SAFE PATIENT MOVEMENT AND HANDLING:

VHA NATIONAL PERSPECTIVE STEPS

Office of Public Health and Environmental Hazards

Office of Nursing Services

Office of Patient Care Services

Tampa PSCI

GOALS OF THIS TALK

Champion reporting to satisfy VHA CO

• Executive Committee

• Deputy Under Secretary for Operations and management

• Health Systems Committee

• Deputy Under Secretary of Health

• Under Secretary of Health

REPORTING NEEDS: EX COM

10/1/08 F/u on $61,000,000 funding

NRM needs for June 08 $s

12/30/08 Estimate of equipment funding

Associated FY09 NRM funds

Identification of facilities with structural assessment needs

3/331/09 Equipment and NRM funding

status

Overall progress (Tampa data)

REPORTING NEEDS: DUSHOM

FY09/Q1 Facility-wide equipment inventory

Identification of prior expenditures

Unit-based hazard assessment

FY09/Q2 Policies, Procedures, protocols

Review of injuries

Initial peer leader training

FY09/Q3 Minimal lift policy

FY09/Q4 Facility strategic plan

Injury Rates by SIC Codes

02468

101214161820

pre1

987*

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Construction Nursing & Personal Care Farmers HospitalsVHA

Injury Type by Fiscal Year

0

5000

10000

15000

20000

25000

30000

Fiscal Year

N

ASSAULT CUMULATIVE TRAUMA MATERIAL HANDLING

LIFTING/REPOSITIONING PATIENTS SLIP/TRIP/FALL STRUCK BY/AGAINST

OTHER TB/PPD CONVERSION LATEX REACTION/ALLERGY

ENVIRONMENTAL/TOXIC EXPOSURE HOLLOW BORE NEEDLESTICK SHARPS EXPOSURE

EXPOSURE TO BODY FLUIDS/SPLASH SUTURE NEEDLESTICK NON PATIENT CARE

NOT ELSEWHERE CLASSIFIED 99

# and Rate of Incidents by Skill Mix(from VANOD ASISTS proclarity cube on VSSC)

Yellow = Total Emp CountOrange= # of IncidentsBlue line= Calc. Rate

Incident Rate by Type of Incident (from VANOD ASISTS proclarity cube on VSSC)

Type of Incident by Skill Mix (from VANOD ASISTS proclarity cube on VSSC)

Lifting & moving patients – most freq. reported

injury

TOTAL AND PATIENT TRANSFER INJURIES BY GENDER

0

2

4

6

8

10

12

14

16

18

20

FY2002 FY2003 FY2004 FY2005 FY2006

Inju

ries

/ 100

FT

E

Female PTI Female TI Male PTI Male TI

PATIENT TRANSFER INJURY RATES BY GENDER AND NURSING LEVEL

0

1

2

3

4

5

6

7

8

9

10

FY2002 FY2003 FY2004 FY2005 FY2006

Inu

ires

/ 10

0 F

TE

Female RN Male RN Female LPNMale LPN Female NA Male NA

0

5

10

15

20

25

30

35

FY2002 FY2003 FY2004 FY2005 FY2006

Inju

ries

per

100

FT

E

Female RN Male RN Female LPNMale LPN Female NA Male NA

TOTAL INJURY RATES BY GENDER AND NURSING LEVEL

Patient Transfer Injury Rates and Age

0

50

100

150

200

250

300

350

400

< 25years

25 to34

years

35 to44

years

45 to54

years

55 to64

years

>= 65years

TOTAL

FY2002

FY2003

FY2004

FY2005

FY2006

WEAKNESSES INHERENT IN ANY BUSINESS CASE

JUSTIFICATION APPROACH

• Under-reporting of injury and disease

• Attention and focus predict long-term consequences

• Horse-racing effect

SYSTEM NEEDS ASSESSMENT

• Data review and call to determine need– VSSC Review– DUSHOM ITEM

• Estimation of cost per dependent– Ceiling lifts– Movable equipment– Supplies

• Estimates by patient category• BIRN Costs

Per Bed Unit Costs

$0.00

$10,000,000.00

$20,000,000.00

$30,000,000.00

$40,000,000.00

$50,000,000.00

$60,000,000.00

$70,000,000.00

Cost by$6,000 per

bed

Cost by$7,000 per

bed

Cost by$8,000 per

bed

Costs Per Unit

Co

sts

SCI

NHC

MSU

CCU

DIA

OR

BUSINESS CASE DEFINITIONSConservative

scenarioDocumented costs and benefits in VISN 8

More likely scenario

Doubling costs (medical, wage loss) because of under-reporting (2001 AES) and 10% retraining / administrative costs

