Working Environment and Adverse Patient Events in Home Healthcare: Issues and Findings

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Working Environment and Adverse Patient Events in
Home Healthcare Issues and Findings

• Penny H. Feldman, Ph.D. - Principal
  InvestigatorRobert J. Rosati, Ph.D. -
  Investigator
• Supported by AHRQ Grant R01 HS11962
• Visiting Nurse Service of New York

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Collaborators
John Bridges, Ph.D. - Investigator Christopher
Murtaugh, Ph.D. - Investigator Timothy Peng,
Ph.D. - Research Associate Doreen Wang, M.A. -
Programmer Lori King, B.A. - Research
Assistant Visiting Nurse Service of New York
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Study Aims

• To examine the variability of adverse events and
  organizational team characteristics across 86
  care teams within one agency
• To examine the relationships between adverse
  patient events and
• Patient characteristics
• Care team objective characteristics
• Care team subjective work environment

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Conceptual Model

• Organizational/Structural Characteristics
• Communication Processes
• Governance
• Information Technology

• Leadership
• Values
• Style
• Strategy

Core Structural Domains
Process Domains

• Quality Emphasis
• Patient Centeredness
• Safety
• Innovation
• Outcome Measurement
• Evidence-based Practice

• Supervision
• Style
• Employee Recognition

• Work Design
• Staffing
• Resources/Training
• Rewards
• Autonomy

• Group Behavior
• Collaboration
• Consensus

• Healthcare Worker Outcomes
• Satisfaction
• Burnout
• Intention to Leave
• Organizational Identification

• Patient Outcomes
• Patient Satisfaction
• Patient Safety
• Health and Function

Outcomes
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Current Study
Measures of care team objective
characteristics and subjective work environment

• Quality Emphasis
• Safety
• Patient Care

• Supervision
• Style
• Employee Recognition

• Work Design
• Staffing
• Resources/Training
• Rewards
• Autonomy

• Group Behavior
• Collaboration
• Consensus

• Patient Outcomes
• Patient Safety

Adverse Events
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Study Context

• Largest non-profit home health care organization
  in the United States
• Average daily census is 25,000 patients
• Diverse and complex patient population with
  post-acute and long-term care needs
• Disproportionately high numbers of
  African-American and Hispanic patients
• Decentralized workforce providing care in
  patients homes
• Patients are seen by over 100 different care
  teams (all programs) across seven counties

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Data Sources

• Outcomes Assessment Information Set (OASIS)
• Standardized patient assessment data
• Patients assessed at the beginning and end of
  each episode of care
• Employee survey
• Patient level service utilization data
• Human Resources employee data
• Other administrative data

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Employee Survey

• Mailed self-administered survey to acute and
  congregate care clinicians and front-line
  managers
• 46 response rate (1,027 surveys)
• 169 items compiled from work environment
  literature
• Approximately 30 minutes to complete
• The survey measured 15 constructs

• Teamwork (0.83)
• Leadership (0.90)
• Top-Down Communication (0.84)
• Perceived Quality (0.76)
• Safety Culture
• General (0.81)
• Leadership (0.84)
• Communication (0.91)

• Manageable Workload (0.74)
• Job Demands (0.86)
• Autonomy (0.88)
• Equity (0.85)
• Access to Resources (0.68)
• Satisfaction (0.85)
• Staff/Patient Communication (0.72)
• Physician Relations (0.94)

Shown with team-level reliability coefficients
(Chronbachs alpha)
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Study Design

• We used a 2-stage regression model to analyze the
  relationship between the dependent variablethe
  risk-adjusted incidence of any CMS adverse
  eventand a set of independent objective and
  subjective variables (e.g., aspects of the team
  structure, staff beliefs about their team, etc.)
• The final results are based on how the dependent
  variable was related to each of the independent
  variables while controlling for (or taking into
  account) all the other variables included in the
  analysis

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Study Design (continued)
Patient Episode Data
Employee Survey Data
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CMS Adverse Events

• The 13 CMS Home Healthcare defined adverse events
  serve as markers for potential problems in home
  care because of their negative nature and
  relatively low frequency
• Whether or not individual patient situations
  resulted from inadequate care provision can only
  be determined by investigating the actual care
  provided to specific patients
• An episode was considered to have an adverse
  event if one or more of the adverse events
  occurred
• For study purposes, we counted events at
  discharge/transfer and at the end of each 60-day
  episode

