introduction to the challenges for hwf employment linking...
TRANSCRIPT
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Introduction to the challenges for HWF employment
Linking HWF and quality of care
Walter Sermeus, RN, PhD
Professor in Healthcare Management
KU Leuven
JAHWF
Rome, December 3-4, 2014
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Outline
• How good is the quality of our health system ?
• The role of HWF in delivering quality of care
• Investing in HWF, lessons from RN4CAST
o Employment: nurse staffing & innovation
o Skills: qualifications & scope of practice
o Health worker: work environment
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Quality of care and patient safety
• 44,000 – 98,000 deaths because of
“Adverse Events”
• 8e cause of death USA
• More than car accidents and breast
cancer
• IOM 1999: 5% - 5%
• Levinson 2010: 13,5% – 10%
Kohn et al. 2000; Levinson D., Department of Health, 2010
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How safe is healthcare?
L. Leape, 2001
1
10
100
1000
10000
100000
1 10 100 1000 10000 100000 1000000 10000000
Number of encounters for each fatality
To
tal
liv
es
lo
st
pe
r ye
ar
DANGEROUS
(> 1/1000)
REGULATED ULTRA-SAFE
(< 1/100K)
Bungee Jumping
Mountain
Climbing
Healthcare
Driving
Chartered Flights
Chemical Manufacturing
Scheduled Airlines
European
Railroads
Nuclear Power
Healthcare
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The six dimensions of quality of care
Quality
Patient Centered
Timely Equitable
Effective
EfficientSafe
IOM, Crossing the Quality Chasm, 2001
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Adjusted odds of death and 95% confidence intervals by day of procedure in English hospitals for 2008-9 to 2010-11.
Aylin P et al. BMJ 2013;346:bmj.f2424
Patient Centered
TimelyEquitabl
e
Effective
EfficientSafe
Timely ?
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Effectiveness ?
RAND:
- 30 conditions
- 439 indicators
- 54.9%
Patient Centered
TimelyEquitabl
e
Effective
EfficientSafe
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Equitable ?
Patient Centered
TimelyEquitabl
e
Effective
EfficientSafe
http://www.rightcare.nhs.uk/index.php/nhs-atlas/atlas-downloads/
7%
-
71%Ave=52%
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Efficiency ?
IOM, The Healthcare Imperative: lowering costs, improving outcomes, 2011
Patient Centered
TimelyEquitabl
e
Effective
EfficientSafe
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Patient-Centered?
Robert Francis Report:
• 400 – 1200 extra deaths
• Patients left uncared
• Too financial driven
executive board
Patient Centered
TimelyEquitabl
e
Effective
EfficientSafe
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Performance of health systems:
Generally poor
Quality
Patient Centered
Timely Equitable
Effective
EfficientSafe
IOM 2001
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How can we do it?
Why are we performing so poorly?
• We do not know what to do …
• If we know we don’t do it …
• If we do it, we don’t do it good enough …
Bohmer, R. (2009). Designing Care. Harvard Business Press, Boston, 261pp.
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Why? Theory of human factors
(Attention)
J. Reason, Cambridge University Press, 1990
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We do not know what to do …
• An analysis of different care pathways show that the existing evidence is not usedo CP Hip Arthoplasty: 19 EBM guidelines 100% - 26% (e.g. pre-op
physiotherapy session)
o CP Normal delivery: 41 EBM guidelines: 100% - 9%
(e.g.postnatal depression screening)
• Knowledge tests of nurses: scores between 20%-60% on prevention of wound infection, prevention of pressure sores, VAP guidelines, pharmacology, ….
