Thank you very much for all the kind
introductions.  It is true that I've known
Richard for quite a long time, so it's
been a special pleasure to be here today
and to learn that our work evolved
actually in some similar directions. I'm
the co-director of the Center for the
promotion of health in the New England
workplace which is funded by the US
National Institute for Occupational
Safety and Health as a center of
excellence in a program that's now
called total worker health which
really started as the idea of what
can be gained by integrating health
promotion in the workplace with
protection from workplace hazards so you
were just talking about health promotion
obviously which is an important area of
Public Health so it's been an
opportunity for me to expand my horizons
and at the same time our funding
mechanism requires a substantial amount
of our resources to go into
translational research and dissemination
to stakeholders so here is
Richard, now in charge of stakeholder
relations within CRE-MSD it just seems
like a perfect set of parallel tracks
and again I'm very happy to be here and
to have the opportunity to have some
dialogue with all of you. So
something nice was said about all my
publications you don't get that long a
list of publications working by yourself
so I have a very valued research team
I've put up a few names here but it's a
it's a large group of people who I've
had the privilege of working with and
learning from and I'll just say one
other comment by way of sort of
introduction coming from working on
musculoskeletal disorders in
manufacturing and in clerical work and
in construction and other sectors
into research on health care workers
about 15 years ago with some
intensity it was really quite
extraordinary
to bump up against such a deeply
entrenched idea that healthcare workers
should sacrifice their well-being in
order to take care of their patients and
to me it's a really fundamentally
contradictory assertion because if
healthcare workers are in pain, if
they're stressed, if the work environment
is not facilitating them working well,
how are they going to take good care of
their patients? So part of the challenge
I think in the dissemination and the
translation of research findings in this
sector, is to think about how can we make
this evidence persuasive to the
decision-makers in healthcare
institutions? The managers and the people
who are allocating resources so this is
actually I think a very important
challenge for public health as a field
because we're concerned about the
quality of health care and we're
concerned about the well-being of
employees.  So we have two reasons to be
thinking about these issues and I hope
that you'll give me some suggestions
about how we can be more effective
exactly in meeting that challenge. So I
am specifically today going to talk
about the results of 10 years worth of
funding which has produced a project
which was called Procare. Promoting
caregivers physical and mental health.
This has been a partnership with a large
company of long-term care services and I
have to say, I learned last night in
Canada, this is a little different so in
the United States long-term care nursing
homes and skilled nursing facilities
those are essentially synonymous so I'm
going to go among those three terms and
if to you they mean different things I
hope you'll cut me a little slack
because I probably won't be able to
remember not to do that.  So we worked
with this chain of nursing homes, skilled
nursing facilities which implemented a
safe resident handling program which
opened the door to us doing a very
comprehensive, multi-faceted evaluation
of that program.
And then as we got near the end of the
first five years of research, we started
uncovering more complications which
you'll hear about and so it raised
some bigger questions for us about
differences among centers even though
they all belonged to the same company
and looking at some of the kind of
larger questions led us very quickly to
this issue about the relationship
between employee health and safety and
resident well-being as well as
other characteristics and in fact again
there's been some groundbreaking
work I would say in Canada and thinking
about kind of leading indicators what
can we intervene on early to prevent bad
things from happening? And those bad
things could be to the patients or to
the workers or both and so this is
the kind of the sets of questions that
that I'll then come to as we moved on
in our second five years of funding
which we're in the process of wrapping up
right now. So this company implemented as
I said a safe resident handling program
which was quite well thought out it had
very detailed policies and protocols I
won't flesh them out in detail but I'll
just say that this is a third-party
company that created this program which
was then implemented by the nursing home
chain and the third party company is a
group of nurses who had seen what can go
wrong when a program isn't well designed.
