This Web-assisted audio teleconference consisted of three sessions broadcast via the World Wide Web and telephone September 20, 30, and October 1, 2002. The program explored the business case for patient safety, how to overcome barriers, and practical solutions to help States and health care facilities improve patient safety. The User Liaison Program of the Agency for Health Care Research and Quality (AHRQ) developed and sponsored the program.
Cindy DiBiasi: Good afternoon and welcome to "Can You Minimize Health Care Costs by Improving Patient Safety?" This is the final of three Web-assisted audio conferences on this topic developed for State and local health policymakers and sponsored by the User Liaison Program within AHRQ, the Agency for Healthcare Research and Quality at the U.S. Department of Health and Human Services. My name is Cindy DiBiasi and I will be moderating today's session entitled, "What Do Workforce Issues Have To Do With Patient Safety?"
This is the final event of this Web-assisted audio conference series on addressing obstacles and developing sensible solutions to improve patient safety. We are focusing on the issue of patient safety during a time of shrinking budgets and fiscal constraints because it has been shown that improving patient safety not only improves the quality of care, it may also contain costs. As we will discuss today, patient safety is also related to the immediate crisis of workforce shortages that many States currently face.
AHRQ, in its capacity as a Federal agency, is playing an important role in supporting research and providing policymakers with information and tools to improve patient safety. State and local policymakers also play a critical role in addressing this issue. The goal of this series is to provide State and local policymakers and program administrators with insights regarding the business case for patient safety and methods to address obstacles to implement sensible solutions to help States and health care facilities improve the safety.
Let me briefly review the previous two calls in this Web-assisted audio conference series. On our first call on September 20, we discussed the business case for patient safety. We looked at the human and financial cost of errors and the potential cost savings from reducing errors. Yesterday on our call we discussed concrete actions to improve patient safety. We explored the issues, opportunities and strategies to create a culture of safety within health care institutions. We also discussed ways in which the Federal, State and local government can help facilitate this effort.
Today's call is entitled "What Do Workforce Issues Have to Do With Patient Safety?" We will examine the relationship between workforce issues and patient safety and specifically the link between health care shortages and medical errors. The call will highlight State approaches to addressing workforce shortages and recent research findings on this topic.
Now I think we are ready to turn to the important issue of patient safety. As I said today, we will take a closer look at the relationship between workforce issues and patient safety. Let me introduce you to today's panelists. In the studio with me I have Edward Salsberg, director of the Center for Health Workforce Studies at the University of Albany, SUNY. And joining us remotely from Boston is Jack Needleman, assistant professor of economics and health policy at the Harvard School of Public Health. Welcome Ed and Jack.
Ed, let's begin with you, director for the Center for Health Workforce Studies. How do workforce issues really affect patient safety?
Ed Salsberg: First, let me just say I think that the basic premise about the health workforce and patient safety is that the health workers are really critical to the delivery of health care. Clearly they are the cornerstones. Your health care delivery system is only as good as your workers are. So workers really directly impact on cost, quality and outcomes. I think there are several issues around the workforce that impact on patient safety.
We have had the most discussion lately about workforce shortages and staffing, but it truly goes beyond shortages and staffing. The basic education and training of health professionals and continuing professional education clearly impacts on the quality of care. The supervision and feedback that workers get are really critical as well. Less talked about is job satisfaction. Clearly, that if workers are unhappy, if they are feeling stressed and burnt out then the quality can suffer. As can turnover and problems with retention will impact on quality. Finally, I think the lack of cultural competency and diversity is another factor that can impact on the quality of health care and patient safety.
Cindy DiBiasi: There are other workforce factors that affect patient safety.
Ed Salsberg: Yes, these are really what I think are the main factors that impact. The whole job design area is also another major area impacting on the workforce and on patient safety.
Cindy DiBiasi: What actions do you think are needed to address these workforce issues and the quality of care problems?
Ed Salsberg: Well, I think there are a number of things that need to be done to address the adequacy of supply. We can talk about that a little later, perhaps. Clearly States and the health industry are concerned with shortages and they are looking at what strategies, what States can do. Beyond that I think it is really critical to create a work environment that is responsive to the workforce, that providers and health facilities need to listen to their workers and they get feedback from the workers about what their needs are to improve quality.
