Safe Resident Handling for Administrators: Making the Business Case

1. Safe Resident Handling for Administrators: Making the Business Case University of Oregon, Labor Education and Research Center (LERC) and Oregon Occupational Safety and Health Administration (OR-OSHA) This material has been made possible by a grant from the Oregon Occupational Safety and Health Division, Department of Consumer and Business Services

2. Acknowledgements Materials for this presentation material made possible by Oregon OSHA Veterans Health Affairs SAIF Corporation HumanFit Oregon Nurses Association (ONA) University of Oregon, Labor Education and Research Center Back Injury Resource Nurses (BIRN) National Institute of Occupational Safety and Health (NIOSH)

3. Today’s workshop will address • Why a Safe Resident Handling (SRH) Program is important • Why resident handling is hazardous • Injury Statistics • Why SRH programs succeed or fail • Program costs and benefits • How to measure and evaluate SRH programs

4. Learning Objectives By the completion of this class you should be able to: • List costs of developing and implementing SRH program • List benefits of SRH program • Identify common reasons programs fail • List components of a successful SRH program

5. Importance of SRH Programs • Research from numerous sources has shown there is no safe way to manually lift or move a dependent resident • Resident handling injuries are costly for the company

6. Why is Manual Resident Handling so Hazardous? • Physical demands of the work • Job exceeds physical demands of individuals • Poor equipment and facility design • Poor work practices • Individual characteristics • Age, past injuries, physical condition, leisurely activities

7. What are work-related musculoskeletal disorders (MSDs)? • Overuse syndromes, repetitive motion disorders, cumulative trauma disorders, soft tissue injuries • Disorders of the nerves, ligaments, tendons, muscles, discs, bursa, cartilage, or joints • Acute, chronic or cumulative injuries • Work contributes to, or worsens condition • Examples are carpal tunnel syndrome, degenerative joint disease, strains, sprains, disc herniations, and sciatica

8. What are risk factors for MSDs? • Risk factors for MSDs include: • Awkward postures (bending, twisting, reaching, stooping) • Static postures • Heavy lifting • Sudden shift in load • Repetitive activities • Risk is increased in magnitude by combining risk factors • Risk increased by repetitive exposure – cumulative trauma

9. How dangerous is long term care? Incidence rates, per 100 full time workers, of nonfatal occupational injuries and illnesses, BLS 2006

10. The Prevalence of MSDs in Oregon Health Care • MSDs (strains, sprains, herniations) accounted for half of the Oregon ADCs between 2001 and 2005 • Resident handling MSDs made up 27.4% of total ADCs • Nurse aids = 32.6% • RNs 14.2% • Other health aides 5.9% “Health care” includes SIC 80 (health services) and SIC 8361 (residential care) Oregon DCBS, IMD, July 2007

11. Resident Handling Injuries • MSDs related to resident handling (2001-2005) • Health aids - 167 • Nursing aids -2,371 • RNs -881 • Most frequent cause of injury: “bodily reaction and exertion” (63.2%) which also includes overexertion and repetitive motions Oregon DCBS, Information Management Division, July 2007.

12. Resident Handling Injury Statistics from Typical Oregon LTC Facility *Other costs include vocational rehabilitation, attorney fees, awards and settlements SAIF Corp data

13. How Costly are MSDs? • Although insurance covers somedirect costs, • they are recouped by insurers in rate changes • over time • Indirect costs associated are generally MORE • expensive than the injuries themselves and are • not covered

14. Cost of Resident Handling MSDs in Oregon Average resident handling injury costs $11,055 in medical and indemnity costs over lifetime of the claim Oregon DCBS, Information Management Division, July 2007

15. What does Workers Comp Insurance Cover in Oregon? Direct Costs Only Medical costs include • Medical treatment of injuries • Drug costs Indemnity costs include • Time loss costs • Temporary and permanent disability payments • Fatality costs/awards • Vocational assistance costs • Settlement costs • Claim expense costs Oregon State Workers’ Compensation Division, SAIF Corporation

16. Patient Handling MSD Claim Covered Cost Components* • Implicit within “indemnity” costs, which comprise 55% of total claims cost, are time loss and disability fees • Insurance does not pay for the costs associated with absenteeism and presenteeism following an injury. *Statistics cover 1997-2006, with 4012 total claims Oregon DCBS, Information Management Division, 2007

17. Discussion Is cost a barrier to implementing a SRH program at your facility?

18. Direct costs are the tip of the iceberg! Direct Costs • Medical costs • Time loss • Workers Comp premiums Indirect Costs • Lost productivity • Resident injury costs • Retention or retraining time • Reduced morale • Break up work team • Extra overtime • Administrator time to manage claims • Punitive costs/time

