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Transcript of Web-assisted Teleconference (continued)

Session 3: What Do Workforce Issues Have to Do with Patient Safety?

Can You Minimize Health Care Costs by Improving Patient Safety?


Cindy DiBiasi: But all the things you have mentioned take money. How much are you estimating an increase in staffing will cost?

Jack Needleman: That is a very good question. I have got some estimates which I would at this point characterize as probably two steps away from back of the envelope and my colleagues and others are trying to improve them. But our rough estimates are that for a hospital to move from the 25th percentile to 75th percentile, from the middle of the bottom to the middle of the top, remember we used two different measures of nurse staffing. To simply keep the number of hours the same, we changed the R.N./L.P.N. mix. You are looking at a cost of about $15 a day, roughly a 2 percent increase. To both change that R.N./L.P.N. mix and then to move the number of hours up from the middle of the bottom to the middle of the top, we are probably looking at about $100 a day or roughly a 10 percent increase in hospital costs associated with upgrading the nurse staffing in a poorly staffed hospital.

Cindy DiBiasi: Jack, just to remind us again, that $15 a day and $100 a day, that translates into what benefits in terms of patient safety?

Jack Needleman: Well, clearly there are, it translates to shorter length of stay, it translates to reduced complications. Both of those have potential cost impacts for hospitals if you can get the patient out faster. If you are paid on a per discharge basis then you can get the patient out faster and that lowers your cost. You can save some money. Likewise you can lower the cost of treating complications that don't occur, you will save some money there as well. It is hard to know what that offset will be, but clearly the increases I talked about need to be balanced against those offsets and my colleague Peter Buerhaus and I have started some work with our data to try to estimate those cost offsets as well.

In addition to the benefits to hospitals, patients clearly benefit by reducing these complications. They have less time in the hospital. They will avoid the risk of death or the risk of discomfort while they are recuperating and I think there is going to be a tension as we debate how to move these issues forward between the benefits to patients which can be sizeable and the benefits to hospitals which are only the way we currently structure things associated with the actual direct reduction of costs within the hospital.

Cindy DiBiasi: Jack, we are going to be back to you in just a moment. We are also going to open up the discussion for questions from our listening audience because both of you have now instigated a lot of questions, I am sure.

Now before we open it up to questions I would like to talk a little bit about the mission of AHRQ. It is to develop and disseminate research-based information that will help clinicians and other health care stakeholders make decisions to improve health care quality and promote efficiency in the way that health care is delivered. As you will be hearing during the course of these Web-assisted audio conference calls, AHRQ has sponsored some very valuable research that is directly relevant to patient safety. AHRQ's User Liaison Program serves as a bridge between researchers and State and local policymakers. ULP not only brings research information to policymakers so that you are better informed, we bring your questions back to AHRQ researchers so they are aware of priorities at the State and local level. Hundreds of State and local officials participate in ULP workshops every year.

We will have videotapes of this Web-assisted audio conference, or rather audiotapes of this Web-assisted audio conference series available for purchase after all three events are completed. I will give further details about this at the end of today's show. You may request copies of the slides presented in this series by sending an E-mail message to info@ahrq.gov. Please indicate whether you would like the slides for the entire series or for specific presentations.

Finally, an archive of these events will also be available on the AHRQ/ULP Web site. The URL is http://www.ahrq.gov/news/ulpix.htm. That will be available several weeks from now.

We would appreciate any feedback about today's program. At the end of the broadcast a brief evaluation form will appear on your screen and easy-to-follow instructions are included on how to fill it out. Also you could E-mail your comments to the AHRQ User Liaison Program at info@ahrq.gov. Please feel free to call in and either talk to our operator and leave your question and I will repeat it on the air or you can ask to be put through directly.

In the meantime, I would like to ask our presenters a few questions. Jack, let me start with you. Why does the relationship between staffing shortages and patient outcomes seem to mainly concern registered nurses?

