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

Higher RN staffing was associated with: For medical patients: 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: 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 Source: Needleman, Buerhaus et al, “Nurse Staffing and Quality of Care in Hospitals,” NEJM, May 30, 2002

Variation in Hospital Staffing th Percentile th Percentile Maximum Minimum 86% 86% Mean RN hours as % Licensed hrs RN hours/day Measure

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

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

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

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

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

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

Why is the association observed with RNs, not LPNs or Aides? Not sure. Possible explanations: 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 Don’t draw conclusion that can cut back LPNs or Aides with impunity

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

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