Transcript Discovering and shaping a career in public health and

Discovering and shaping a career in public
health and health policy
Jack Needleman, PhD FAAN
Department of Health Policy and Management
UCLA Fielding School of Public Health
October 15, 2013
A brief bio
 Education
 BS, City College, 1969, Political Science
 MA, Syracuse University, 1972, Political Science
 PhD, Harvard University, 1995, Public Policy
 Employment
 Lewin and Associates, 1973-1990
 Health Policy research and consulting firm
 Harvard School of Public Health, 1995-2003
 Department of Health Policy and Management
 University of California Los Angeles SPH, 2003-Present
Along the way
 17 years in health policy consulting
 Adjunct teacher at Georgetown U and American U
 3 first authored articles designated patient safety classics
by US Agency for Healthcare Research and Quality
 Additional patient safety classic
 100+ journal publications
 First AcademyHealth Health Services Research Impact
Award for research on quality of care and nurse staffing
 Asked to evaluate process improvement initiative
 Honorary Fellow of American Academy of Nursing
 Elected member of the Institute of Medicine
 Extensive experience on advisory committees for National
Quality Forum, Joint Commission, Centers for Medicare and
Medicaid Services and others
Partly planning, much serendipity
Three first authored patient safety classics
 Needleman, Buerhaus et al., “Nurse Staffing-Levels and
Quality of Care in Hospitals,” New England Journal of
Medicine, 2002
 Needleman, Buerhaus et al., “Nurse Staffing in Hospitals: Is
there a Business Case for Nursing,” Health Affairs, 2006
 Needleman, Buerhaus et al., “Nurse Staffing and Inpatient
Hospital Mortality,” New England Journal of Medicine, 2011
NURSING MATTERS
Nurses Impacts on Patient Outcomes
 Nurses’ work is core function of hospital care
 Have outpatient surgery, imaging, labs, therapy
 Only reason patient is hospitalized is they need nursing care
 Range of outcomes influenced by nurse staffing reflect
range of nurses’ work
 Delivering ordered care
 Assessment and monitoring
 Timely and appropriate intervention
 Coordination and patient management
 Patient education
 Because nurses involved in all aspects of care, interacting
with other care givers, identifying the contribution of
nursing to care, safety, quality, efficiency is difficult to
parse out
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New England Journal of Medicine, 2002
Sample: Low and High Staffed Hospitals
Needleman/Buerhaus
Low
High
Hospitals
399
400
Beds
201
252
Census
126
149
Licensed hours per day
7.5
10.4
Aide hours per day
2.3
2.6
RN as % Licensed
84%
90%
Staffing Specifications
5 Models * 2 (With & without interactions)
RN hours
LPN hours Aide hours (+interact’ns)
Total hours
RN %,
LPN %
Total hours
RN%
Aide %
Lic’d (RN+LPN) hrs RN%Lic
Aide hrs
RN hrs
NonRN hrs Aide%NonRN
When appropriate model is uncertain, look for robustness in results
Outcomes Associated with Nursing
Needleman/Buerhaus simulation results
Outcome
Models
Impact of
High RN
Impact of
High All
LOS
8 of 10
3-6%
3-12%
Urinary Tract Infection
6 of 10
4-12%
4-25%
Pneumonia
3 of 10
3-8%
2-17%
All
5%
3-10%
Shock
4 of 10
6-10%
7-13%
Failure to Rescue
(Surg)
5 of 10
4-6%
2-12%
Upper GI Bleed
The Business Case for Quality
 Discussions of the business case key off Leatherman,
Berwick et al, Health Affairs, 2003

“A business case for a health care improvement
intervention exists if the entity that invests in the intervention
realizes a financial return on its investment in a reasonable
time frame, using a reasonable rate of discounting. This may be
realized as “bankable dollars” (profit), a reduction in losses for a
given program or population, or avoided costs. In addition, a
business case may exist if the investing entity believes that a
positive indirect effect on organizational function and
sustainability will accrue within a reasonable time frame.”