Jack Needleman: Well, we are not sure. I think there are several possible explanations to this. One is the registered nurses are in fact the largest nursing category and the one with the greatest variation in our data. Variation is what makes it possible to see the impact of staffing on outcomes. So that is one possible explanation. The second possible explanation is that the R.N. staffing is the most accurately measured of the three staffing categories that we use. Still a third possible explanation is preventing the outcomes that we looked at and examined draw on registered nurse skills.

Ed commented earlier on the emotional and physical aspects of the work of the health care workforce. I think that includes registered nurses. I think that people are familiar with that and understand that. What I think is less appreciated is the intellectual work involved in nursing care. In a community hospital the physician may be in the hospital very briefly during the day, see the patient briefly, leave instructions. The registered nurse has to implement that care plan, but is also the eyes and ears of the physician and the hospital in terms of tracking the patient's progress against expectations and is the person who has to blow the whistle, possibly intervene or call on others to intervene when things are not going right. A lot of the outcomes we are looking at really draw upon those skills of diagnosis and assessment that registered nurses bring to the bedside.

Having said that, I did hear one story from the field after our article appeared of a hospital that started cutting back on licensed practical nurses or aids on the argument that our research had found no association between those staffing levels and the patient outcomes. I think it is important to keep in mind we used only a limited set of outcomes. Others say some that may be particularly sensitive to registered nurses.

Also hospital nursing is organized around a team, even if the team is dominated by the registered nurse and one should be very careful about cutting back on membership in that team. It is not at all clear to me that you can cut back on those other categories with impunity.

Ed Salsberg: Jack, I have a question. You would think with your methodology used they would be difficult to get out, but the issue of how activities are shared between R.N.'s, L.P.N,'s and aids strikes me as an important issue. You mentioned the importance of the team. Particularly in facilities where there, or in areas of the nation where there may be shortages. The potential to look at how you use your registered nurses strikes me as a strategy that might allow for improvements in quality. In other words, just having a nurse, a nurse is not a nurse is a nurse, that how they are used, how the mix, how the team is put together would have an impact on quality.

Jack Needleman: I think that is absolutely right. In terms of some of the other things that are important to measure that are difficult to measure in the study we did are in fact the organization of nursing. AHRQ has some other research which is underway which is actually going to try to capture information about the way nursing is organized and see if that is associated with outcomes as well.

Cindy DiBiasi: I would like to get both of your opinions on this. What do you think are the implications of this study are for policymaking?

Jack Needleman: I guess, should I start since it relates to my study?

Cindy DiBiasi: Yes, go ahead.

Jack Needleman: I think clearly one of the implications is nursing matters to patient's safety in hospitals and that efforts that are underway to assure adequate nursing are absolutely legitimate. What the right solution to those problems are remains subject to and should be subject to substantial debate and discussion. Along that line we need to clearly define what adequacy of nursing is. That all relates to the issue of staffing.

With respect to outcomes and creating a climate of safety, many of the outcomes we were looking at, it is hard to go to a chart and say "Aha! That is what caused the urinary tract infection. It was this breakdown in care." So we need to pay more attention to actually monitoring the outcomes themselves. I think one of the implications of our research is that it is possible using datasets such as those that have been created by many States to effectively monitor nurse staffing, nursing-sensitive indicators as measures of patient safety in hospitals.

Cindy DiBiasi: Ed?

Ed Salsberg: One of the policy questions that policymakers are facing in response, and part a response to this study is should States or other organizations or the federal government for that matter, mandate a minimum staff/patient ratio? I think it is a dilemma States face. Jack, I don't know your perspective on this, but some of the concerns, while it seems to, Jack's study seems to show that higher staffing is associated with patient care. Does that therein mean that government should mandate a minimum staffing? One of the concerns that I have heard is that the case mix can vary so much that there is not a simple formula that you can translate the minimum nurse staffing or the relationship with nurse staffing to outcomes into a simple formula.

