Discovering and shaping a career in public health and health policy - PowerPoint Presentation

1. Discovering and shaping a career in public health and health policyJack Needleman, PhD FAANDepartment of Health Policy and ManagementUCLA Fielding School of Public HealthOctober 15, 2013

2. A brief bioEducationBS, City College, 1969, Political ScienceMA, Syracuse University, 1972, Political SciencePhD, Harvard University, 1995, Public PolicyEmploymentLewin and Associates, 1973-1990Health Policy research and consulting firmHarvard School of Public Health, 1995-2003Department of Health Policy and ManagementUniversity of California Los Angeles SPH, 2003-Present

3. Along the way17 years in health policy consultingAdjunct teacher at Georgetown U and American U3 first authored articles designated patient safety classics by US Agency for Healthcare Research and QualityAdditional patient safety classic100+ journal publicationsFirst AcademyHealth Health Services Research Impact Award for research on quality of care and nurse staffingAsked to evaluate process improvement initiativeHonorary Fellow of American Academy of NursingElected member of the Institute of MedicineExtensive experience on advisory committees for National Quality Forum, Joint Commission, Centers for Medicare and Medicaid Services and othersPartly planning, much serendipity

4. Three first authored patient safety classicsNeedleman, Buerhaus et al., “Nurse Staffing-Levels and Quality of Care in Hospitals,” New England Journal of Medicine, 2002Needleman, Buerhaus et al., “Nurse Staffing in Hospitals: Is there a Business Case for Nursing,” Health Affairs, 2006Needleman, Buerhaus et al., “Nurse Staffing and Inpatient Hospital Mortality,” New England Journal of Medicine, 2011

5. 5NURSING MATTERSNurses Impacts on Patient OutcomesNurses’ work is core function of hospital careHave outpatient surgery, imaging, labs, therapyOnly reason patient is hospitalized is they need nursing careRange of outcomes influenced by nurse staffing reflect range of nurses’ workDelivering ordered careAssessment and monitoringTimely and appropriate interventionCoordination and patient managementPatient educationBecause 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

6. New England Journal of Medicine, 2002

7. Sample: Low and High Staffed Hospitals Needleman/BuerhausLowHighHospitals399400Beds201252Census126149Licensed hours per day7.510.4Aide hours per day2.32.6RN as % Licensed84%90%

8. Staffing Specifications5 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 hrsRN hrs NonRN hrs Aide%NonRNWhen appropriate model is uncertain, look for robustness in results

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10. Outcomes Associated with NursingNeedleman/Buerhaus simulation results

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12. 12The Business Case for QualityDiscussions 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.”

13. 13Needleman, Buerhaus, Business Case for NursingNeedleman, Buerhaus, NEJM, 2002 examined two dimensions of staffingHours/patient dayRN/LPN mixWide variation across hospitalsRobust association of staffing variables and outcomes for:Medical patients: length of stay, urinary tract infection, pneumonia, upper GI bleedingSurgical patients: failure to rescueIncorporated results into business case analysis in Health Affairs, 2006 by estimating impact of moving lower staffed hospitals upUpdated in Needleman, PPNP, 2008, “Is What's Good For The Patient Good For The Hospital? Aligning Incentives And The Business Case For Nursing”

14. 14Avoided Days and Adverse Outcomes Associated with Raising Nurse Staffing to 75th PercentileEstimates from Needleman/Buerhaus, Health Affairs, 2006 Raise RNProportionRaiseLicensedHoursDo BothAvoided Days1,507,493 2,598,339 4,106,315 Avoided Adverse OutcomesCardiac arrest and shock, pneumonia, upper gastrointestinal bleeding, deep vein thrombosis, urinary tract infection59,938 10,813 70,416 Avoided Deaths4,997 1,801 6,754

15. 15SOCIAL AND BUSINESS CASE FOR NURSINGNet Cost of Increasing Nurse Staffing Estimates from Needleman/Buerhaus, Health Affairs, 2006 Raise RN Proportion Raise Licensed HoursBothCost of higher nursing$ 811 Million$ 7.5 Billion$ 8.5 BillionAvoided costs (full cost)$ 2.6 Billion$ 4.3 Billion$ 6.9 BillionLong 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%

16. 16Conclusions from this analysisIncreasing proportion of RNs without increasing hours recovers its costs, even considering only variable costsEconomic caseWhether business case depends on whether hospital retains savingsFor other two options, net costs are not recovered via direct patient care savingsBut cost increases are relatively small, 1.5% if only variable costs recovered, 0.4-0.8% if fixed costs recoveredContext: MedPAC suggested 1-2% of Medicare payments be set aside for performance incentives

17. March 17, 2011

18. ObjectivesAddress concerns raised about prior studies that questioned relationship of staffing and patient outcomes, including mortality:Cross-sectional studies comparing high and low staffed hospitalsNot clear that adverse outcomes associated with nursing or unmeasured variables correlated to nursingRough match to concept of “short staffed”Imprecise nurse staffing measurementLack of adjustments for patient acuityFunded by the Agency for HealthCare Research & Quality

19. We address these challenges byExamining 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 mortalityhigh average nurse staffing levelsrecognized 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 deathPatient diagnosis and surgical statusPatient demographicsUnit admitted to

20. Increased Risk of Death With Exposure toLower RN Staffing and Higher Patient Turnover

21. Key findings – Patient MortalityIncreased risk of patient mortality significantly associated with:Patient’s exposure to shifts 8 hours or more below target2% increase in risk/below target shift Patients exposure to high turnover units4% increase in risk/high turnover shiftRobust to alternative specificationsEven 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

22. Implications for Hospital ManagementNo free passes for hospitals with high average staffingNeed to strive to hit targets every shiftFindings should also apply to hospitals less successful in routinely meeting nursing needs of patientsPatients at higher average riskOperational implicationsNursing service line, not just cost centerNeed systems for:Identifying target staffingManaging staffing against targetStaffing for anticipated turnoverSmoothing turnover

23. Career/life lessonsUnderstand your passionsDevelop a sense of what is importantFind and work with good colleagues and mentorsBecome a mentorBuild networksRemain openNew learning, new understanding, new opportunitiesUnderstand the purpose of your training and educationCronon, “Only Connect”