Matching Caregiver Ratios and Hours of Care to Work Intensity/Acuity

by ChrysMarie Suby RN, MS

Do you suspect that your budgeted RN-to-patient ratios and HPPD targets are inadequate? Follow this hypothetical example for how to justify a possible increase. 

Note: This illustrative example refers to the following two exhibits.

• Case Example: Hours of Care Benchmark Data
• Case Example: CMI, Actual/Target HPPD, and RN-to-Patient Ratos

Among the strategies that finance and nursing leadership consider when they must reduce costs is a reduction in caregivers and a reduction in the hours/unit of service, such as hours per patient day (HPPD). Such reductions must be measured against the potential impact to outcomes for both nurses and patients if the bedside nurse must now be the secretary, patient transporter, and “hunter and gatherer” for supplies and equipment. Adequately planning labor hours for support staff (indirect caregivers) will help to decrease total overtime, which we have found increases the risk for medical errors and patient falls. (“Identifying Root Sources of Overtime; Managing Your Overtime Plan; Taking Your Overtime Pulse; Non-Productive Replacement FTE Plan,” March 2007, Perspectives in Scheduling & Staffing, vol. XXVII, no. 2).

There are steps that nurse leaders can take with their executive leadership if they believe their patients or nurses are suffering due to unrealistic HPPD targets or caregiver-to-patient ratios. Here’s how one hypothetical nurse leader handled the situation.

Are These Targets Accurate?

The oncology/stem cell transplant unit manager at a large teaching hospital believed her unit could improve patient outcomes and relieve staff burnout by increasing HPPD targets and, thereby, increasing RN-to-patient ratios. The current unit HPPD target was based on an average oncology unit benchmark. The target RN-to-patient ratio was 1:5. But the oncology/stem cell transplant unit regularly cared for patients who needed greater levels of nursing care than typical general oncology patients did. The unit averaged 1 RN to 3.3 patients, and was coping with an average of 1.4 events per day requiring 1:1 RN-to-patient care.

The first step was to convince the hospital finance department that direct, indirect, and total worked HPPD targets should change. The nurse manager scheduled a meeting with the vice president of nursing and their contact in the finance department. Together the three-person team took several key steps to evaluate the oncology unit’s target values. 

Review patient placement criteria. The team talked with admitting/bed placement personnel to ensure that patients were being assigned to units that reflected similar diagnoses for stem cell transplants in terms of work intensity and/or acuity and the appropriate RN-to-patient ratios.

Review a 30- to 60- day history of patient admissions to the oncology/stem cell transplant unit. The team looked to see if these patients were more acutely ill than patients being admitted to the general oncology unit.

The team also checked to see whether the high-acuity patients on the oncology/stem cell transplant unit were predominantly coming from a single physician or physician group. This did not turn out to be the case with the oncology/stem cell transplant unit. However, this exercise had proved helpful with other units. One unit resolved its RN-to-patient ratio issues by encouraging physicians to cooperate with the placement of patients into units that could better serve their patients’ needs.

Benchmark HPPD. The team compared the oncology/stem cell transplant’s HPPD targets and actual worked hours against benchmark data from similar types of units, including bone marrow transplant, ICU, and step-down units. As shown in the exhibit, the oncology/stem cell transplant unit’s direct HPPD was more similar to the mid-range of HPPD for a step-down unit in intermediate care than for a general oncology unit in the medical-surgical unit group. 

To make sure they were comparing direct and total worked HPPD values, the team checked the formulas and glossary of terms being used by the company that provided the benchmark data.

Review a rolling three-year average case mix index (CMI). The team wanted to see if the patient population on the oncology/stem cell transplant unit was changing. Team members checked the unit’s CMI as a rolling three-year average to see if they could justify changing the unit’s true type from a general oncology unit (i.e, within the general medical-surgical unit group) to an intermediate or critical care unit. See the exhibit for the comparative data that the team reviewed. 

And the Decision Is …

The target direct and total worked HPPD for the oncology/stem cell transplant unit was higher than benchmark step-down units in the intermediate care unit group. Plus, the CMI was comparable to the step-down unit in intermediate care and the ICU in the critical care unit group.

When nursing and finance leaders compared these data, they were able to identify that the patient population for the oncology/stem cell transplant unit should be further evaluated for reassignment to the intermediate care unit group at a minimum and possibly the critical care unit group. This would allow leaders to set more realistic target HPPDs and RN-to-patient ratios in line with the patient population being served.