Discovering and shaping a career in public health and health policy Jack Needleman, PhD FAAN Department of Health Policy and Management UCLA Fielding School.

Discovering and shaping a career in public health and health policy

Jack Needleman, PhD FAANDepartment 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

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NURSING MATTERSNurses 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

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 NursingNeedleman/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%

Upper GI Bleed All 5% 3-10%

Shock 4 of 10 6-10% 7-13%

Failure to Rescue (Surg)

5 of 10 4-6% 2-12%

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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 PercentileEstimates from Needleman/Buerhaus, Health Affairs, 2006

Raise RN

Proportion

RaiseLicensed

Hours Do Both

Avoided Days 1,507,493 2,598,339 4,106,315

Avoided Adverse OutcomesCardiac arrest and shock, pneumonia, upper gastrointestinal

bleeding, deep vein thrombosis, urinary tract infection 59,938 10,813 70,416

Avoided Deaths 4,997 1,801 6,754

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SOCIAL AND BUSINESS CASE FOR NURSINGNet 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

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 toLower 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”