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13 CMS Adverse Events

• Emergent Care (EC) Events
• EC for injury caused by fall or accident at home
• EC for wound infection or deteriorating wound
  status
• EC for improper medication administration or
  medication side effects
• EC for hypo/hyperglycemia

Significant Decline in Health or
Function Development of urinary tract
infection Increase in number of pressure
ulcers Substantial decline in 3 or more
ADLs Substantial decline in management of
medications
Significant Unmet Care Need Unmet need for wound
care or medication assistance Unmet need for
toileting assistance Unmet need for management of
behavioral problem
Serious Unexpected Event Unexpected nursing home
admission Unexpected death
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Characteristics of Patient Episodes

• The data set contained 51,560 episodes of care (6
  months)
• The populations average age was 71 years
• The majority of the group was female (67)
• 40 lived alone 30 had no primary caregiver
• The most common clinical diagnoses were diabetes
  (14), hypertension (7), and congestive heart
  failure (5)
• The ethnicity of the population was

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Characteristics of Survey Respondents

• The data set contained 951 survey respondents
• Their average age was 45 years
• They had an average of 9.3 years of experience in
  the home care setting
• Their average tenure at the agency was 7.5 years
• 81 had a bachelors (or higher) degree

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Adverse Events Across Teams
Variation in rates of adverse events across care
teams
of teams
Episodes with any one CMS event over a 6-month
time period (unadjusted mean approx. 7)
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Results Volume and Distribution of Work

• ? Volume R2.010
• ? Concentration of visits among nurses R2.021
• ? Number of weekend admissions R2.126

• lower rates of team-attributable adverse events

The degree to which the teams visits are evenly
distributed across many nurses or concentrated
among a few nurses is measured using a
Herfindahl-Hirschman Index of team
visits Risk-adjusted based on a methodology
developed by the health economist on our team
Note The partial R-squared is displayed next to
each variable
Overall Model R-squared .345
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ResultsWorkforce Characteristics

• lower rates of team-attributable adverse events

• ? Experience R2.039

Note The partial R-squared is displayed next to
each variable
Overall Model R-squared .345
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ResultsPerceived Organizational Climate

• ? Equity R2. 011
• ? Teamwork R2.019
• ? Supervisor Safety Culture R2. 022
• ? ManageableWorkload R2.046

• lower rates of team-attributable adverse events

Overall Model R-squared .345 including all
eight variables
May be due in part to association of increased
awareness of safety with increased reporting
(identified in health care literature)
Possibly due to complacency or burnout
factors
Note The partial R-squared is displayed next to
each variable
Overall Model R-squared .345
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Summary of Results

• After controlling for patient case-mix severity,
  this study found that work design, safety
  culture, teamwork, and workforce characteristics
  all affected team-attributable adverse event
  rates.
• Specifically, adverse event rates were lower for
  teams that had

• higher volume
• higher concentration of visits
• fewer weekend admissions
• more experienced clinicians

• greater perceived equity
• greater perceived teamwork
• lower perceived supervisorsafety culture
• less workload manageability

Possibly due to a combination of safety
awareness, complacency, and burnout factors
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Summary of Results
Overall Model R-squared .345
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Implications for Patient Safety

• Findings are consistent with other patient safety
  studies that
• Link higher volume and greater experience to
  safer care
• Show higher rates of reported adverse events
  where safety culture is emphasized
• Show that managerial span of control and teamwork
  make a difference
• Association between better patient safety
  outcomes and less manageable workload
• Raises questions about possible burnout among
  high performing teams or complacency among
  poorer performing teams
• Suggests the need for further investigation

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Next Steps

• Complete chart reviews to analyze the
  relationship between adverse events and specific
  types of patient care errors for two adverse
  events
• Emergent care for wound infection or
  deteriorating wound status
• Emergent care for hypo/hyperglycemia
• Prepare study results for publication
• Pursue additional research
• Assess the impact of quality/safety on team
  climate (reverse causation)
• Design and evaluate interventions to improve
  teamwork and reverse adverse events
• Develop a diagnostic tool to predict the
  likelihood of future adverse events

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Contact Information
Robert J. Rosati, Ph.D. Center For Home Care
Policy and Research Visiting Nurse Service of New
York 5 Penn Plaza, 11th Floor New York, NY
10001 [phone] Robert.Rosati_at_vnsny.org