The other thing I should note is the Bureau of Labor Statistics has forecasted that between 2000 and 2010 that the nation is going to need an additional 500,000 nurses and some 500,000 or so nurses will be retiring. So in total, the nation would need a million additional nurses. It is going to be very difficult for us to do that, to meet that need. So I think we are going to be facing a situation where we have less nurses than we might ideally want. So I get concerned if the suggestions of mandating a minimum-staffing ratio when the nurses just aren't there which may mean that services might not be able to be offered at all.

Cindy DiBiasi: But what do you think we can do, what can States do to encourage more people to go into the nursing profession?

Ed Salsberg: I think States and the profession and the industry actually are doing a lot. I mentioned earlier, we have begun to see an upswing in the nursing school enrollment. A lot of States have offered scholarships. There has been a good deal of marketing. Johnson and Johnson actually undertook a major campaign that invested in marketing nursing careers. It is a very good campaign. The American Hospital Association had a commission on workforce shortages which I sat on which was a very good commission. It developed a set of recommendations that I think are good recommendations. It wasn't focused on public policy; those recommendations and the report was called In Our Hands, Sort of how hospital leaders can build a thriving workforce, really looked at what hospitals can do. So I think the nation is responding in a variety of ways.

My personal sense is that we will see an increase in supply over the next three to five years. My concern is really over the next ten and twenty years, will we be able to sustain it? I do think Jack's suggestion that there is a whole series of areas where we need additional research is really going to be critical in the long run to assure quality of care.

Cindy DiBiasi: Jack, let me ask you a tough question. Given Ed's scenario that maybe we are going to be in trouble 10-15 years from now or 10-20 years from now, what is our alternative? If we don't have enough nurses, then what?

Jack Needleman: OK. I think that scenario and the trouble that it highlighted is quite real. Let me back up and say there are two things that we need to do. One is we need to minimize how much that shortfall is. Ed's comments about some of the State actions that can be engaged in to expand supply I think are dead on. The only thing I would add to that is a substantial number of nurses are being trained right now in community colleges, two-year associate programs. It has become the major source of nursing. These are often sponsored by either State universities or local governments.

One of the real challenges in terms of expanding the nursing supply is to bring people who have not traditionally considered nursing into that workforce and making it easier for them to become trained. So I think those units of State government, the State universities, the community colleges and so forth that are involved in the training of nurses need to think about ways to expand educational opportunities in non-traditional ways to bring in people who were potentially working at other jobs full time, who have families, to find ways to enable people who have an interest in nursing to in fact get the training they need to become nurses. That is on the supply side.

On the demand side of the market here, I think one of the comments that Ed has made and that I have noted is that we have hospital working conditions that are not ideal for nursing. My sense of the field is that hospitals have become a much less congenial working environment for nurses over the last decade. That has got to be reversed and the AHA commission that Ed referred to recognized that very important need.

So the question is can States facilitate or encourage that set of activities? I believe there are some opportunities for States to do that through their licensing requirements, through their accreditation programs to really hold hospital's feet to the fire to be improving the working conditions so that patient care can work well. So both of those things should help increase the likelihood that a hospital can hire an R.N. and an R.N. will be available to be hired.

If the shortfalls are correct, if we are not going to be able to hire as many R.N.'s as we would ideally like in hospitals, hospital workforce is going to need to be reorganized around a different mix and different model of nursing. Truth to tell, that was tried by individual hospitals through the '90's and I think the results were generally considered poor. Many hospitals that looked to reduce the mix of R.N.'s in their nursing workforce have moved back to a higher level of R.N. staffing given some of the problems that they encountered in that earlier period. So work redesign for a smaller R.N. workforce is going to be a critical issue. Again that is an important area for research that State universities, because of their heavy involvement in nursing education, can really be in the lead in.