How the idea can be implemented less
than successfully when there are
obstacles in the workplace.  So they
really thought it through quite well and
we were very impressed just at the very
beginning we were very impressed by the
the depth of the analysis that lay
behind all the details of the program
itself.  So as I said, we started out with
the question of is this program
effective?  And how do you define
effective?  So there are lots of
different ways you can think about
success of this
and then we kind of happened on the
question of whether effectiveness varied
either among centers? Or at the level of
the individual workers?  And then that led
us to some questions about the
implications for resident satisfaction
or for clinical outcomes. So as you can
see, over ten years we did a lot of work.
This was really a pretty ambitious
undertaking.  So we made direct
observations of direct care staff;
nursing staff working in patient care
and we used those observations to
characterize ergonomic exposures,
which is the first set of results
I'll show you.  We then analyzed workers
compensation claims and costs, this was
the big motivation for the company to
implement this program in the first
place, so we looked at injury rates as
well as recurrences of injuries and we
also looked at return on investment of
the program.  So we-got, we had an
economist who conducted those
analyses.  We also did a large number of
surveys of individual workers in a large
number of these facilities and some of
the data that I'll show you, there are
many papers that we've published out of
that, but two that I'll show you are quick
excerpts from our workers
self-reported use of equipment and low
back pain.   And then we looked at the
relationship between employee and
resident outcomes from another set of
surveys conducted by a different
third-party company that surveys
thousands of nursing homes around the
United States every year and we also
extracted data from the Center for
Medicaid and Medicare services which is
the government agency that oversees
long-term care and to which all nursing
facilities have to submit data every
quarter about their resident status.  So you can see we had many different
types of data and I will try to get
through this efficiently but hopefully
without being unclear if there's
something I say that really doesn't make
any sense it's fine to raise your hand
and ask
a quick clarification. So the direct
observations were using a method that we
actually developed a couple of decades
ago within my department to have a
systematic observational protocol for
observing workers postures, activities,
tools and handling, that's the path. And
specifically, we customized it here to
add whether or not workers were using
resident handling devices, lifting
equipment in addition to their
ergonomic feature.  And we made these
observations, there's this little
timeline is going to keep showing up on
these slides, so we made these
observations at baseline which was
literally the week in each center when
the first all department meeting was
held about the safe resident handling
program being brought in so that
counts as the intervention date and then
we had follow-up observations at three
months after baseline, 12 months, 24 and
36. Some of the surveys went on even
longer you'll see you later. And the data are
collected in a categorical form so this
is just one example, what the trunk
posture categories look like so they're
a little bit crude but it permits us to
make visual observations and our
protocol involved making observation,
following each worker around for hours
at a time and at 60 second intervals
recording what the person was doing
their postures and so on.  And you can see
we collected thousands and thousands of
data points which then get summarized
into some hopefully useful results. So
for example, we found that some of these
centers actually had some resident
handling devices already in place when
the program began.  So the use of lifting
equipment is not zero at baseline, it's
it's at about ten percent of
observations and there wasn't much
change in the first few months but then
you can see that the use
of equipment during resident handling
work increased steadily over the course
of three years. If I showed you the
graph just for transferring, that is,
taking the resident out of the bed into
the wheelchair or from the wheelchair to
a chair or from the commode into the
wheelchair that percentage of
tasks in which the equipment was being
used was much higher.  And you can see
that the frequency of high weight in the
hands went down notably over time so
these increasing bars are for the lowest
weight category and the highest weight
category went down that's all
good that's what we were hoping for.