Segal et al., JECP, 2011; Sarrechia et al., JAN, 2012; Dilles T, NET, 2010
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If we know we don’t do it
• Our memory is limited
• Low compliance to guidelines
• Low quality of patient documentation
o E.g. quality of nursing record documentation
• Poor/moderate (76%)accuracy of nursing diagnoses
documentation
• Poor/moderate (95%) accuracy of intervention documentation
(10 Dutch hospitals, 341 patient records)
Paans et al. 2010
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If we do it, we don’t do it
good enough …
Nurses’ work:
• Staccato work pace (av. task: 3 min)
• Mid task interruptions (8x/h)
• Patient shifts (157x/shift)
• Cognitive shifts (9x/h)
• High workloads
• Is leading to inaccuracies, errors, …
Tucker & Spear, HSR, 2006; Potter et al., AHQR, 2005
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Different factors
Latent failures Active failures
SYSTEM FACTORS PROCESS FACTORS
- Low staffing – high
Workload
- Long shifts, rotating
Shifts
- Agency/floating/
Temporary staff
- Poor lighting
- Emergency situations
- Patient transfers
- Safety Climate
-Distractions
-Interruptions
-Double check
procedures
-Technology
-Communication
-Complexity
HUMAN FACTORS
-Knowledge
-Skills
-Experience
-Fatigue
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Swiss cheese model - J. Reason
03/03/2002 16
Some holes due
to active failures
Other holes due to
latent conditions
(resident ‘pathogens’)
Successive layers of defences, barriers, & safeguards
Hazards
Losses
Safety Revisited :
Reason ‘s “Swiss cheese model” We can’t change the
humancondition,
but we can change theconditions
under which humans
work.
James Reason, 1990
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Date of download: 11/23/2014Berwick D, Hackbarth A, Eliminating Waste in US Healthcare, JAMA. 2012;307(14):1513-1516
Impact of the cost of low quality on GDP:
estimated +/- 3% GDP
Figure Legend:
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The way to go? Making prevention costs (e.g.
HWF) to decrease failure and overall costs.
20
Crosby Ph, Quality is free, 1979
HWF
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Investing in HWF? Lessons from RN4CAST
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Nurse Forecasting in Europe (RN4CAST)
• Largest Nurse Workforce study in Europe/world
o 12 European countries, 486 hospitals, 33731 nurses,
11318 patients, 422730 patient records
o Comparison with US, China, South-Africa data
o Acute hospitals, general medicine & surgery
o Nurse survey: nurse staffing and qualification levels,
nurses’ work environments, scope of practice,
o Patient survey: patients’ experiences with care of
doctors/nurses
o Analysis of hospital discharge summaries
o 2009-2011
o Reported in Lancet, BMJ, BMJ Q&S, IJNS, …
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Employment perspective
Nurse Staffing levels
Innovation
Skills perspective
Qualifications
Scope of Practice
Health worker perspective
Work environment
Investing in HWF
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Employment perspective
Nurse Staffing levels
Innovation
Skills perspective
Qualifications
Scope of Practice
Health worker perspective
Work environment
Investing in HWF
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Employment perspective:How many nurses do we need?
25
Aiken et al. 2014 The Lancet
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Significant effect of staffing and education
Aiken et al. 2014 The Lancet
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How many nurses do we need?
• High variability in nurse staffing in Europe: 5ppn (NO) – 13
ppn (ES)
• Evidence that nurse staffing and patient outcomes are
related: mortality, complication rates, LOS,….
• Current nurse staffing levels are not useful for
forecasting/planning purposes
• No single nursing staff-to-patient ratio can be
recommended* – context specific / more research
• Nurse staffing is not absolute, the cost-effectiveness
should be evaluated
* NICE, 2014, Safe staffing for nursing in adult inpatient wards in acute hospitals
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Cost-effectiveness of nurse staffing
• One RN more will generate 72% of her salary in medical
savings: less deaths, less complications, short length of
stay, less medical costs,…
• This is only a partial estimate of the economic value of
nursing, omitting the intangible benefits such as:
o of reduced pain and suffering by patients and family members;
o benefits to the hospital such as improved reputation, reduced
malpractice claims and payouts, and reduced compliance-related
costs;
o the benefits of increased staffing related to improved work
environment (e.g. reduced turnover)
Dall et al. 2009 Economic Value of Professional Nursing, review, Medical Care
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Moderator: capacity for innovation
• Support systems for human failure
• Technological innovation (ICT, EPR, reminder/alert
systems, ….)
• Clinical process innovation (care pathways, lean
management, redesign, communication tools, ….)
• Organizational innovation (integrated practice units IPUs,
integrated care delivery across organizations, care
coordination, clinical affiliates,…)
• ….
Porter M., Lee T., HBS, 2013; Levinson D., 2010
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Tomblin Murphy G et al., An applied simulation model for estimating the supply of
and requirements for registered nurses based on population health needs. Policy
Polit Nurs Pract. 2009 Nov;10(4):240-51.
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Employment perspective
Nurse Staffing levels
Innovation
Skills perspective
Qualifications
Scope of Practice
Health worker perspective
Work environment
Investing in HWF
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Skill perspective:What nurses do we need?
