This document discusses how human factors such as staffing levels, skill mix, and competency assessment are frequently cited as root causes of medical errors based on reviews of sentinel events. It summarizes research showing connections between various staffing variables like nurse-to-patient ratios, overtime, experience levels, and patient outcomes including falls, hospital-acquired infections, pressure ulcers, mortality, readmissions, and length of stay. The document advocates for data-driven workforce management strategies like acuity-based staffing and competency management to optimize staffing and improve patient outcomes.
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In the United States, healthcare is a $
2.9 trillion industry,
costs $
9,255 per capita and consumes 17.4% of the
GDP.1
Healthcare is big business, and the way the
entire industry conducts business is changing. While
hospitals have always been in the business of providing
patient care, the care delivery and payment models are
undergoing an enormous paradigm shift. It’s no longer
about the number of services provided, but instead
about the quality of care delivered.
In January, 2015, the US Department of Health and Human Services (HHS) announced
a focused, accelerated shift from fee-for-service to pay-for-performance. That
announcement came with measurable goals and an aggressive timeline: 85% of all
traditional Medicare payments tied to quality or value by 2016 and 90% by 2018.2
Private insurers are also moving away from the fee-for-service model. In early 2015,
UnitedHealth announced that they are expecting a 20% increase in value-based
reimbursements, with that number growing even more in subsequent years.3
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One factor that has an enormous impact on the quality of care is the occurrence of
medical errors. With some experts estimating an astonishing 400,000 deaths caused by
medical errors each year4
and the cost of medical errors topping $17 billion annually,5
reducing the number of medical errors is a clear priority for an industry driving towards
improved outcomes and better quality.
Understanding the factors that lead to medical errors provides a framework for
improvement. As part of its mission to improve healthcare, the Joint Commission reviews
sentinel events, defined as “any unexpected occurrence involving death or serious
physical or psychological injury, or the risk thereof.”6
Their findings show that the most
frequently cited root cause for sentinel events reported by Joint Commission accredited
hospitals is “human factors,” which includes staffing levels, skill mix, competency
assessment, fatigue and more.7
Human Factors are the Most
Frequent Root Cause of Medical Errors
5. Human
Factors
CommunicationLeadership Assessment Information
Management
547
517
489 482
505
392
203
155
72
563
532
547557
635614
2012
Number of
respondents = 901
2013
Number of
respondents = 887
2014
Number of
respondents = 764
Five Most Frequently Identified Root Causes of Sentinel Events
Reviewed by The Joint Commission by Year7
The majority of events have multiple root causes.
6. PATIENT FALLS
An additional hour of RN
care per patient day
reduced the fall rate
by 2.8%.8
Patient falls are 3.36 times
more likely when nurses
work voluntary overtime.9
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HOSPITAL ACQUIRED
PRESSURE ULCER
(HAPU)
– HAPU are 3.50x more likely
when nurses work voluntary
overtime.13
HAPU rates could be
reduced by 11.4% by
simultaneously increasing
the percentage of hours
supplied by RNs from 60%
to 70% and increasing the
average experience of RNs
by five years.12
HOSPITAL ACQUIRED
INFECTIONS
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Hospital-acquired infections
are 3.39 times more likely
when nurses work more
than 40 hours per week.11
For each additional patient
a nurse is assigned, there
was approximately one
additional infection per
1,000 patients.10
A growing body of research shows the impact that staffing variables
have on a wide range of patient outcome metrics. With so many staffing
variables impacting patient outcomes, determining a course of action
can initially be daunting. The increasing prevalence of reliable workforce
analytics can provide a data-driven solution to the dilemma. Long-term
workforce management strategies and short-term staffing decisions
have a profound impact on patient outcomes.
How Staffing Variables
Impact Patient Outcomes
7. PATIENT
MORTALITY
PATIENT
READMISSIONS
MEDICATION
ERRORS
An increase of 1 RN per
1,000 inpatient days
decreased mortality
by 4.3%.19
Each one patient increase
in the hospital’s average
pediatric staffing ratio
increased a surgical child’s
odds of readmission by 48%
and a medical child’s odds
of readmission by 11%.21
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– The risk of death increased
2% for each below-target
shift (low staffing) and 4%
for each high-turnover shift
(patient churn).18
LENGTH OF
STAY
Increases in RN staffing in
general hospital units have
resulted in a reduction of
5.7% in patient days.14
A one-year increase in the
average tenure of RNs on a
hospital unit was associated
with a 1.3% decrease in
length of stay.15
Nurse-to-patient ratios of
1 to 4.95 or lower reduced
heart failure readmissions
by 7%, acute myocardial
infarction readmissions by
6% and pneumonia
readmissions by 10%.20
Medication errors are 3.71
times more likely when
nurses work more than
40 hours per week.17
For every 20% decrease in
staffing below the staffing
minimum, medication errors
increase by 18%.16
8. Please indicate which two workforce management tactics
your organization views as having the biggest impact to
improve clinical outcomes: (Select 2)
Overtime monitoring and management 13 14%
Staffing skill and competency mix 66 69%
Staff satisfaction 25 26%
Acuity-based staffing (staffing based on patient need) 46 48%
Learning, development & competencies management 41 43%
Answer
Options
Response
Count
Respondent
Percentage
Becker’s Healthcare 2015 Survey “Aligning Organizational Goals with Workforce Management Initiatives”
Optimizing Staff to
Improve Patient Outcomes
With the potential to impact every patient outcome metric, workforce management
and staffing decisions are critical. In fact, a recent Becker’s survey revealed that 81% of
healthcare executive respondents consider workforce management a top priority.22
That survey probed deeper into the tactics that the healthcare executives felt were
having the biggest impact on improving clinical outcomes and reducing medical errors
and never events, and three emerged as frontrunners:23
Staffing skill and competency mix
This initiative requires the ability to utilize workforce analytics to make better short-term
and long-term staffing decisions. In the short-term, staffing plans should be based on
the optimal skill mix so that staff can be deployed to the right place at the right time to
balance both care needs and budget constraints, while ensuring patient satisfaction.
