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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
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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
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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)
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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
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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
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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
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# and Rate of Incidents by Skill Mix(from VANOD ASISTS proclarity cube on VSSC)
Yellow = Total Emp CountOrange= # of IncidentsBlue line= Calc. Rate
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Incident Rate by Type of Incident (from VANOD ASISTS proclarity cube on VSSC)
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Type of Incident by Skill Mix (from VANOD ASISTS proclarity cube on VSSC)
Lifting & moving patients – most freq. reported
injury
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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
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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
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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
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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
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WEAKNESSES INHERENT IN ANY BUSINESS CASE
JUSTIFICATION APPROACH
• Under-reporting of injury and disease
• Attention and focus predict long-term consequences
• Horse-racing effect
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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
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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
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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
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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%
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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
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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)
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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
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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?
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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
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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
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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
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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
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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
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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)