Similarly, trunk postures improved quite
a bit so this is the increase in the
percentage of time in which the trunk is
neutral a person is standing upright not
twisting and you can see decreases in
moderate flexion, severe flexion, lateral
bend or twist with or without flexion.  So
so all of these were changes in the
right direction.  As well and we had
similar observations for arm postures, that
less of the time, the arm was elevated at
shoulder height or above.  And also
interestingly there was no increase
observed in the total proportion of
resident handling time even though how
much time it takes to use these devices
is often cited as an objection against
them, we did not see that increase in our
observations.  We put all these different
pieces together to
compute a physical work load index so
this red line, and don't worry about the
units, they're kind of arbitrary but this
red line shows you the physical work
load index score for nursing assistants
while they are performing resident
handling.  And you can see it's a quite
notable drop down so there's a little
getting used to the devices in the first
three months but then a very notable
drop and this is essentially loading on
the lumbar spine while performing
resident handling tasks.  So a really
tremendous drop in that exposure.  And
just to, sort of anchor that, the orange
line is for all nursing assistant work
whatever they're doing; pushing a
cart or getting a meal on a tray.  And
the green line is for nurses, RNs and
LPNs who in nursing homes don't perform
much resident handling, so they
have much less loading on the spine. So
that's a good story but then this is
really interesting in five centers where
we made repeated observations over this
two-year period, the slope downward
in the physical work load index so the
kind of summarized trend here for this
red line you can see it's much steeper
for this centre "B" and almost as steep
for centre "D," but for the other three
it's much closer to flat.  So there wasn't
the same decrease, it wasn't the same
relative decrease in physical work load
over time, which was the first indication
we had that there were these differences
that we really hadn't anticipated.
Because again, the same program, same
protocols.  No reason why there
should be this level of variability
among centers.  So looking kind of post-hoc just at these five centres, we found
that this particular centre that seemed to have the biggest benefit in terms of
biomechanical loading on the spine of the individual workers, they also had,
according to the employees themselves, less time pressure, better communication among staff
and more access to equipment and devices when they were needed.
So there were organizational features which
also varied among the centres that
seemed to be predicting what the kind of
moment by moment exposures were of the
individual workers. Okay hold on to that
thought. So now as I said, the workers
compensation experience was an important
motivator for the employer.  So these are
data for the rates of injury claims for
clinical staff and specifically pulling
out the claims where resident handling
was coded as the cause of the incident.
And the rate of those claims in up to three years before the program was
implemented was about 9 per 100 person-years dropping to 6 per 100-person years,
pooled across 136 facilities.  So a quite notable decrease
in the risk of resident handling related
injury claims. Most of these were back
injuries.  We looked at some of the
subcategories of types of injuries, so
these were all resident
handling.  And we actually separated this
into the first three years after and the
second.  Because, in the first three years,
the third party company was in charge of running the program and then after three
years, they handed it off to the individual centres to manage it.  So we
were really curious whether the company
could continue the keep the program
effective after they didn't have someone
else doing it for them.  So the good news
was, that at least as measured by workers'
compensation claims, the answer was yes.
Because you can see that the rate of all
resident handling claims stayed low.  And
then looking specifically at some of
these subcategories, claims where the
incident was coded as "helping in and out
of bed," those were those went way down
after the program, so these are all before after.  The ratio of point five means that you've halved your risk,
right.  So those went down and stayed down.
"Helping in and out of chair or toilet,"
went way down and stayed down and the same for the resident handling not
otherwise classified, so we didn't get a subtype there.  The "help move in bed"
didn't really change, it stayed about where it was before the program.  And then
you can see this quite unexpectedly, "help in and out of bath," the risk the rate
went up and then went up even more.  And we don't have any idea why, really can't
tell you, and we haven't been able to figure that out with the company either.
The "help move in bed," so this is not
about lifting someone out of bed, this is repositioning and this can be actually
quite strenuous because you're having to lean onto the bed you're leaning down
you're leaning forward so it's biomechanically quite disadvantageous.
And there are low-tech devices that reduce friction; slide boards and slip sheets and things like that.  And these
were also part of the program.