In the long-term, decisions need to be made to determine how to recruit, retain and
develop a workforce with the right competencies and skills to meet both current and
future demands. Identifying the specific staff needs across the health system and then
how to engage, empower and ensure the highest potential performance is core to
establishing quality of care improvements.
Acuity-based staffing
New care delivery models are changing how and where care will be delivered, and
the variations in location and type of care needed will be significant. An acuity-based
9. Please indicate which workforce management tactics
your organization views as having the biggest impact to
reduce medical errors and never events: (Select 2)
Overtime monitoring and management 16 17%
Staffing skill and competency mix 65 68%
Staff satisfaction 20 21%
Acuity-based staffing (staffing based on patient need) 35 37%
Learning, development & competencies management 53 56%
Answer
Options
Response
Count
Respondent
Percentage
Becker’s Healthcare 2015 Survey “Aligning Organizational Goals with Workforce Management Initiatives”
staffing initiative takes into account that not all nurses are equal, patients are all
different and care delivery models are changing. Within this new paradigm, ratios
can provide a baseline, but they are only a starting point for developing effective, safe
staffing plans.
Instead, acuity-based methodologies rely on objective, reliable data and sophisticated
analytics to make staffing decisions that are based on evidence and outcomes. A
sophisticated acuity-based staffing strategy takes into account the characteristics of
the nurse (such as experience, education, competencies and potential fatigue factors),
specifics about the patient (such as complexity and family dynamics), and information
about the environment (such as availability of support staff and layout of
the unit).
Learning, development and competencies management
A robust talent management strategy includes the ability to continuously evaluate
competencies for relevancy and readiness, identifying areas for future development
necessary to meet the organization’s strategic objectives. By aligning each employee’s
knowledge, skill levels and certifications with the immediate and evolving needs of the
organization, the health system achieves higher efficiency while mitigating risk. That
leads to better patient outcomes.
A comprehensive learning management strategy takes into account the management,
measurement and tracking of learning and training. Then, the ability to analyze that
information allows for data-driven decisions that help to better develop, retain, hire or
contract talent. In addition, workforce metrics can be used for trend analysis that helps
uncover any gaps in the organization and identify additional workforce management
strategies that can be implemented to deliver better patient care.
10. Please indicate which workforce management tactics
your organization is enabling through automated
workforce management software: (Select all that apply)
Overtime monitoring and management 48 51%
Acuity-based staffing (staffing based on patient need) 38 40%
Learning, development & competencies management 34 36%
Staffing skill and competency mix 31 33%
Staff satisfaction 18 19%
None 22 23%
Other (please specify) 4 4%
Answer
Options
Response
Count
Respondent
Percentage
Becker’s Healthcare 2015 Survey “Aligning Organizational Goals with Workforce Management Initiatives”
While healthcare executives recognize the importance of workforce management, the
majority are not using automation to help manage their workforce optimization efforts
beyond cost containment. In fact, the Becker’s survey uncovered that only slightly
over half of respondents are using automation to enable overtime monitoring and
management.
The use of automation drops off even further for initiatives that enable staffing based
on patient needs, staff satisfaction or talent management.24
However, as health systems
continue to develop more robust staffing and workforce management strategies
in response to clinical and financial demands, the use of workforce analytics and
automation will continue to expand.
Leveraging Automation
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Healthcare is unlike any other business – it’s about people caring for people. So, it comes
as no surprise that human factors can be traced as a root cause of the majority of never
events. Understanding that connection is only the first step in making progress to reduce
errors and improve clinical outcomes. Action must be taken to overcome those human
factors and improve the quality of care.
The link between staffing and patient outcomes is indisputable. In an industry that
is striving to improve patient outcomes while simultaneously driving down costs, the
impact of each health system’s workforce management strategy will be magnified.
Fortunately, the increasing availability of reliable workforce analytics will empower
healthcare organizations to achieve workforce optimization, propelling them to a
successful synergy between patient outcomes and cost containment.
Closing Thoughts