Ed Salsberg: Jack, I think you are right. States have tended to focus so far on the supply side. It is easier and more direct; they can provide scholarships. The number of States working at providing grants for faculty development, as you know there is concern about faculty, the aging of the faculty.

More difficult is the supply side and I am so pleased that the AHA report focused very much on the supply side, I'm sorry, on the demand and the use of workers. The other benefit of focusing some on the demand and the use side is I do think that has benefits around quality as well. Just producing more nurses will certainly help on the shortage, but does nothing to address those other issues that do impact on the quality of care.

There is also really a need, and this is another strategy that States need to think about, of investing more in education and training, continuing professional education training. As Jack mentioned, we have the majority of new nurses are two-year Associate degree nurses, yet the complexities of care are getting greater every year with each new development in medical intervention. Developing, creating more opportunities for registered nurses and others to go on and get continuing professional education, to move to the next degree level, would be helpful both to the nurses and to patients as well in terms of patient outcomes. So investing in that education is one of the strategies. I know that financing is tight. Unfortunately often facilities faced with tight budgets, one of the first things they cut out are the education and training programs. But I think if we are concerned with quality, we have to recognize that facilities and the States need to make this commitment. Ideally I think we should be saying, I don't know what the percentage is, but one or two or three percent of our investment in health care should really be going to continuing professional education.

Cindy DiBiasi: It is really an investment. There is a cost savings associated with this in the long run if you deal with the shortage. You are either going to pay now or pay later, right?

Ed Salsberg: Right.

Cindy DiBiasi: Let's talk a little bit about the cost savings. Jack, were you able to estimate the cost savings of increasing staffing in dollars?

Jack Needleman: Oh, you know I said my estimate of the cost increase of the staffing was two steps away from back in the envelope. My estimate of the cost offsets at this point are about half a step away from back in the envelope. But a real quick estimate of, and a really rough estimate of just the improvements associated with cutting length of stay suggested it covered around a third of the cost of the increased staffing. If we see similar offsets for some of the other complications, I am not going to say that increasing nursing will fully pay for itself, but it will go a long way towards paying for itself.

Cindy DiBiasi: OK. When you were doing your research, did you find any facilities that did not have shortages and were you able to learn anything from them?

Jack Needleman: Well, technically we all didn't look at shortages. We are comparing high and low facility, relative staffing levels in facilities. I can say that we saw a fair number of facilities that the absolute levels of staffing that were being reported at those facilities scare the heck out of me as I look at those numbers. I would not like to be in those hospitals.

Ed Salsberg: As I said, I just want to jump in, the AHA commission we looked at a number of models. One of the ones that people in the nursing field are certainly aware of are the magnet hospital models. They clearly seemed to have shown their ability to recruit and retain nurses better than other forms of organizing services. I think there are some models out there that work, that the industry can look at and that State leaders can look at.

Cindy DiBiasi: I know you conducted your study and you used State data for the study, but is the situation the same in all States? How can I know how bad the situation is in my particular State?

Jack Needleman: There are a couple of resources. One is there are these surveys of hospitals in terms of reports of numbers of vacancies and one can go and try to capture that information, capture it from the surveys. States have tremendous authority to obtain data from hospitals. Clearly hospitals are tightly staffed and one shouldn't abuse that authority. But on critical policy issues, it is important to do that. We did our work for the federal government using State databases and they were absolutely invaluable assets. It would not be unreasonable in this time of concern about working conditions for hospitals to routinely report to the State department of health or State licensure agency how many of their funded nursing positions are currently unfilled.

Ed Salsberg: I would jump in. It is clear that we generally lack good data on the workforce. In many ways we probably should have seen this current shortage coming. Nursing school enrollments dropped nearly a third nationally over a five-year period. A very sharp drop in a short period of time. We really haven't invested as much as we need to on collecting data on who the workforce is, where they are, what they are doing and to a certain extent their State of mind about their satisfaction with the job. It almost feels as if this nursing shortage suddenly came upon us; it was really brewing for several years if we had done a better job of collecting data.