32
Aiken et al. 2014 The Lancet
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Significant effect of education
Aiken et al. 2014 The Lancet
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Skills perspective: Scope of practice
Care left undone in European hospitals
Ausserhofer et al. 2014 BMJ Q&S
LOWMEDIUMHIGHSTAFFING LEVELS
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Scope of practice: Nursing Care Left Undone because of Lack of Time
35
Ausserhofer et al. 2014 BMJ Q&S
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Skills perspective: qualification
• Economic evaluation of the 80% BSN nurse workforce
recommendations
• Design:
o Patient-level analysis of electronic data in 1 hospital
(USA)
o 8526 med-surgical patients, matched with 1477 direct
care nurses
• Results:
o Lower mortality (OR=0,89, p<0,01)
o Lower rate of readmissions (OR=0,81, p=0,04)
o Shorter length of stay (-2%, p=0,03)
Yakusheva, Lindrooth & Weiss, Medical Care, October 2014
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Skills perspective
• Impact of qualification on patient outcomes
• High variability on scope of practice of nurses across
Europe
• Depending on nurse staffing, availability of support staff, …
• Current division of labor: not useful to future predictions
and forecasts
• More research into task reallocation
o of medicine to nursing/allied health professionals
o of nursing/allied health professionals to non-qualified
staff and patients
Niezen M, Mathijssen J., Health Policy, 2014, 151-169
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Employment perspective
Nurse Staffing levels
Innovation
Skills perspective
Qualifications
Scope of Practice
Health worker perspective
Work environment
Investing in HWF
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Health worker perspective
• Existing evidence on effective HRM practices in healthcare
o Relation focused > task focused leadership style
o Focus on clinical autonomy, management support
o Interdisciplinary practice, relational coordination
• Impact on:
o Staff satisfaction with work, roles and pay
o Staff relationships with work
o Staff health & wellbeing
o Patient satisfaction and wellbeing
Gittell J. High perfomance healthcare, 2009; Cummings et al., IJNS, 2010
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Captures 5 dimensions:
� Staffing adequacy
� Nursing foundations for
quality
� Nurse manager ability &
leadership
� Nurse-physician relations
� Nurse involvement in
hospital affairs
Hospitals classified into
quartiles by PES scores
The reality check: Nurses’ work environment
40
0% 50% 100%
Belgium
Switzerland
Germany
Spain
Finland
Greece
Ireland
Netherlands
Norway
Poland
Sweden
England
Total
poor
mixed
better
Aiken et al., 2013 IJNS
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Hospitals with Better Work Environments: Lower Nurse Burnout, in every country
Best41
Aiken et al. 2012 BMJ
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Intention to leave hospital & profession
42
Heinen et al., IJNS, 2012
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Explaining factors for intention-to-leave the
profession
Factor Odds Ratio 95% BI
Nurse-Physician
Relationship
0,86 0,79-0,93
Leadership 0,76 0,70-0,86
Participation in hospital
affairs
0,68 0,61-0,76
Age (older) 1,13 1,07-1,20
Gender (female) 0,76 0,55-0,80
Hours/week (FT) 0,76 0,66-0,86
Burn-out 2,02 1,91-2,14
Heinen et al., IJNS, 2012
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Explaining migration from a practice
environment perspective
44
• Linking RN4CAST & Prometheus for Germany
• Destination countries: UK, NL, SE, NO, CH
• Source countries: PL, GR, ZA
Zander et al., IJNS, 2012
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Source countries worse than destination
countries: myth or reality?
45
Zander et al., IJNS, 2012
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Health worker perspective
• High variability on work environment and effective HRM
practices in Europe
• Current turn-over and migration data not useful if not
adjusted for work environment
• Improving work environment may have important impact
on:
o HWF retention
o HWF migration (between and within countries)
o Estimates of inflow and retention of HWF
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General conclusions
• Main focus of our health system is quality of care: safe,
effective, efficient, patient centered, timely and equitable
care
• Health workforce is a key-element
• Often seen as a cost, but should been as an investment
(preventive cost) leading to reduction of failure costs &
overall costs (impact estimated to be 3%)
• Key messages for discussion:
o Employment: Numbers & capacity for innovation
o Skills: Qualifications, skill mix, scope of practice
o Health worker: Work environment
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THANK YOU FOR YOUR ATTENTION
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