We need to assure that there has been appropriate education and training. We need to design a system that provides continuing professional education in response to problems are identified. Facilities can use their professional education, continuing professional education to try and respond to where they find problems and outcomes and quality.
We probably also need to invest more in information systems. There is a lack of effective information systems and the time spent on paperwork are extremely frustrating to workers and I think also simultaneously impact on the quality of care.
Finally I would add that I think we need to invest more in the training of our managers and supervisors. We sort of assume that if an individual is a good professional, whatever that profession is, they can move up and become a good manager. Clearly a lot of workers are very frustrated with the management and supervision they are receiving. So I think investing in managers and supervisors is another strategy that will both address shortages and quality.
Cindy DiBiasi: So you talked about the workforce shortage as being a factor, but how serious are the current workforce shortages?
Ed Salsberg: I think the shortages are really quite serious. They are widespread across the country. Truly almost in every State. We have found that in 46 States they have created task forces or commissions in response to shortages so it really is widespread. There has been discussion about long-term care but clearly also hospitals and home care. So in almost every setting that services are delivered. I think the extensiveness of the shortages is seen by the wide range of professions that people are concerned about, so we are facing shortages with pharmacists and dentists, which obviously are at the high-end of education. We have shortages in rad techs and lab techs in the mid-range and nurses. But we also have shortages of home health aids and nurse aids so it is really a very, very widespread set of shortages that the nation is now encountering.
Cindy DiBiasi: How did the workforce shortages specifically affect patient safety?
Ed Salsberg: Well again I think if you are understaffed, if you have too few staff, clearly the workers that are there are going to feel stressed and burnt out. They are likely to be rushing. They are going to have less time to pay attention to patient needs. Also in some cases facilities will bring on temporary staff to fill in for the shortages and that temporary staff may not be familiar with the facilities flow of work and with the patients. Then sometimes they may substitute less qualified workers when they can't find the workers they need. So there are a series of ways that we think shortages can impact on patient safety.
Cindy DiBiasi: Now you would think in a down-turned economy as we are in that this would not be a problem, that we would have a workforce shortage. What are some of the factors that are contributing to this?
Ed Salsberg: You may be right. It may be that the current economy will begin to help address, but again the concerns about the workforce and quality and not just about shortages. I think there are several reasons for being very concerned about the shortage. There are those short-term factors you mentioned which was a very competitive economy. The educational system often lags behind that; they get signals very slowly and we are seeing now that many of their nursing programs are beginning to increase enrollment, which is encouraging, but it will still be several years before a significant number of new nurses are produced.
Another factor is that there are a series of major, long-term factors that we have to be very concerned about. The nation is aging. That means that older folks use more services. The workforce is also aging and many may be retiring over the next decade. The changing demographics of the nation and so I think there is clearly going to be an increase in demand for health services and as the Bureau of Labor Statistics has forecasted job opportunities, jobs in health care will grow some 29 percent this decade, twice the rate of the rest of the economy. So it is going to be very challenging and very difficult for the health industry to find enough workers.
Finally, I think there is a series of workplace factors that contribute to shortages. Jobs that are not well designed. This is often, not always, but often a very physically and emotionally demanding work. Again we sometimes don't have the well-trained managers and in some occupations the wages aren't competitive. So there is a whole series of factors that are contributing to the current shortages.
Cindy DiBiasi: What are States doing to try to address this shortage?
Ed Salsberg: As I mentioned, a large number of States have developed task forces and committees that are looking at this. The most common responses are on the supply side: scholarships or grants for faculty development. There has also been a fair amount in, about 28 States that are involved in, some sort of health careers marketing, particularly making young people aware of health careers. Some additional work in career ladders. A few States, not too many, are looking at jobs design. I should mention that several States are also using the Labor Department Fund, particularly the Work Incentive Act money to try and train in health professions. So we are seeing States undertake a variety of initiatives but I should be clear that we are still at the early stages. I don't think anyone feels that we have sort of solved the workforce shortage problem yet.