There were devices like this that were
purchased in addition to the whole body
lifts.  But we actually didn't see them
very often when we were out on the floor
making observations.  We don't really know
what happened to them.  Did people take
them home?  Did they get thrown out?  Did the
residents take them?  We don't know, you know, did residents' family members take
them home?  We have no idea what happened
to them.  They weren't chained to the bed, we know they were purchased, we don't
know where they went.  But we didn't see them in use.  So then, it didn't surprise
us so much that the "help move in bed"
risk didn't change over time.  But it
wasn't something that company had been
monitoring on its own at this level of
detail, so that was important
feedback.  So going along with the
decrease in rates of injuries of course
we expected to see a decrease in cost as
well and in fact, our economist has
published that paper a few years ago.  She
estimated that the total savings to the
company in the first three years after
the program was implemented was four and
a half million dollars a year, US dollars
a year, that the program would pay for
itself between one and two years after
implemented and the range is because
there were in addition to reduction in
costs of compensation claims there was
also a reduction in employee turnover,
which is very expensive and but we don't
assume that all of that was necessarily
due to this program and there are also
different ways to attach a dollar figure
to what the turnover cost so we played
around with some different numbers and
we used the the smallest one so to be as
conservative as possible and still the
program would more than pay for itself
within two years.  And to put it in terms
that have meaning to the nursing home
administrator, individually, the average
net savings is equivalent to a hundred and forty-three dollars per bed per year.
Which is quite substantial, cash flow is
always an issue in this industry. But/and
you can see again a tremendous amount of
variability from one centre to another
all within the same company.  So 61
percent 61 centres that realized savings
49 that didn't. Of the ones that realized
savings some of them saved an enormous
amount of money over this three-year
period and some of them saved very little
and conversely there were some that had
lost money during this time. That was
also extremely surprising to us.  So we
started digging around and to that, what/how can we understand that better? And we
found a few different patterns; so one is
that in the homes that in the facilities
that had, by then, accrued more than five
years of experience with the program,
they had much higher savings.  So there is
some maturation of the program there's
some institutional learning.  I don't know
if anyone here has knowledge about that
kind of organizational development
issues and organizational psychology but
this is clearly a piece I think of
what's going on here is the is the
learning and the incorporating the
program and into ordinary daily practice.
Then there's another piece of this, which
is really quite intriguing, so some of
these centres also had workplace health
promotion programs in place
simultaneously with the the resident
handling program.  So this is centres
without workplace health promotion
average net savings of about thirty
dollars.  Centres with simultaneous
workplace health promotion programs
average net savings about one hundred
and eighty dollars.  Enormous difference.
But here's the really strange thing, when
we looked separately at the workplace
health promotion programs we actually
didn't find much evidence that they were
achieving their goals of reducing
smoking or increasing exercise or weight
loss.  So how could they have this
enormous impact on the effectiveness
of reducing back injury rates if it's
not through those mechanisms?  So this
brought us back again to questions of
the larger work climate because when we
looked at some of the other survey data
we found that these centers also had,
according to the employees, better social
support, lower intention to leave the job,
so there was higher job satisfaction in
the centres.  Which makes me think it's
okay, what is the workplace health
promotion program a marker for?  Maybe
it's a marker for an administration that
is concerned about work or well-being
and even though what they're doing isn't
having that much effect, the the desire
to create a more health promoting
environment is somehow being experienced
by the employees in some other way even
if they're not stopping smoking or
getting more exercise outside of work time. 
 So again, I think a topic that
really has been looked at a little bit
here by Dr. Yazdani but which really
needs to be dug into quite a bit more
and which which we're hoping to continue
to do in future work.  So I mentioned
another aspect of what we examined was
in recurrence of back injury.  So you may
know claims where individuals are absent
and then return to work and then have
recurrences, these are compensation
claims that are far more expensive both
in terms of lost wage replacement what's
called "indemnity" and also in terms of
medical costs.  These are, these tend to be,
much longer absences with the with the
recurrence when the person has hurt a
second time, people have much harder time
coming back to work, the medical costs
may be much higher and so this bar chart
but and no one has really looked at this
kind of secondary prevention aspect of
safe patient handling programs before
that we're aware of so please correct me
if I'm wrong because this paper isn't
published yet but it's it's it's under
review.  So here's the reduction
in resident handling-related injury
recurrences over this 9 year time period
before the program and then in the two
after periods.  No change overall in the
recurrences of non-resident handling.
