What Do Workforce Issues Have To Do With Patient Safety?

1. What Do Workforce Issues Have To Do With Patient Safety? Jack Needleman, Ph.D. Assistant Professor of Economics and Health Policy Department of Health Policy and Management Harvard School of Public Health Boston, MA

2. Higher RN staffing was associated with: • For medical patients: • Shorter length of stay • Lower rates of urinary tract infections, shock and cardiac arrest, upper gastrointestinal bleeding, pneumonia, and “failure to rescue” • For surgical patients: • Lower rates of “failure to rescue” and urinary tract infections • Source: Needleman, Buerhaus et al, “Nurse Staffing and Quality of Care in Hospitals,” NEJM, May 30, 2002

3. Measure RN hours/day RN hours as % Licensed hrs Mean 7.8 86% Minimum 2.0 49 Maximum 15.5 100 25th Percentile 6.4 81 75th Percentile 9.0 94 Variation in Hospital Staffing

4. Pool Outcome Reduction Medical Length of Stay 3.5%-5.2% Urinary Tract Infect 3.6%-9.0% Upper GI Bleed 5.1%-5.2% Pneumonia 6.4% Shock/Cardiac Arrest 9.4% Failure to Rescue 2.5% Surgical Urinary Tract Infect 4.9% Failure to Rescue 5.9% Estimate of increasing RN staffing from 25th to 75th percentile

5. Why these outcomes are important • Longer length of stay adds to cost, discomfort, may reflect other complications • Urinary tract infections common • Failure to rescue deaths among patients with serious complications • Pneumonia, upper GI bleed, shock/cardiac arrest have risk of death These impacts are lower bound estimates of effect of nursing

6. Other research needed • Quantifying impact of other factors influencing nursing’s impact on patients • Why staffing varies so much • Improvements in measures of nursing need of patients • How to improve hospital nursing work environment

7. Other factors potentially influencing nursing’s impact on patient outcomes • Working conditions • Nursing organization at unit level • Organizational culture & climate • Overtime • Physical organization of nursing unit • Technology

8. How much would increasing nursing cost • Rough estimate to move from 25th to 75th percentile: • Change RN/LP mix only: • $ 15/day ( 2% increase) • Change RN/LP mix and increase hours • $100/day (10% increase) • Estimates need further refinement

9. Potential cost offsets of increasing nursing • To hospital • Reduced costs of shorter length of stay • Reduced costs of treating complications • To patients • Lost time at hospital • Avoided death or discomfort • How to measure willingness to pay or value?

10. Why is the association observed with RNs, not LPNs or Aides? • Not sure. Possible explanations: • RNs largest nursing category, most variation • Preventing these outcomes draws on RN skills • Most accurately measured • Don’t draw conclusion that can cut back LPNs or Aides with impunity

11. Some implications for policy making • Nursing matters to patient safety in hospitals • Efforts to assure adequate nursing are legitimate • Adequacy needs to be clearly defined • Possible to monitor nursing sensitive indicators as measures of patient safety in hospitals

12. Quality and usefulness of state data • Used state discharge data sets and state staffing survey data. Invaluable assets • Improvements needed: • Discharge data • Present on admission coding of secondary diagnoses • Selected “must report” secondary diagnoses • Staffing data • Inpatient/outpatient split • Aide data