
One measure of patient satisfaction that could reveal some potential customer service deficits is the correlation between HPPD and Hospital Compare scores over time to identify and review any patterns such as bottlenecks developing with patient discharges and cleaning. The Hospital Compare website (www.medicare.gov/hospitalcompare/search.html) presents comparison data, aggregated from surveys sent to randomly selected patients discharged from over 4,000 Medicare-certified hospitals. The Hospital Compare database is frequently accessed by potential patients and insurers who are seeking information regarding the best places to get health care.
In addition to influencing patient choice, hospitals face potential fines or reduced reimbursement if satisfaction scores are low, because of the incentive program known as value-based purchasing (VBP). Hospital VBP programs adjust Medicare payments to reward hospitals based on the quality of care they provide to patients. In these high-stress environments, nurse satisfaction is also a significant consideration. When workloads are high, nurse satisfaction may be low. Comparing HPPD and measures of nurse satisfaction such as turnover may also yield valuable outcome data that can be addressed as appropriate.
Calculating HPPD is not the beginning or end of the description of nursing care quality and productivity. HPPD does not allow for adjustment when caring for several patients throughout the day, or for discharges—concerns commonly expressed by clinical staff. Studies such as Dabney and Kallisch’s 2015 work on the influence of nurse staffing on patient care are providing important information in this area. We assert that as quality is measured, HPPD must be included in the discussion as an important correlated variable in understanding low satisfaction scores of patients and staff.
It is critical that clinical staff have access to HPPD levels and how they are calculated in a particular institution in order to inform their practice. Evidence-based care must use data and research on measures of productivity, patient satisfaction, quality, and financial accountability. In the meantime, some hospitals are implementing a number of strategies to account for the staffing level on all units and to address bottlenecks in processing patient admissions, transfers, and discharges. At the heart of these activities is a shared desire to provide the best person-centered, timely, efficient, and effective care.
Geraldine C. Fike DNP, MSN, RN, CCRN, is assistant professor in the College of Natural Sciences, Department of Nursing, at California State University San Bernardino. Marilyn Smith-Stoner, RN-BC, PhD, is professor emeritus at California State University San Bernardino.
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Wertheimer B, Jacobs RE, Iturrate E, Bailey M, Hochman K. Discharge before noon: Effect on throughput and sustainability. J Hosp Med. 2015;10(10):664-669.