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Needleman, Buerhaus, Business Case for Nursing
 Needleman, Buerhaus, NEJM, 2002 examined two
dimensions of staffing
 Hours/patient day
 RN/LPN mix
 Wide variation across hospitals
 Robust association of staffing variables and outcomes for:
 Medical patients: length of stay, urinary tract infection,
pneumonia, upper GI bleeding
 Surgical patients: failure to rescue
 Incorporated results into business case analysis in Health
Affairs, 2006 by estimating impact of moving lower staffed
hospitals up
 Updated in Needleman, PPNP, 2008, “Is What's Good For
The Patient Good For The Hospital? Aligning Incentives
And The Business Case For Nursing”
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Avoided Days and Adverse Outcomes Associated with Raising
Nurse Staffing to 75th Percentile
Estimates from Needleman/Buerhaus, Health Affairs, 2006
Avoided Days
Raise
RN
Proportion
Raise
Licensed
Hours
Do Both
1,507,493
2,598,339
4,106,315
59,938
10,813
70,416
4,997
1,801
6,754
Avoided Adverse Outcomes
Cardiac arrest and shock, pneumonia, upper gastrointestinal
bleeding, deep vein thrombosis, urinary tract infection
Avoided Deaths
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SOCIAL AND BUSINESS CASE FOR NURSING
Net Cost of Increasing Nurse Staffing
Estimates from Needleman/Buerhaus, Health Affairs, 2006
Raise RN
Proportion
Raise
Licensed
Hours
Both
Cost of higher nursing
$ 811 Million
$ 7.5 Billion
$ 8.5 Billion
Avoided costs (full cost)
$ 2.6 Billion
$ 4.3 Billion
$ 6.9 Billion
Long term cost increase
($ 1.8 Billion)
$ 3.2 Billion
$ 1.6 Billion
As % of hospital costs
-0.5%
0.8%
0.4%
Short term cost increase
(save 40% of average)
($ 2.4 Billion)
$ 5.8 Billion
$ 5.7 Billion
As % of hospital costs
-0.1%
1.5%
1.4%
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Conclusions from this analysis
 Increasing proportion of RNs without increasing hours
recovers its costs, even considering only variable costs
 Economic case
 Whether business case depends on whether hospital retains
savings
 For other two options, net costs are not recovered via direct
patient care savings
 But cost increases are relatively small, 1.5% if only variable
costs recovered, 0.4-0.8% if fixed costs recovered
 Context: MedPAC suggested 1-2% of Medicare payments
be set aside for performance incentives
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March 17, 2011
Objectives
 Address concerns raised about prior studies that questioned
relationship of staffing and patient outcomes, including
mortality:
 Cross-sectional studies comparing high and low staffed
hospitals
 Not clear that adverse outcomes associated with nursing
or unmeasured variables correlated to nursing
 Rough match to concept of “short staffed”
 Imprecise nurse staffing measurement
 Lack of adjustments for patient acuity
Funded by the Agency for HealthCare Research & Quality
We address these challenges by
 Examining association between mortality and day-to-day,
shift-to-shift variations in staffing at the unit level and
individual patient experience of “low” staffing
 Conducting study in a single institution that has:
 lower-than-expected mortality
 high average nurse staffing levels
 recognized for high quality by the Dartmouth Atlas, rankings
in U.S. News and World Report, and Magnet hospital
designation.
 Including extensive controls for potential sources of an
increased risk of death
 Patient diagnosis and surgical status
 Patient demographics
 Unit admitted to
Increased Risk of Death With Exposure to
Lower RN Staffing and Higher Patient Turnover
Key findings – Patient Mortality
 Increased risk of patient mortality significantly associated
with:
 Patient’s exposure to shifts 8 hours or more below target
 2% increase in risk/below target shift
 Patients exposure to high turnover units
 4% increase in risk/high turnover shift
 Robust to alternative specifications
 Even in a high quality hospital that generally meets its’
targets and manages patient turnover, and extensive
controls for the influence of other factors, we still could
detect the effects of staffing and high pt turnover
Implications for Hospital Management
 No free passes for hospitals with high average staffing
 Need to strive to hit targets every shift
 Findings should also apply to hospitals less successful in
routinely meeting nursing needs of patients
 Patients at higher average risk
 Operational implications
 Nursing service line, not just cost center
 Need systems for:
 Identifying target staffing
 Managing staffing against target
 Staffing for anticipated turnover
 Smoothing turnover
Career/life lessons
 Understand your passions
 Develop a sense of what is important
 Find and work with good colleagues and mentors
 Become a mentor
 Build networks
 Remain open
 New learning, new understanding, new opportunities
 Understand the purpose of your training and education
 Cronon, “Only Connect”