NR 532 Week 7 Productivity Report Review Example

Productivity Report Review: Fewer Hours Worked in October and a Worse Hours-per-Patient-Day Figure Anyway, Explained by the Observation Patients the Denominator Stopped Counting

Student Name

College of Nursing, Chamberlain University

NR 532: Healthcare Operational Planning and Management

Instructor Name

Month Day, Year

Productivity Report Review: Fewer Hours Worked in October and a Worse Hours-per-Patient-Day Figure Anyway, Explained by the Observation Patients the Denominator Stopped Counting

Summary for the Finance Reader

In October the spine and neurosurgery unit worked 5,620 hours, 90 fewer than in September, yet its worked hours per patient day rose from 9.60 to 10.11, against a target of 9.70. The unit did not become less efficient. The figure is a fraction, and its bottom moved: inpatient days fell from 595 to 556 because 71 patients who would previously have been admitted as inpatients were placed in observation status after a change in how the surgeons' office registered single-level decompressions. Those patients occupied beds and used nursing hours, but observation hours are not counted as patient days. Counting them as equivalent patient days, the unit's October figure is 8.88, well under target. I recommend that the productivity report add observation hours to the unit of service from November. The remainder of this review shows the arithmetic.

The Report as Issued

The monthly productivity report measures worked hours per patient day: productive nursing hours, meaning registered nurse, technician and unit clerk hours worked on the unit, divided by inpatient days. Table 1 shows the September and October figures as issued.

Table 1

Productivity Report, September and October

What Changed in October

On October 1, the surgeons' office began registering most patients undergoing single-level lumbar decompression as outpatients in observation status rather than as inpatients, following a payer review of short stays. The patients themselves did not change, and nor did their surgeons, their procedures or the nurses caring for them. They arrived from the recovery unit in the afternoon, received the same neurological checks, pain management, first mobilization and discharge teaching, and most went home the next day. The average observation stay was 26 hours.

Observation status has grown across hospitals in the last two decades. A study of Medicare enrollees documented a sharp rise in hospital stays classified as observation and raised concerns about the causes and consequences for patients (Feng et al., 2012). At one academic medical center, observation stays made up about a tenth of all stays, with a mean length of 33 hours, and many were indistinguishable from short inpatient stays (Sheehy et al., 2013). Our October change is a local example of the same shift. It changes the billing category, not the nursing work. It does change something for patients. Observation stays are billed as outpatient care, so patients may face different cost sharing, and older adults who need a skilled nursing stay afterward may find that observation days do not count toward the inpatient stay that coverage requires. Those issues belong to case management and the surgeons' office rather than to a productivity report, but a manager who notices a sudden rise in observation status should raise them.

Recalculating the Denominator

The standard way to include observation patients in a productivity measure is to convert observation hours into equivalent patient days by dividing by 24. In October, 1,846 observation hours equal about 77 equivalent patient days. Adding them to 556 inpatient days gives 633 equivalent days. The unit's 5,620 worked hours divided by 633 gives 8.88 hours per equivalent patient day.

The same correction for September, with 310 observation hours or about 13 equivalent days, gives 5,710 divided by 608, or 9.39. On a like-for-like basis, the unit's productivity improved from September to October, from 9.39 to 8.88. Part of that improvement comes from the short observation stays themselves, since patients who stay one night generate their nursing work in a compressed period and are counted for only about a day.

Why the Report Should Change

Nurse managers are held to productivity measures, and a measure should move when the work moves. Financial management texts for nurse managers describe hours per patient day as a ratio whose meaning depends entirely on a unit of service that reflects the workload (Finkler et al., 2013). When a large share of patients is excluded from the unit of service, the measure no longer describes the unit's efficiency. If the report is left as it is, the unit will appear to be over target every month from now on, and the likely response, cutting hours to bring the figure down, would reduce staffing for patients who are still in beds. A productivity figure that is wrong in a consistent direction is worse than no figure, because it produces confident decisions. The finance office has corrected similar distortions before, for example when the hospital began counting newborns separately from mothers, so the change requested here has a precedent.

The distortion will also grow. The surgeons' office expects to register more short-stay procedures as observation over the next year. If 90 observation stays a month become typical, the uncorrected figure would reach about 10.5 hours per patient day with no change in work at all.

What the Correction Does Not Hide

The corrected figure should not become a reason to ignore real problems. Two are visible even after the correction. First, October's evening shifts on Tuesday through Thursday ran 64 hours over the grid because of recovery holds and late discharges, as the unit's flow analysis showed. Those hours are real overuse, and the discharge timing plan addresses them. Second, observation patients may need more nursing hours per equivalent day than inpatients, because their whole stay is arrival and discharge. If so, a unit with many observation patients will always look busier than its equivalent days suggest, and the target itself may need review after three months of corrected data.

Action

I am asking the finance department to add observation hours, converted to equivalent patient days, to the unit of service in the productivity report from November, and to restate September and October on the same basis for comparison. I am also asking for a separate line showing observation stays and hours each month, so that the effect of registration changes remains visible. In the unit, I will continue to review evening overtime weekly against the grid. I will report back in February with three months of corrected figures and a recommendation on whether the 9.70 target should change for a unit whose patients are increasingly short-stay.

References

Feng, Z., Wright, B., & Mor, V. (2012). Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Affairs, 31(6), 1251-1259. https://doi.org/10.1377/hlthaff.2012.0129

Finkler, S. A., Jones, C. B., & Kovner, C. T. (2013). Financial management for nurse managers and executives (4th ed.). Elsevier.

Sheehy, A. M., Graf, B., Gangireddy, S., Hoffman, R., Ehlenbach, M., Heidke, C., Fields, S., Liegel, B., & Jacobs, E. A. (2013). Hospitalized but not admitted: Characteristics of patients with "observation status" at an academic medical center. JAMA Internal Medicine, 173(21), 1991-1998. https://doi.org/10.1001/jamainternmed.2013.8185