Cindy DiBiasi: Ed, we are going to be back with you. We are going to move on to Jack Needleman now, assistant professor of economics and health policy at the Harvard School of Public Health. Jack, you recently completed a study on the relationship between workforce shortages, staffing levels and patient safety. What did you find?
Jack Needleman: Very briefly, we found that hospitals that had higher staffing of registered nurses appeared to have shorter lengths of stay and lower rates of a variety of fairly serious complications. Within medical patients we saw lower rates of urinary tract infections, shock, cardiac arrest, upper gastrointestinal bleeding, pneumonia, and the measure that we called failure to rescue which was deaths in patients that had one of five serious life-threatening complications. In surgical patients, whom we analyzed separately, we saw lower rates of failure to rescue and lower urinary tract infection rates.
Cindy DiBiasi: Now is there a lot of variation among hospitals and staffing levels because I would seem to think it would be based on some kind of per-capita formula?
Jack Needleman: I was shocked at how much variation we in fact saw in the data we were working with. We looked at two different measures of registered nurse staffing at hospitals. One was the number of registered nurse hours per patient day. The average number we saw in the hospitals we were looking at and we had a sample of 799 hospitals, was a little under eight hours per day. But the range that we saw in the data was two hours to fifteen or sixteen hours. The nurses and nurse consultants that we were working with on that study said that is a plausible range.
The second measure that we had was the percentage of licensed nursing hours, hours from R.N.'s and licensed practical nurses that are provided in fact by R.N.'s. The mean value we saw in our data was 86 percent, but again we saw a wide variation from a minimum of about half those hours being provided by R.N.'s to all those hours being provided by R.N.'s.
Cindy DiBiasi: How large is the impact of the staffing levels on patient outcomes?
Jack Needleman: What we did in our analysis is we picked two data points and compared what we would estimate as the reduction in rates moving from a low rate to a high rate. The low rate was kind of right in the middle of the bottom half of the range and the high rate, the high staffing level was in the middle of the upper half. What we saw with length of stay, we would estimate would be 3-5 percentage points lower, 3-5 percent lower in the high-staffed hospitals compared to low-staffed hospitals. For the complications that we were examining, the reduction in rates associated with the higher staffing was anywhere from 2.5 percent to almost 10 percent.
Cindy DiBiasi: Why are these relationships important?
Jack Needleman: Well, as I said, these can be serious complications. Longer lengths of stay can add to cost, discomfort, they may reflect the fact that patients have experienced complications that needed to be treated. Urinary tract infections are common and very uncomfortable. The other measures that we found associations with failure to rescue, which is death, pneumonia, upper GI bleeding, shock, cardiac arrest, all have substantial risks of death associated with them. I would also argue that we were working with data in which it is hard to see associations. These impacts that we have estimated in this study I truly believe are a lower bound estimate of the effect of nursing.
Cindy DiBiasi: Is there more research going on in this area?
Jack Needleman: There is more research going on and more that is needed. There is a need to look at other factors influencing nurse's impact on patients. Ed commented about the organization of work and the work environment and those are critical issues.
A second question is why the staffing in fact varies as widely as it does? I think it is important to understand the factors that are determining how many nurses hospitals and other health care providers employ. We found that one of the challenges of doing this work was simply to understand how the nurse staffing in hospitals compared to the need for patients, for nursing in those hospitals. Hospitals with less complex case mixes are going to need fewer nurses per patient day. There are no really good ways to control for that now. We took the best available measure. There is real room for improvement there.
Finally, again Ed commented on the importance of work environment and we know work environment makes a difference. There are more studies trying to quantify that effect, but what we need is research on how to improve the work environment to create change in the work environment.
Cindy DiBiasi: What types of working conditions are you talking about?
Jack Needleman: Well, some of the things that are important are influencing nurse's impact on patient outcomes that need to be thought about is the nursing organization at the unit level, the organizational culture and climate, the roll of overtime, which has been a major issue for nurses and nurse's unions around the country. Clearly also physical organization of nursing units can have a major impact on how many nurses are needed and how effectively nurses can work. Long corridors versus short, compact units will change how many nurses are needed. Likewise we know that the technology that is available on nursing units can make a difference. Computerized medical records and computer data entry for charting by nurses can influence the need for nurses in hospitals and the efficiency with which the nurses work.