Discovering and shaping a career in public health and health policy Jack Needleman, PhD FAAN Department 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,  Health Policy research and consulting firm  Harvard School of Public Health,  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

5 NURSING MATTERS Nurses 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 LowHigh Hospitals Beds Census Licensed hours per day Aide hours per day RN as % Licensed84%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 Nursing Needleman/Buerhaus simulation results

12 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.”

13 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”

14 Avoided Days and Adverse Outcomes Associated with Raising Nurse Staffing to 75 th Percentile Estimates from Needleman/Buerhaus, Health Affairs, 2006 Raise RN Proportion Raise Licensed HoursDo Both Avoided Days1,507,4932,598,3394,106,315 Avoided Adverse Outcomes Cardiac arrest and shock, pneumonia, upper gastrointestinal bleeding, deep vein thrombosis, urinary tract infection 59,93810,81370,416 Avoided Deaths4,9971,801 6,754

15 SOCIAL AND BUSINESS CASE FOR NURSING Net Cost of Increasing Nurse Staffing Estimates from Needleman/Buerhaus, Health Affairs, 2006 Raise RN Proportion Raise Licensed HoursBoth 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%

16 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, % 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 to Lower 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”