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Managing to Nursing HPPD

Written by: Bob Habasevich, PT on Thursday, September 27, 2012 Posted in: Inpatient Rehab

Hours per patient day (HPPD) is a common expression to justify the amount of man-hours required to care for patients in hospitals. This measure tracks the total number of direct nursing care hours (RNs, LPNs and PCTs), compared to the number of patients in the hospital. A higher number may indicate that a hospital provides a higher level of patient care.

While there are no national requirements for specific staffing levels, many hospitals measure “nursing hours per patient day” as a way to monitor and improve quality of care and service.  In many states, hospitals must report these data to the Department of Public Health.

Nursing and finance administration have evolved an annual stalemated approach to determining the “best fit” to operate the hospital’s nursing care delivery for the immediate future.

Is the question, “How many nursing hours are required to run a hospital?” or should it be, “How many nursing hours do patients require to receive the care they need?”  The questions are not the same and seeking an answer to the hours per patient day dilemma continually frustrates anyone attempting to balance supply and demand issues of hospital operations. As evident in all other issues of healthcare transformations, seeking cost reductions and quality improvement elevates nurse staffing again into the limelight for cost justification of the largest single personnel cost for most hospitals. As budget season approaches, those charged with maintaining financial viability while improving outcome and process effectiveness, are looking to the nursing HPPD requirements. Historical add or subtract percentages from previous budgets is giving way to a deeper look into what hospital nursing must accomplish and a closer analysis of what it takes to get it done. Nursing leadership is feeling the pressure, as strong leadership alone no longer is sufficient to maintain the status quo of the hospital’s staffing matrix approach, to assure patient safety and delivering excellent care. Changing roles of professional nurses, balancing skill mix with patient care demands, evolving cultural and practice changes and payment reductions all require an expanded systems approach to address the issue of how many nurses are required.

Whether we always have the funding to screen or provide those services is a different matter than the ethical and moral issue of identifying and documenting the health or social conditions that if left untreated have more dire consequences than whether someone can manage three hours of daily therapy.

American Nurses Association for the National Database of Nursing Quality Indicators (NDNQI) offers this guidance. “Nursing care hours” are the number of hours worked by nursing staff that have direct patient care responsibilities for more than 50 percent of their shift.

  • Total nursing care hours include hours worked by registered nurses (RNs), licensed practical and vocational nurses, licensed nursing aides, mental health technicians and personal care attendants.
  • RN nursing care hours include hours worked by RNs.

“Patient days” are the daily average of the number of patients on the unit, as counted at least once during each shift for 24 hours.

It has become common to compare HPPD metrics between hospitals and may serve some purpose of general reference.  However, there are some very important reasons why hospitals should not be compared to each other for this measure:

  • The results are not adjusted to account for factors that might require more nursing care hours (e.g., age of patients, severity of patient illnesses).
  • The measure does not account for hospital differences in physical layout, frequency of admissions and discharges, or other factors that might impact nurse staffing needs.
  • Specialty care and program requirements differ widely with expectations of nursing roles and how they are filled.
  • Nursing skill sets, competency and physical attributes of the workforce in responding to patient care demands vary widely between hositals and influence the time spent in delivering care.
  • Patient care demand lacks universal systems of classification to standardize measurement of the patient centric variables of nursing care demand and will be required to compare hospital populations.

The number of nursing staff caring for patients is determined by how many patients are in the hospital and the nursing care requirements of patients. Nursing hours per patient day is the total number of nursing staff providing patient care compared to the number of patients. The nursing hours reflect the number and complexity of patients for each clinical area. Each hospital must define its nursing practice and staffing standards specific to the patients it serves with the unique brand of patient care delivery and process. Having access to the information systems to monitor and measure effectiveness and improve performance will answer the question of how many HPPD of nursing care are required to care for each patient. Medilinks RNS has been shown to be an effective system of data collection and management to calculate and predict patient acuity when used in a coordinated system of rehabilitation nurse management and  inpatient rehabilitation hospital care.


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