Lessening the Negative
Impact of Human Factors
Linking Staffing Variables & 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. 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.
1
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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Human Factors are the Most
Frequent Root Cause of Medical Errors
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 year 4 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
Five Most Frequently Identified Root Causes of Sentinel Events
Reviewed by The Joint Commission by Year7
The majority of events have multiple root causes.
614 635
547
563
557 547
517
532
489
482
505
392
203
155
72
Human
Factors
2012
Leadership
Number of
respondents = 901
Communication Assessment
2013
Number of
respondents = 887
Information
Management
2014
Number of
respondents = 764
How Staffing Variables
Impact Patient Outcomes
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.
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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
HOSPITAL ACQUIRED
PRESSURE ULCER
(HAPU)
HOSPITAL ACQUIRED
INFECTIONS
PATIENT FALLS
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For each additional patient
a nurse is assigned, there
was approximately one
additional infection per
1,000 patients.10
Hospital-acquired infections
are 3.39 times more likely
when nurses work more
than 40 hours per week.11
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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
HAPU are 3.50x more likely
when nurses work voluntary
overtime.13
LENGTH OF
STAY
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MEDICATION
ERRORS
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For every 20% decrease in
staffing below the staffing
minimum, medication errors
increase by 18%.16
Medication errors are 3.71
times more likely when
nurses work more than
40 hours per week.17
PATIENT
MORTALITY
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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
An increase of 1 RN per
1,000 inpatient days
decreased mortality
by 4.3%.19
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
PATIENT
READMISSIONS
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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
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
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
Please indicate which two workforce management tactics
your organization views as having the biggest impact to
improve clinical outcomes: (Select 2)
Answer
Options
Overtime monitoring and management
Staffing skill and competency mix
Staff satisfaction
Acuity-based staffing (staffing based on patient need)
Learning, development & competencies management
Response
Count
Respondent
Percentage
13
66
25
46
41
14%
69%
26%
48%
43%
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.
Please indicate which workforce management tactics
your organization views as having the biggest impact to
reduce medical errors and never events: (Select 2)
Answer
Options
Response
Count
Respondent
Percentage
Overtime monitoring and management
16
17%
Staffing skill and competency mix
65
68%
Staff satisfaction
20
35
21%
37%
Learning, development & competencies management 53
56%
Acuity-based staffing (staffing based on patient need)
Becker’s Healthcare 2015 Survey “Aligning Organizational Goals with Workforce Management Initiatives”
Leveraging Automation
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.
Please indicate which workforce management tactics
your organization is enabling through automated
workforce management software: (Select all that apply)
Answer
Options
Response
Count
Respondent
Percentage
Overtime monitoring and management
48
51%
Acuity-based staffing (staffing based on patient need)
38
40%
Learning, development & competencies management
Staffing skill and competency mix
34
31
36%
33%
Staff satisfaction
18
19%
None
22
4
23%
4%
Other (please specify)
Becker’s Healthcare 2015 Survey “Aligning Organizational Goals with Workforce Management Initiatives”
Closing Thoughts
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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.
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About API Healthcare
API Healthcare (www.apihealthcare.com) is focused on workforce optimization solutions exclusively for the healthcare
industry. The company’s staffing and scheduling, patient classification, human resources, talent management, payroll,
time and attendance, business analytics, and staffing agency solutions are used by more than 1,600 health systems
and staffing agencies. Founded in 1982, API Healthcare has been rated by KLAS in the Top 20 Best in KLAS Awards Report
(www.KLASresearch.com) as the top time and attendance provider system for the last 13 years (2002-2014) and the top
staffing and scheduling solution in 2012, 2013 and 2014.
About GE Healthcare
GE Healthcare provides transformational medical technologies and services to meet the demand for increased access,
enhanced quality and more affordable healthcare around the world. GE (NYSE: GE) works on things that matter - great
people and technologies taking on tough challenges. From medical imaging, software & IT, patient monitoring and
diagnostics to drug discovery, biopharmaceutical manufacturing technologies and performance improvement solutions,
GE Healthcare helps medical professionals deliver great healthcare to their patients.
1
Healthcare Expenditures. http://www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed May 29, 2015.