19. Indirect Costs Overtime Decreased productivity Poorer worker- management relations Work stoppage Fear of injury Poor morale Material depletion expense Clean-up, damaged material replacement costs Indirect Costs Recruitment costs Hiring/retraining costs Orientation Costs Employee benefits Training time Investigation costs Trainer time Legal costs Documenting time loss Supervisor time Punitive Costs Court time Productivity ramp-up Attorney fees Fines Compliance inspections Reports to state/regulators

20. SRH is Affordable! Wyandot County Nursing Home (Ohio) • Developed SRH program with • Equipment (ceiling lifts, FEB, sit-stand) • Ergonomic & equipment training • Worker participation in all aspects • Sustainability • Transformed into a zero-lift facility • No MSDs in > 9-years!

21. Wyandot Costs & Benefits • Costs • $140,000/year workers comp costs 3 years prior to SPH program • $251,000 on equipment over 4 years (1998-2001) • Savings • $100,000 workers comp costs • $125,000 staff turnover costs (hiring time, training) • Turnover decreased from 75% to 5% • $55,000 payroll savings for sick-time and overtime • $126,000 savings in cost of additional staffing not needed • Benefits • Enhanced morale • Increased productivity • Better quality care (attracted and hired best workers) $406,000 - $251,000 = $155,000 savings over 4 years!

22. SAIF Low Lift/SRH Program • SAIF program implemented 9/17/2004 • 19 facilities included • acute care, skilled nursing facilities, assisted living, residential care, and developmentally/physically disabled group homes • Client utilized zero/low lift program, with policies, in at least one facility or department

23. SAIF Low Lift/SRH Program

24. MSD injury prevention program in nursing homes (Collins et al, 2004) Investment • $143,556 in equipment and $27,600 in training ($498 and $77 per employee respectively) • Trained 288 employees 1 ¼ hours each on equipment use Results • MSD claims reduced by 57% from 129 to 56 • Direct injury costs dropped from $441,670 to $277,061 yielding annualized saving of $54,870 • The 10 year net present value of the project at the time of implementation was $594,605 • Accounting for capital maintenance, retraining, and training backfill, the adjusted recovery time on investment = 3 + years, but ROI for some OR programs < 2 yrs

25. Making the Business Case for a SRH Program

26. Demonstrate the Financial Value of a SRH Program: A systems approach • Define the problem and outline the goals • Too many injuries/costs associated with resident handling • Need to implement ergonomics based SRH program • Determine solutions • SRH policy • Appropriate equipment • Collect data to demonstrate a change • Injury rates & costs, indirect costs, etc • Anticipated costs and benefits of solutions • Cost justification analysis • Return on investment • Program effectiveness Humanfit, 2002

27. What are Costs versus Benefits? Program Benefits • Reduced Work comp costs • Reduced turnover • Increased labor pool • Enhanced productivity • Improved morale • More resident care time • Improved quality of care • Decreased resident fall risk • Greater resident satisfaction • Reduced workplace violence Program Costs • Equipment costs • Installation costs • Maintenance • Equipment supplies • Worker training • Equipment lifespan

28. Conduct an Economic Analysis • Single year • Cost/Benefit Ratio • Payback period • Single year return on investment • Multi-year pay back • Profit margin analysis Humanfit, 2002

29. Cost/Benefit Analysis • Cost/Benefit Ratio = Dollar value of benefit (gain/loss) Dollar amount of cost Example: Lateral transfer injuries • Three injuries in past year • Average injury cost (direct) = $11,000 per worker x 3 = $33,000 (in potential savings) • Solution investment cost (2 air mats) = $10,000 • Benefit to cost ratio = 3.3 The benefit is over 3 times the cost Humanfit, 2002

30. Payback Period Payback period in years = Cost Benefit (gain or loss) Payback period in years = $10,000 = 0.3 years $33,000 or 4 months A 2-year (or less) payback on facility wide resident handling equipment is common Humanfit, 2002

31. Single Year Return on Investment Return on Investment (ROI) = Gain or Loss x 100% Investment cost ROI = $33,000 x 100% = 330% $10,000 Humanfit, 2002

32. Multi-year Payback • Issues to consider • Identify the lifespan of the equipment and interest rate needed to pay for investment • Determine future versus present value of the dollar (inflation costs) • Determine cost of capital (interest, dividends, payment to providers of funds) • Calculate savings in year 1 and subsequent years with value discounted due to inflation Humanfit, 2002

33. Profit Margin Analysis • Calculate the services that must be reimbursed to compensate for the loss of profit due to injuries: • Average profit margin for health care in the US is ~4% • Average cost of a back injury is ~$25,000 ___Injury cost___ = $625,000 Avg profit margin • This is the amount that has to be found through service reimbursement or cost cutting to compensate for loss of profit due to injury costs for 1 back injury Humanfit, 2002

