Ensure correct HPPD for best patient care

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Ensure correct HPPD for best patient care


Determining and agreeing on how many hours per patient day (HPPD) it takes to care for your patient population is a challenging aspect of our work as nurse leaders. HPPD is not the total number of staff needed on the unit, but a measurement of the average number of hours needed to care for each patient on the unit. Unlike the unit census, this number takes into consideration several factors that drive the need for care hours. Let's look at the variables that make this comparison so difficult.


Patient care unit-related variances

  • Number of patients: Larger units will require a higher number of staff; however, they may deliver that care at a lower HPPD than smaller units caring for the same type of patients. At some point, smaller units have fixed costs that are there no matter how many patients are on the unit. A good example of this is the monitor technologist or the unit secretary. These positions may be able to support many more patients than a smaller unit has, but are necessary even if the unit census is much lower.
  • Levels of intensity of the patients for whom care is being provided: This is what we in nursing call acuity. Obviously, the more care needed by the patient, the higher the HPPD will need to be in order to provide this care.
  • Contextual issues: What a difference architecture and technology makes when nurses have to go to get linen, medications, and supplies; answer phones; access patient information; and so on. Designing the unit so that these functions require the least amount of travel time will lower HPPD.


Patient-specific physical and psychosocial variances

  • Age and functional ability: The older your patients are and the less that they function independently, the more care they are going to require. Factors such as the percentage of your patients who are admitted from home or are discharged to home, occupational and physical therapy consults, and independent completion of activities of daily living can be used as indicators of functional ability.
  • Communication skills: Patients who have communication barriers require more time for care activities. Whether the barrier is a different language than what is predominately spoken by the caregiver team or the patient cannot communicate due to illness, this creates a greater demand for caregiver hours.
  • Cultural and linguistic diversities: Working with a diverse patient population with different preferences regarding food, care issues, time of day care is delivered, religious practices, and rituals can challenge caregivers to meet these needs without disrupting the normal activities of the unit. Planning and ensuring that the patient's preferences are honored can require additional time from nurses.
  • Severity and urgency of admitting condition: The admission process is one of the biggest time consumers in a patient's care. Completing a patient's history, assessment, vital signs, medication reconciliation, orientation to the environment, and admission orders consumes on average at least two hours of nursing time. Some hospitals have created admission units where patients go first for these time-intensive responsibilities to be completed before arriving on the nursing unit. This arrangement would reduce the ­HPPD on the arriving unit. If patients arrive to your unit directly from an emergency room, it can be concluded that they have an urgent need for care, again adding to HPPD.
  • Scheduled procedures: Scheduled procedures performed on the unit create additional HPPD. Examples of such procedures would be bronchoscopes, percutaneous endoscopic gastrostomy tubes, peripherally inserted central catheter lines, and central line catheter insertions and cardioversions that can be done bedside but require additional nursing assistance and post-procedure assessment.
  • Availability of social support: Patient populations who have family or friends who can assist with care activities, be available for teaching opportunities, or sit with patients who are at risk for falls or who are confused reduce the need for care hours.


Unit function variances

  • Unit governance: An important benchmarking variable is whether the unit practices with a shared governance model. Shared governance models demand that hourly staff be allowed paid hours to participate in such activities as unit practice councils, policy and procedure development, and self-scheduling. Hourly staff participation in these activities will increase HPPD initially. However, once the unit is functioning at a high level and staff are accustomed to making decisions that impact care, HPPD may decrease. Staff in such a unit know how best to design care to take the work out of work and utilize evidence-based practice from other resources to make decisions regarding patient care.
  • Involvement in quality measurement activities: Units who are responsible for collecting, interpreting, and reporting their own quality measurement data will have higher HPPD than those in which this function is done by someone whose hours are not charged to the unit; however, there is much value in self- and peer monitoring. The quality of work often improves more quickly in units who "own" their own quality data activities.
  • Development of critical pathways or protocols: Fully developed pathways or protocols take variance out of work and therefore create efficiencies.
  • Evaluation of practice outcomes: Much like the previous discussion regarding quality measurement and unit governance, units who are responsible for data collection, analysis, and reporting of patient outcome measurements will have a higher HPPD.