Cindy DiBiasi: Have we identified the cause of, it is one thing for nurses to leave the profession, but why aren't new nurses coming into the profession?

Ed Salsberg: I think that there are a variety of reasons. Sometimes the industry and the profession may be hard on the industry. It is important to note that we have been growing as an industry so we really have not needed to stay equal; we have been really taking a larger share of workers. In many of the health professions that have been predominantly women, they are now competing with a whole, wide array of careers for women. As was mentioned, the jobs are difficult, these aren't easy jobs. In many cases, wages have not been competitive. The wage issue is a very important one for many of the paraprofessionals. I should add many of us who look at workforce shortages are equally concerned with the shortages of nurse aids and home health aids and we think that is going to be a very difficult long-term issue. There the wages and benefits are clearly an issue.

Another cause, contributing factor to the shortages in some of the professions has been the lack of diversity. We do not have men, enough men, in many of the health professions and we do not have adequate representation of racial and ethnic minorities. This is a negative in terms of the cause of the shortage. It is also an opportunity though to the extent we can expand our efforts at recruitment, there are many pools out there that we could seek to draw into the field to address some of those shortages. I do think expanding the diversity will also in the long run improve the quality of care.

Cindy DiBiasi: Now with, you can look at a crisis as a crisis or you can look at it as a potential opportunity. What opportunities, if any, do you see with this current workforce shortage?

Ed Salsberg: I think as I have tried to mention at the outset, there are a whole series of workforce issues that policymakers and the public needs to be concerned about. The shortage of workers is really allowing or forcing health leaders and elected officials to look at the workforce. I think if you look at the workforce clearly, the quality of care, it is not just a numbers issue. It is the quality of care issue. We have a large number of workers that are unhappy and frustrated and I think we can do more for the quality of their lives, which I think will also improve quality of care.

Some of the inefficiencies are created by not having the right workers in the right place with the right skills. So to the extent that we can address those issues, I think we can end up with more cost-effective care.

As I mentioned, workers are very frustrated about the time they spend on documentation and paperwork. If we can improve the information systems, that clearly will improve, increase worker satisfaction and improve quality. If we can reach out to those other pools of population groups, minorities and men, we can end up with a more culturally diverse workforce.

It is interesting, nursing enrollment is up, but there are other health professions, lab technicians and rad techs, where we are not yet seeing an increase in enrollment. So some of those programs which are actually urgently needed because we are going to need those workers, I think to the extent that we market health careers more effectively will help increase enrollment in some of those programs. So this is a crisis and I think it is a long-running crisis, but given that workers are really the cornerstones of the health care delivery system increased attention to the workforce is really a major step forward.

Cindy DiBiasi: Jack, when you were doing this study, did you find a lot of variation among hospitals and the RN staffing by the size of the hospital or where it was located or any other factors?

Jack Needleman: There were some regional differences in staffing and some differences in staffing by size and location in terms or urban or rural. But within each of those categories, we still saw really wide variation. We need research that helps us understand what accounts for some of the differences in staffing by individual hospitals. But we should recognize that there seems to be a fairly strong component of either management discretion in the way the hospital is staffed or local market-to-market variations in supply that might influence staffing decisions. That work really remains to be done.

Cindy DiBiasi: What other positions did you look at besides R.N.'s?

Jack Needleman: We looked at registered nurses, we looked at licensed practical nurses and we looked at aid level workers, assistive personnel and so forth which are all categories in that aid category. Getting data on aids actually proved to be very difficult. The American Hospital Association, which the American Hospital Association does an annual survey of hospitals which is one of the bedrock data sources for a whole variety of information about hospitals, has included information on staffing, questions on staffing, over a very long time period. In 1994, right around the time these issues were heating up, the AHA dropped from its survey questions about aid personnel in hospitals. We wound up going to State level data sets which States either collect financial reports from hospitals or collect staffing survey information from hospitals for the data source so that we would have information on aids and be able to understand what some of the impacts and interactions between aids and registered nurse staffing were.