More Likely Scenario with .1BIRN FTE

Doubling costs (medical, wage loss) because of under-reporting (2001 AES) and 10% retraining / administrative costs and .1 FTE BIRN per high-risk unit over 10 years

High Cost Scenario

Medical and wage costs tripled (common private sector assumption

BUSINESS CASE CONSIDERATIONS: CALCULATIONS

  Payback period

Net Present Value Internal Rate of Return

Conservative scenario

4.13 yrs $1.4M 20%

More likely scenario

3.39yrs $2.0 M 27%

More Likely Scenario with .1BIRN FTE

3.50yrs $1.19M 25%

High Cost Scenario

2.71yrs $2.6M 33%

HISTORY OF SPMH in VHA1998-1999 Tampa program development1999 HSR&D Tampa SPMH grant (expert panel)

IOM Report: Safe Work in the 21st Century2001-2003 VISN 8 Demonstration project2001 1st Conference on SPMH2004 VISN 1 EDM and program roll-out

Publications on economicsVHA CO staff support for roll-out

2005-2007 VISN 3, 9, 11 initiatives2006 10N data call on implementation initiatives2007 SPMH initiative for FY2009-11 budget

series2008 VA * OMB negotiations on 6 vs. 3 year roll-

outConcurrence$61,500,000 distributed in June 2008

LESSONS RFOM PROGRAM IMPLEMENTATION IN 4 VISNs

• 2 years of VISN-level support• .5 FTE facility staff support

– Program equipment management– Peer safety leader leadership

• Peer Safety Leader functionality (“back injury resource nurses”, “injury prevention nurses”)– Essential element– Issues of fiscal support (“certification” vs step

increases)

COSTS AND BENEFITS

$150,000,000 - equipment and construction

$4,000,000 / year - facility champions$5,000,000 / year – injury prevention

nurses on each unit$10,000,000 – data system redesign /

support ASISTS inadequateWARIMS application to IDMC

CONSIDERATIONS:Decision-making criteria

• Is program necessary: can VHA afford not to do it?

• Does the program pay for itself (when does the program pay for itself)

• What happens if we do not implement the program?

CONSIDERATIONS

1. Construction vs. medical programs (80% vs. 20%): need national assessment at facility / patient room level

2. VISN roll-out experience: 2 – 3 years of VISN support and planning

3. Facility-level program management: Staff support (program development, leading assessment, equipment maintenance, peer safety leader training and coordination)Likely ~$4,300,000 / year

CONSIDERATIONS

4. Facility level – front-line worker support – peer and coordination) (.1 peer safety leader/injury prevention nurse / shift): $~$5,000,000 / year

5. IT Support: ASISTS does not address unit level rates, instrumentation/ equipment / track intervention recommendations (Accident Review Board solutions)

6. Roll-out timing: VISN, facility staffing; facility-level assessment, equipment

CONSIDERATIONS

7. Prior expenditures and early adopters: reimbursement issues (10N solution: include information on actual equipment/construction expenditures)

8. Budget shifts1. Initial estimates: no facility- or unit level

coordination

2. $16,000,000 in initial draft for 3 years of unit-level peer safety leaders

3. Move to 6 years: inadequate funding

CONSIDERATIONS

9. First year funds expenditures:1. Universally needed equipment (lateral

sliding devices ~ $15,000,000)2. $4,300,000 facility level staffing3. Reimbursement (10N model)

10.Program oversight in CO11.Future delays and reimbursement:

consequences of 6-year implementation delay and impatience in the field

OPTIONS

• Option 1: $30,000,000 / yr x 6– VHA CO staff support, national

assessment, facility level support, devolution of program to 10N in ~3 years

• Option 2: assign moneys to VISNs without oversight

• Option 3: do nothing

REPORTING NEEDS

10/1/08 F/u on $61,000,000 funding

NRM needs for June 08 $s

12/30/08 Estimate of equipment funding

Associated FY09 NRM funds

Identification of facilities with structural assessment needs

3/331/09 Equipment and NRM funding

status

Overall progress (Tampa data)