Staff-related variances

  • Experience with the population served: Units who have a stable workforce with experience with the types of patients cared for in the unit are able to provide care in a more efficient manner than those who have staff who are new to the type of patient care that is done in the unit. This contrast is seen especially in units such as surgery, obstetrics, and critical care.
  • Level of experience (novice to expert): Staff who are experts in their area of practice are able to provide care at a lower HPPD than those who are new to the profession. New graduates bring new ideas and often new enthusiasm to the work environment, but they require perception and mentoring and are not as proficient at time management as the expert staff.
  • Education, preparation, and certification: When staff are highly educated and have achieved specialty certifications, it makes sense that they would be more efficient due to a higher level of decision-making skills and knowledge that does not require them to stop and locate information.
  • Tenure on the unit: Staff with longevity on one unit are more likely to work more efficiently and therefore reduce the HPPD. When units experience a large amount of turnover all at once, the unit productivity will suffer as the new team members learn the unit routines.
  • Level of control of practice environment: Discussed earlier in the unit function ­variances section, the more control the staff has over the practice environment, the more productive the unit becomes.
  • The number of competencies: Competencies are necessary in order to ensure patients are being cared for properly. The nurse leader needs to recognize that the more competencies, skills fairs, and similar events are required, the more HPPD this is going to require. Hospitals have attempted to streamline this information as best they can to decrease the amount of time needed and provide the education and assessment of learning necessary.


Organization-related variances

  • Effective and efficient support services: Who on the unit performs the functions of transport, clerical support, housekeeping, laboratory draws, and meal tray passes? If the answer is the staff members who report to the nurse leader's cost center, HPPD needed to provide patient care will increase. You can understand that a unit that is responsible for laboratory draws, passing meal trays, cleaning the patient refrigerator, performing echocardiograms, and transporting patients would have a much greater HPPD than a unit where these functions were done by other cost centers. This demonstration is a great example that the nurse leader can use when comparing to benchmark HPPD data.
  • Access to timely, accurate, relevant information: Having easy accessibility to previous medical records through an electronic medical record (EMR) is a good example of time-saving information. In comparison to having to call for medical records, locate the record, and physically bring it to the unit, an EMR where the patient's previous visit is a couple of clicks away saves an amazing amount of time.
  • Sufficient orientation: Allowing for sufficient orientation will require additional HPPD in the beginning but will pay off in the end. Sufficient orientation will reduce turnover, reduce errors, and provide for improved quality of care of the patients on the unit.
  • Preparation specific to technology: Technology such as an EMR not only requires more orientation time but often upgrades to the software on an annual basis. With the upgrades, additional training is sometimes required for the staff members who use the system. Again, this will increase the HPPD required.
  • Necessary time to collaborate with and supervise other staff: Time must be considered to coach, mentor, orient, and evaluate team members.
  • Support in ethical decision-making: Ethical decisions can be very time-consuming and stressful to the unit team. Departments who have support, either from pastoral care services or an ethics team, find that the bedside staff spend less time providing this type of support. Departments that naturally face a higher amount of ethical decision-making, such as a critical care unit, should consider how often they are faced with counseling.
  • Sufficient opportunity for care coordination: Care coordination between team members including nursing, pharmacy, dietary, case management, and physician staff needs to be considered and built into the HPPD. Patient populations with more complicated illnesses require more coordination than those who are less complex. A logical method for determining staffing levels and skill mix: When a staffing plan is developed based on logical, historical data and implemented, the unit will function with improved efficiency. The schedule should be completed based on the core number of staff needed to care for the average daily census of the patient population on the unit. Clear policy should direct the staffing, scheduling, and unit assignments. This level of organization will improve unit functioning and productivity.


The previous lists contain a lot of variables to consider when determining the need for HPPD. It is clear that the nurse leader who knows his or her department, patients, functions, and staff must be involved in the determination of the correct HPPD required for his or her unit. All of the aforementioned variables need to be considered when agreeing upon the budgeted HPPD to be used in unit staffing.