Cindy DiBiasi: Did you focus specifically on hospitals?

Jack Needleman: We focused specifically on hospitals in this study. I know there are other researchers, both those that have published and those who have studied on the way they are looking at nursing homes and trying to address the same issues. Does the presence of aid staffing, does the presence of registered nurse staffing in the nursing home make a difference in patient outcomes or patient safety in the nursing home? The research I have read suggests that the answer to that question is yes as well.

Cindy DiBiasi: Ed, as you mentioned workforce shortages affect many settings of caring professions as Jack is implying, but are the shortages more critical in some areas than in others? Are we seeing that?

Ed Salsberg: Well, certainly some parts of the country have greater shortages. The hospital, nearly half the workers in America and about 59 percent of the nurses work in hospitals. So they are likely to feel, and they have a very broad array of professionals that work there, so hospitals are likely to feel the shortages. But clearly, it has really been widespread. Many homecare agencies have had to turn away patients or a delay giving care because of the lack of nurse aids or registered nurses.

Cindy DiBiasi: We have a caller. Joanne Rawlings-Sekunda, who is with the Bureau of Insurance in Maine.

Joanne Rawlings-Sekunda: Hi. This is a question for Ed. Hi Ed, how are you?

Ed Salsberg: Good.

Joanne Rawlings-Sekunda: I had two questions, actually. When you talked about diversity, I wanted to get your thoughts about importing nurses from other countries.

My second question is about pharmacists. Last year here in Maine we had a bill that pharmacists wanted to be included as health care practitioners, which are physicians and other practitioners that are certified registered to license in the healing arts. The bill didn't go anywhere, but the supporters were arguing that it would increase the pharmacist's status, which would therefore lessen this pharmacist shortage. My question on that is there any validity to that?

Ed Salsberg: OK. First on the immigration question, that is a good question. This nation has historically relied a good deal on immigration to fill a variety of workforce needs. There are concerns about using immigration in health care. Not that we haven't done it, but there are concerns that the individuals will not be adequately schooled and prepared in American modern health care and/or their cultural differences will be significant.

One of the concerns that others have had is it is not inexpensive to recruit overseas. It can cost a lot and that those funds really would be better spent invested in the workers that are here already. Even in something like the nursing shortage, I think there is probably no shortage of people who would like to be nurses, if we can provide them with the education at the times and locations and the support. So again, there is some concern about investing in immigration rather than in your own workforce and some concern about the quality of outcomes.

Having said that though, if you are a hospital administrator and you don't have any staff for nights and weekends, a program that is going to produce new nurses in three years doesn't help you and so I can understand why there is this tendency to look overseas. Again, I don't think it is a good long-term solution and it is much preferable to deal with the more fundamental issues about the nature of the job and the workforce supply issues.

On the pharmacy shortage, pharmacists are really, I think, very well respected as a health professional across the country. We are facing pharmacy shortages today partly because there is just really a true explosion in the use of pharmaceuticals in America. It is interesting that productivity of pharmacists has actually gone up quite sharply over the last several years, but America is just using so many pharmaceuticals that there is a shortage. I don't think the strategy around status is necessarily the answer.

Some people have also raised the fact that sort of unlike nursing, you have in pharmacy what is now, as you may know, pharmacy has moved to a doctorate as entry. That may make it tougher for some people to become a pharmacist. Then you have pharmacy techs, which are a very sort of low-end person who is an assistant and no middle ground. We may need to look at how we structure that workforce.

Another thing that is happening in pharmacy is that pharmacists are being used more to get more involved in patient care. I think that is a positive development to have them enter the patient care team, but it comes at a time when we are facing shortages. So we may need to look at an increase in the production of pharmacists in the country.


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