The terms “outdated” and “gross, anachronistic” don’t conjure up positive feelings. Yet, those were the reactions from healthcare leaders when asked about “nursing productivity” in the U.S., as released in a recent UKG study, Rethinking Nursing Productivity to Enhance Organizational Performance. It’s possible that these concerns stem from the idea that nursing productivity alludes to cost cutting at the expense of patient care. But that’s counterintuitive to why healthcare workers enter the field: Nursing leaders genuinely want to provide the best possible patient care. So, the important question is: How do you improve nursing productivity while also improving patient care?
As I introduced in the first part of this series, patient-centric productivity is not about cost cutting but about making the most of limited resources and ensuring they are oriented toward delivering the highest quality care. In this second part, we’ll explore how productivity and patient care support one another, particularly as it relates to bedside nursing—or face-to-face patient interaction.
Step 1: Transition to a Flexible Model Budget
The first step to calculating patient-centric productivity is to transition from a fixed budget to more flexible models centered around patient needs. Today, many healthcare organizations still hold their departments responsible to fixed budgets, which is not only an ineffective way of measuring productivity, but it communicates that productivity is just about meeting a number and is independent from the needs of their patients. In reality, the workload fluctuates based on the number of patients being cared for and each patient’s needs, so staffing levels should reflect that. Adopting a variable budget based on the number of patients in the unit is a minimum requirement for patient-centric productivity—even better is a budget that’s based on individual patient workload and their required level of care.
Step 2: Measure Nursing Productivity
Nursing productivity is defined as matching caregiver supply to demand. This is often expressed as a productivity or utilization percentage: hours demanded divided by hours supplied. Calculating hours supplied is relatively straightforward. For nursing productivity, generally only direct care hours are considered. Staff nurses working regular bedside shifts are relatively simple to calculate because usually all their worked hours are considered direct care hours. Charge nurses can be a little more complicated because typically only a portion of their hours are considered direct care.
There are two basic methods of calculating patient demand: a method that considers individual patient needs (acuity or intensity) and one that does not. Both methods allow an organization to staff according to patient demand on a department level. However, only one considers individual patient needs to ensure optimal patient-centric productivity down to the individual caregiver level (more on that later). Either way, an organization must determine how many hours of care their patients require and this is generally done by determining “hours per patient day” (HPPD) or similar for each department or individual patient. This indicates how many hours of care patients require. For the organizations using acuity or intensity levels, each patient will have a different requirement whereas those who do not use acuity or intensity levels will have the same requirement for each patient. HPPD projects the demand and direct patient care hours is the supply. It is vital that clinical data is used to determine HPPD because this serves as the foundation for patient-centric productivity. HPPD should never be determined using last year’s actuals, especially since many healthcare organizations have been chronically understaffed. Using past data as a projection may prolong understaffing. HPPD should always be determined with meeting patient needs as the target.
Now that we’ve discussed how caregiver supply and demand are calculated, we can calculate productivity by dividing hours demanded by hours supplied. Let’s say a nursing unit has 20 patients that require 60 hours of care during a 12-hour shift and the unit has 5 caregivers who work that 12-hour shift for a total of 60 hours. That unit is 100% productive because their patients required 60 hours of care and they supplied 60 hours of care (60/60=1[100%]). But if they only have 4 caregivers providing 48 hours of care, they are understaffed and 125% productive (60/48=1.25). Conversely, if they provide 6 caregivers and 72 hours, they are overstaffed and 83% productive (60/72=.86). The goal is 100% but most organizations set a target range of 90-110% or 95-105%. Achieving this department-level productivity target is the first step in using productivity to meet patient needs.
Improving productivity and improving patient care can and should be part of the same conversation.
Step 3: Determine When to Measure Productivity
However, measuring productivity at the department level on a monthly or weekly basis isn’t enough. It is vital that productivity is analyzed at every level of the organization—from the facility to the department to the unit all the way down to the individual. It is equally important that we analyze productivity at the shortest possible time interval. Failing to do so can result in missed fluctuations in productivity that occur at lower levels or shorter time intervals.
As discussed in my previous post, a department can achieve 100% productivity during a given month but can do so inequitably, where some days are over 150% and other days are under 50%. If they are only evaluating productivity monthly, they would appear successful but the nurses working on the floor would know something isn’t right. They would feel overworked and unable to provide the best patient care on the days they are at 150%. This could lead them to conclude that measuring productivity is worthless or even harmful. They can even be 100% productive during a given day but do so with the night shift at 50% and the day shift at 150%. At minimum, each shift should be analyzed and adjusted accordingly but even shorter intervals are better (such as 4-hour blocks). Many organizations now evaluate and adjust staffing levels multiple times per shift. This ensures that patient needs are met as they fluctuate throughout the shift while ensuring caregivers are not overworked.
Step 4: Consider the Details
Even if a department is achieving their productivity goals in every 4-hour block, it is still possible to have inequitable caregiver assignments. They can even have inequitable assignments if each caregiver has the same number of patients. This is why it is important to measure productivity down to the caregiver level and to understand the level of care each individual patient requires. If a caregiver works a 12-hour shift while their five patients require 15 hours of care, they are overworked and 125% productive (15/12=125). This might happen while another caregiver is underworked with the same number of patients. Their five patients might only require 8 hours of care: 67% productive (8/12=0.67). This is why it is vital to any organization’s patient-centric productivity initiative that they have an assignment tool that calculates individual patients’ workload requirements. Assignments can be adjusted so all caregivers’ workloads are as close to equal as possible so they are able to provide the best possible care to their patients. In this example, adjusting patient assignments would not result in any additional expense to an organization but still have a significant positive impact on patient care, patient satisfaction, and staff satisfaction. Expand this concept to an entire organization and the impact can be substantial.
Conclusion: A Win-Win Situation
Ensuring that organizations accurately capture patient demand considering all its fluctuations over time, between departments, between shifts, and between individual patients is essential to patient-centric productivity. Missing any possible inequity can lead to sub-optimal staffing and decreased patient care, patient outcomes, and staff satisfaction. Productivity initiatives that foster patient-centricity are more likely to resonate throughout all levels of the organization and can help avoid the negative reactions to the term “productivity” uncovered in our study—instead of “outdated” and “anachronistic” let’s aim for “modern” and “up-to-date.” Patients should always be at the center of everything we do in healthcare even when it comes to improving productivity. Improving productivity and improving patient care can and should be part of the same conversation.