U.S. Department of Health and Human Services. “Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting
Medicare reimbursements from volume to value.” January 26, 2015. http://www.hhs.gov/news/press/2015pres/01/20150126a.html
3
Forbes Business. “UnitedHealth’s $43 Billion Exit From Fee-For-Service Medicine.” January 23, 2015. http://www.forbes.com/sites/
brucejapsen/2015/01/23/unitedhealths-43-billion-exit-from-fee-for-service-medicine/
4
Allen, Marshall. “How Many Die from Medical Mistakes in U.S. Hospitals?” ProPublica September 13, 2013. http://www.propublica.org/article/
how-many-die-from-medical-mistakes-in-us-hospitals
5
Van Den Bos, et al. “The $17.1 Billion Problem: The Annual Cost of Measureable Medical Errors.” Health Affairs, April 2011, No. 4: 596-603.
http://content.healthaffairs.org/content/30/4/596.full.pdf+html
6
The Joint Commission. “Facts about the Sentinel Event Policy.” Accessed May 29, 2015 http://www.jointcommission.org/
assets/1/18/Root_Causes_by_Event_Type_2004-2014.pdf
7
The Joint Commission. “Sentinel Event Data Root Causes by Event Type 2004 – 2014.” Accessed May 29, 2015. http://www.jointcommission.org/
Sentinel_Event_Statistics/default.aspx
8
Lake ET, Shang J, Klaus S, et al. “Patient falls: association with hospital Magnet status and nursing unit staffing.” Res Nurse Health. 2010; 33:413–425.
9
Bae, Sung-Heui. “Presence of Mandatory Overtime Regulations and Nurse and Patient Outcomes.” Nursing Economics. March/April 2013; 31, no.2: 59-89.
10
Cimiotti, Jeannie P. et al. “Nurse staffing, burnout, and health care–associated infection.” American Journal of Infection Control , Volume 40 ,
Issue 6 , 486 – 490.
11
Bae, Sung-Heui. “Presence of Mandatory Overtime Regulations and Nurse and Patient Outcomes.” Nursing Economics. March/April 2013; 31, no.2: 59-89.
12
Dunton, N., Gajewski, B., Klaus, S., & Pierson, B. “The relationship of nursing workforce characteristics to patient outcomes.” OJIN: The Online Journal of
Issues in Nursing, 2007;12(3).
13
Bae, Sung-Heui. “Presence of Mandatory Overtime Regulations and Nurse and Patient Outcomes.” Nursing Economics. March/April 2013; 31, no.2: 59-89.
14
Staggs, V., & He, J. (2013). “Recent trends in hospital nurse staffing in the United States.” The Journal of Nursing Administration, 43(7/8), 388–393.
15
Ann P. Bartel, et al. “Human Capital and Productivity in a Team Environment: Evidence from the Healthcare Sector.” American Economic Journal: Applied
Economics, 2014; 6 (2): 231.
16
Frith, K., Anderson, E., Tseng, F., & Fong, E. “Nurse staffing is an important strategy to prevent medication errors in community hospitals.” Nursing
Economics, 2012; 30(5), 288–294.
17
Bae, Sung-Heui. “Presence of Mandatory Overtime Regulations and Nurse and Patient Outcomes.” Nursing Economics. March/April 2013; 31, no.2: 59-89.
18
Needleman, Jack, et al. “Nurse Staffing and Inpatient Hospital Mortality.” New England Journal of Medicine, 2011; 364:1037-1045.
19
Shekelle, P. “Nurse-Patient Ratios as a Patient Safety Strategy.” Annals of Internal Medicine, 2013; 158, (5), 404–410.
20
McHugh, M., & Ma, C. “Hospital nursing and 30-day readmissions among Medicare patients with health failure, acute myocardial infarction, and
pneumonia.” Medical Care, 2013; 51(1), 52–59.
21
Tubbs-Cooley, HL, et al. “An observational study of nurse staffing levels and readmission among children hospitalized for common conditions.”
BMJ Qual Saf. 2013; 22:735-742.
22
Becker’s Healthcare survey “Aligning Organizational Goals with Workforce Management Initiatives” conducted May/June, 2015.
23
Ibid.
24
Ibid.
2
© 2015 API Healthcare Corporation, a GE Healthcare Company. All rights reserved.
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