SAFE PATIENT MOVEMENT AND HANDLING: VHA NATIONAL PERSPECTIVE STEPS Office of Public Health and Environmental Hazards Office of Nursing Services Office of Patient Care Services Tampa PSCI

GOALS OF THIS TALK Champion reporting to satisfy VHA CO Executive Committee Deputy Under Secretary for Operations and management Health Systems Committee Deputy Under Secretary of Health Under Secretary of Health

REPORTING NEEDS: EX COM 10/1/08F/u on $61,000,000 funding NRM needs for June 08 $s 12/30/08Estimate of equipment funding Associated FY09 NRM funds Identification of facilities with structural assessment needs 3/331/09Equipment and NRM funding status Overall progress (Tampa data)

REPORTING NEEDS: DUSHOM FY09/Q1Facility-wide equipment inventory Identification of prior expenditures Unit-based hazard assessment FY09/Q2Policies, Procedures, protocols Review of injuries Initial peer leader training FY09/Q3Minimal lift policy FY09/Q4Facility strategic plan

Injury Rates by SIC Codes

Injury Type by Fiscal Year

# and Rate of Incidents by Skill Mix (from VANOD ASISTS proclarity cube on VSSC) Yellow = Total Emp Count Orange= # of Incidents Blue line= Calc. Rate

Incident Rate by Type of Incident (from VANOD ASISTS proclarity cube on VSSC)

Type of Incident by Skill Mix (from VANOD ASISTS proclarity cube on VSSC) Lifting & moving patients – most freq. reported injury

TOTAL AND PATIENT TRANSFER INJURIES BY GENDER

PATIENT TRANSFER INJURY RATES BY GENDER AND NURSING LEVEL

TOTAL INJURY RATES BY GENDER AND NURSING LEVEL

Patient Transfer Injury Rates and Age

WEAKNESSES INHERENT IN ANY BUSINESS CASE JUSTIFICATION APPROACH Under-reporting of injury and disease Attention and focus predict long- term consequences Horse-racing effect

SYSTEM NEEDS ASSESSMENT Data review and call to determine need –VSSC Review –DUSHOM ITEM Estimation of cost per dependent –Ceiling lifts –Movable equipment –Supplies Estimates by patient category BIRN Costs

BUSINESS CASE DEFINITIONS Conservative scenario Documented costs and benefits in VISN 8 More likely scenario Doubling costs (medical, wage loss) because of under-reporting (2001 AES) and 10% retraining / administrative costs More Likely Scenario with.1BIRN FTE Doubling costs (medical, wage loss) because of under-reporting (2001 AES) and 10% retraining / administrative costs and.1 FTE BIRN per high-risk unit over 10 years High Cost Scenario Medical and wage costs tripled (common private sector assumption

BUSINESS CASE CONSIDERATIONS: CALCULATIONS Payback period Net Present ValueInternal Rate of Return Conservative scenario 4.13 yrs$1.4M20% More likely scenario 3.39yrs$2.0 M27% More Likely Scenario with.1BIRN FTE 3.50yrs$1.19M25% High Cost Scenario 2.71yrs$2.6M33%

HISTORY OF SPMH in VHA Tampa program development 1999 HSR&D Tampa SPMH grant (expert panel) IOM Report: Safe Work in the 21 st Century VISN 8 Demonstration project st Conference on SPMH 2004 VISN 1 EDM and program roll-out Publications on economics VHA CO staff support for roll-out VISN 3, 9, 11 initiatives N data call on implementation initiatives 2007SPMH initiative for FY budget series 2008VA * OMB negotiations on 6 vs. 3 year roll-out Concurrence $61,500,000 distributed in June 2008

LESSONS RFOM PROGRAM IMPLEMENTATION IN 4 VISNs 2 years of VISN-level support.5 FTE facility staff support –Program equipment management –Peer safety leader leadership Peer Safety Leader functionality (“back injury resource nurses”, “injury prevention nurses”) –Essential element –Issues of fiscal support (“certification” vs step increases)

COSTS AND BENEFITS $150,000,000 - equipment and construction $4,000,000 / year - facility champions $5,000,000 / year – injury prevention nurses on each unit $10,000,000 – data system redesign / support ASISTS inadequate WARIMS application to IDMC

CONSIDERATIONS: Decision-making criteria Is program necessary: can VHA afford not to do it? Does the program pay for itself (when does the program pay for itself) What happens if we do not implement the program?

CONSIDERATIONS 1.Construction vs. medical programs (80% vs. 20%): need national assessment at facility / patient room level 2.VISN roll-out experience: 2 – 3 years of VISN support and planning 3.Facility-level program management: Staff support (program development, leading assessment, equipment maintenance, peer safety leader training and coordination) Likely ~$4,300,000 / year

CONSIDERATIONS 4.Facility level – front-line worker support – peer and coordination) (.1 peer safety leader/injury prevention nurse / shift): $~$5,000,000 / year 5.IT Support: ASISTS does not address unit level rates, instrumentation/ equipment / track intervention recommendations (Accident Review Board solutions) 6.Roll-out timing: VISN, facility staffing; facility-level assessment, equipment

CONSIDERATIONS 7.Prior expenditures and early adopters: reimbursement issues (10N solution: include information on actual equipment/construction expenditures) 8.Budget shifts 1.Initial estimates: no facility- or unit level coordination 2.$16,000,000 in initial draft for 3 years of unit- level peer safety leaders 3.Move to 6 years: inadequate funding

CONSIDERATIONS 9.First year funds expenditures: 1.Universally needed equipment (lateral sliding devices ~ $15,000,000) 2.$4,300,000 facility level staffing 3.Reimbursement (10N model) 10.Program oversight in CO 11.Future delays and reimbursement: consequences of 6-year implementation delay and impatience in the field

OPTIONS Option 1: $30,000,000 / yr x 6 –VHA CO staff support, national assessment, facility level support, devolution of program to 10N in ~3 years Option 2: assign moneys to VISNs without oversight Option 3: do nothing

REPORTING NEEDS 10/1/08F/u on $61,000,000 funding NRM needs for June 08 $s 12/30/08Estimate of equipment funding Associated FY09 NRM funds Identification of facilities with structural assessment needs 3/331/09Equipment and NRM funding status Overall progress (Tampa data)