34. What should management know? Injury Trends? Program Costs?

35. What Management Should Know: Annual Costs and Benefits

36. Assembling Data Use injury data for direct costs • OSHA 200/300 logs • # incidents, lost work days, restricted work days • MSD type (strain, herniation etc.) • Body part affected • By wing or unit • % of total injuries that are MSDs • % MSDs related to resident handling • % time loss on cases

37. What Management Should Know: Injury Trends

38. Know the Trends Collect data before you start your SRH program to assess trends • Lagging Indicators • No direct correlation to daily activities • Difficult to directly influence • Leading Indicators • Direct correlation to work activities • Easy to influence or control • Predicts change in lagging indicators • Quality indicators

39. Indicators of Worker Safety & Health • Lagging indicators • OSHA 200/300 logs • Workers comp claims • First aid cases • Use of temporary staff • Leading indicators • Injury risk indicators (ergonomic assessment) • Employee surveys: symptom surveys & satisfaction • Resident satisfaction • Safety audits

40. Direct Costs Metrics • Incident Rates • Used for comparison within facility and across the industry • Lost Workday Case Incident Rates • Severity Rates • Tracks changes in lost and restricted work days

41. Incident Rates Follow SRH program progress by • Tracking incident rates over time and compare to previous rates to give an idea of the program’s efficacy: IR = (# of incidents per year) x (200,000 hrs of work) (# of hours worked by employees) Ex: 3 MSDs x 200,000 hrs = 3 100 employees x (50 wks x 40 hrs) • Incident rates control for employee population change and employee hours worked so figures can be compared between facilities Lynda Enos, “Cost Justification of Ergonomics Programs,” Central Oregon Occupational Safety & Health Conference 2005

42. Severity Rates • Records of changes in injury Severity Rates (SR) can provide information about whether or not the program is reducing severity of injuries that still occur: SR = (# of lost or restricted workdays) x (200,000 hrs of wk) # of hrs worked by target population Ex: If MSDs keep 3 employees home for 20, 30 and 50 days, respectively: SR = (20 + 30 + 50) x 200,000 = 100 100 employees x (50 wks x 40 hrs) Lynda Enos, “Cost Justification of Ergonomics Programs,” Central Oregon Occupational Safety & Health Conference 2005

43. Workers Compensation Costs • Calculate cost per MSD by type and total MSDs • Calculate average costs of MSDs by type and total • i.e. Injury cost/# MSDs • Look at trends over the last 3-5 years • Assess impact on Workers Comp premiums • Gather information from • Workers comp carrier (SAIF, Liberty Mutual, etc) • OR OSHA • Loss Run Report

44. Indirect Cost Estimates for MSDs • Based on Oregon data, the average resident lifting MSD in health care between 1997 and 2006 cost $11,055 in medical and indemnity costs • Federal OSHA’s “Safety Pays” model – these direct costs correlate with an indirect cost of $12,500 yielding a total cost of $23,555 • Indirect costs vary considerably depending on many situation-specific conditions $afety Pays, OSHA, 1998

45. Successful SRH Programs

46. What makes a SRH Program successful? • Management commitment • Employee involvement • SRH policy • Education and Training • Worksite assessments • Hazard identification • Medical management • Program evaluation • Sustainability Humanfit, 2006

47. Successful ProgramImplementation • Tracks project closely • Identify projects • Assign responsibility • Monitor progress • Revisit goals and program plan often • Maintain management support • Maintain energy and enthusiasm • Communicate, Communicate, Communicate! As program matures (after initial successes and high risk hazards fixed) use employees teams to audit work areas and solve problems Humanfit, 2006

48. Why do SRH Programs Fail? • Lack of awareness of equipment • No program plan or project manager • Program plan not actively and consistently implemented and evaluated • No program coach or champion • Mismatch between equipment, task, and resident needs • Program scope too limited e.g. only administrative controls Humanfit, 2006

49. An Effective SPH Program isachieved when: • Goals are met • Early results are demonstrated and commitment ongoing • SRH incorporated into environment of care programs and the organizational culture • A proactive program is developed where ergonomics principles are incorporated into design/purchase of all equipment and processes Humanfit, 2006

50. Facility of Choice (FOC) in Oregon • FOC certification will verify that a facility has met criteria for a sustainable SPH program • Marketing benefits include: • Safe environment for workers • Nursing staff change jobs less often • Safe environment for residents • Residents cared for in safest way possible • Enhanced regulatory compliance • Improved facility efficiency LTC facilities can apply for FOC certification once SRH program criteria met