A Micro-Costing or 'Bottom-Up' Approach to Measuring Nursing Costs Using Data From Electronic Health Records

John M. Welton, PhD, RN, FAAN; Peggy Jenkins, PhD, RN; Marcelo Coca Perraillon, PhD

Disclosures

Nurs Econ. 2018;36(1):46-48. 

In This Article

Data Structure and Time Measurement

The starting point for creating a micro-costing measurement of nursing care is with measuring the unique time each nurse and other nursing personnel spends with each patient from data from the EHR. This can be established using the nurse-to-patient assignment (e.g., a nurse caring for four patients in a 12-hour shift provides on average 3 hours of care for each patient) (Welton, Zone-Smith, & Bandyopadhyay, 2009). Capturing the assignment in the EHR provides a means to allocate nursing intensity based on staffing patterns.

Because patients often have different care needs and as a result nurses may spend more time with any single patient, a nursing acuity tool can be used to allocate nursing care hours to each patient from the assignment based on relative differences in demand for nursing care (Garcia, 2017). In the assignment above, a nurse could expend 6 hours for one patient and 2 hours for each of the other patients; therefore, a nursing acuity tool is used to reallocate time accordingly. With this information in place, a bottom-up or micro-costing approach to measure nursing intensity by patient is straightforward. The actual nursing time provided to each patient is multiplied by either the actual or mean wage as well as other direct-care costs such as shift differential. The contribution of other nursing personnel such as LPN/LVN or nursing assistant can be included in the actual costs of care in the same manner.

These are the direct costs of nursing care or the actual time and resources expended for each patient. Other nursing personnel costs are not directly allocable to each patient (e.g., a charge nurse who may not take assignments or clinical nurse specialists who work with nurses providing care). Other nursing costs not directly allocable to an individual patient include hours worked but the nurse is involved with in-service education or orientation. These can be viewed as direct costs which benefit the patient but cannot be directly assigned.

A third component of nursing costs are those that are not actually worked, but incurred as a benefit such as vacation or sick time, or obligation such as jury duty or military leave. These indirect nursing costs add to the overall cost of nursing care and must be considered and monitored. When all costs are identified and linked to each patient, we can more fully understand both the actual or true costs of nursing care provided to each patient. When linked to each patient and the additional data that can be extracted from the patient record in the EHR such as DRG, LOS, patient demographics, or hospital outcome, we can better understand how nursing care resources are uniquely expended for each patient and what patterns can be identified from the data. For example, do older patients need more nursing care than younger patients for the same DRG? Does a higher skill mix of registered nurses, and the higher cost of that skill mix, produce better clinical outcomes which reduces overall costs of health care? Which patients consume more nursing care than others and can we identify these nursing intensity outliers early in the trajectory of a hospitalization and provide more comprehensive and ultimately less costly care?

processing....