Resident handling claims specifically
causing back injury the recurrence rate
went down and again not so for claims
that were not associated with resident
handling.  So so fairly impressive changes
there.  And again, we did an economic
analysis and found just looking at the
numbers of recurrences, so if you think
the the number of occurrences would have
continued as they were but we had this
impact so that the difference right it's
like the difference between the height
of this pale blue bar and the yellow one
right that's the that's that space is
the avoided cost.  So if you if you
compute that out and add it up, the total
six year savings for all avoided
recurrences was about 3.8 billion U.S.
dollars.  So per year is this number and
per centre is about four and a half
thousand dollars so again a very
substantial savings for a center with
maybe 100 or 125 employees.  Okay next
piece of the study was the the self
reports of back pain and also self
reports of resident handling equipment
use from surveys.  So we surveyed
thousands of employees at a couple of
dozen of these centres, so about ten
percent of the company overall we
couldn't afford to do all 200 nursing
facilities.  But we did collect thousands
of data points and we have here pulled
out the survey data for eight centers
where we did four surveys now over a
longer follow-up period.  So so at least
five years after the program was
implemented.  And this is about, first of
all, just the frequency of equipment use
according to the respondents themselves.
So you can see the good news is about
two-thirds of them said they use
resident handling equipment "often" or
"always" when they were handling residents.
About twenty percent said "sometimes" that
did go down over time, these to me
represent a real opportunity for
intervention because these are people
who either aren't motivated or they're
not sure how to do it or even though
they've been trained or external
circumstances may be impacting them more
than other people.  And then a pretty
small proportion this is this is very
good news from ten percent down to five
percent eventually said "never" or "rarely"
so so quite high equipment use
corresponding also to what we had
observed that I showed you earlier.  And
then with some fancy multi-variable
modelling, we identified factors at the
individual level that were associated
with use of equipment.  So three of these
are kind of personal characteristics, "I
expected the program to be successful so
I use the equipment more often."  Health
self-efficacy, some of you may know is
the idea that I can do something to
improve my health, to protect my health
so again that's not really surprising
it's perhaps a little bit of a
self-fulfilling prophecy.  But that's it
that's the thing to think about how can
we enhance that.  And then interestingly,
older workers were actually a little
bit more likely to say that they use the
equipment.  So whether that represents
having seen people be injured or having
themselves had back pain and recognizing
the value or maybe just for feeling a
little more vulnerable as you age to the
possibility of injury.  And then there
were three work environment
characteristics that predicted people's
likelihood of using equipment.  One was
their perception of institutional
commitment to the program and this was
at multiple levels; so it included "my
supervisor supports people to use the
equipment," "if I have input about the
program it's listened to and respected
by people above me" and also "I support my
co-workers and using the equipment" so it
was kind of a multi multi level score.
Very interestingly, because I think
there's a tremendous interaction between
resident handling and the issue of being
assaulted by residents, those who had who
had not been assaulted at the workplace
recently were more likely to use resident
handling equipment.  And I'll come back
to that topic.  And then kind of
surprisingly, lower supervisor support
was associated with higher use but I
think there was some negative
confounding between that and the
institutional commitment.  So then we
asked if you don't use equipment when
you're handling residents, what's the
reason?  And the two biggest ones were
"device unavailable when needed" that's
these bars which bounced around a little
bit up and down but but are in the range
of twenty to thirty percent of the
people who answered that question and then
"the residents dislike them" which is a
pretty constant fifteen percent of
responses.  So those are really the
big two that needed attention the other
three, "not enough time," "takes too much
effort," "my co-workers don't use them." They were small and they went down quite
markedly over the course of the program.
So that may be part of the the
institutional learning it is those those
things becoming less of an obstacle over
time.  And interestingly, even among the
people who said they "always" used
equipment, these two issues of; "the
residents dislike them" and "the device
isn't always available," those remained as
high responses.  Which I think means, "I
always use these devices except when..." And
this is really important because these
are the people who are really motivated
to use them who are really trying to be
consistent and yet they're running up
against these obstacles.  So these are
very important places for us to
intervene and help the program be more
successful.  Okay and then just to sort of
close the loop with the workers
compensation claims we wanted to also
look at self-reported back pain.  So we we
asked about that in the survey.  You can see
that overall, the prevalence went down
from baseline to five-year follow-up.  It
went down a bit not enormously went down
about twenty percent or so and and then
we did a lot of modeling of this of
these questions in several different
analyses this paper has just been
accepted for publication.  So so the key
that a red star here is to draw your
attention to people who use the lift
equipment more often were less likely to
have back pain.  This is two years after
the program had gone in.  There was also
this kind of residual association with
higher physical workload variability
workload as well as psychological job
demands, which does overlap a little bit.
And again, the association with physical
assault, so people who'd been assaulted
more recently were more likely to have
back pain.  Whether that's mediated
through lift use or not, I don't actually
know.  And then looking at follow-up over
a five-year period where, of course, the
numbers dropped off quite a bit from
baseline to follow up but you can see
that the impact of lift use frequency is
even greater there.  So, it's observational
it's not a randomized clinical trial but
it's it's a notable apparent impact from
as much as we can determine.  And then the
last piece of what I promised you is
about the relationship between the
experiences of nursing home workers and
residents.  As I said, these data come from
third-party surveys we didn't collect
these surveys are completely independent
of our estimate there they come from an
enormous database of thousands of
nursing homes or we extracted the data
points that applied to the centre's
owned by this company.  And we computed
centre-level averages for employee
satisfaction, resident satisfaction and
centre-level rates of resident falls,
pressure ulcers and medically unexplained weight loss.  So,
these are obviously objective adverse
outcomes to residents and those are data
that are reported to the federal
government every year.  So this is just
the simple XY plot: average employee
satisfaction on the x-axis average
resident satisfaction on the y-axis you
can see a pretty nice trend.  A lot of
people talk about this issue, not enough
people have been able to produce
empirical data.  So this this is I think
really noteworthy and this paper also I
hope is very close to being published.  We
these are obviously these these are the
five year average values we did the same
analysis with a multi-level analysis of
year by year data and found the same
trend.  So essentially, for every one point
increase in employee satisfaction on
this sort of arbitrary index that goes
from one to five for every one point
increase you have about a 1.7 point
increase in resident satisfaction that
corresponds to that.  So that's that's
important because nursing homes at least
in the United States compete with each
other for market share even as even as
manufacturing companies do, so so
resident satisfaction is a very
important feature.  And in the multi-level
models employee satisfaction explained
about twenty five percent of the
variability in resident satisfaction
which is large, quite impressive.  We also
looked again at the at the associations
with these objective outcomes.  So this is
taking employee satisfaction score as
the predictor again kind of think of it
as on the x-axis and so you can see that
the risk of adverse resident outcomes
goes down as the employee satisfaction
score goes up.  So that's also quite
compelling because nursing homes are
rated by the Center for Medicaid
Medicare services you can
look up any given nursing home on the
website and you can see, how well does it
do and taking care of its residents? and
so if there's something you can do to
improve the reduce the risk of these
outcomes that is again going to impact
your your competition for market share,
basically.  So then we took this even
further we said you know we have data on
so many different characteristics of
these nursing homes if you pull it all
together into one pot.  So we used cluster
analysis which is sort of like a
correlation or analysis of variance
except that you're grouping the
observations not the variables.  So so
this was a way to see how many groups of
nursing homes are there, if we say make
that make the groups as similar as
possible according to this set of
characteristics.  And we ended up with
basically two clusters so the blue ones
are kind of the good ones if you'll
permit me to oversimplify so they're
there they're above zero basically on
the x-axis and the red triangles
represent the nursing homes that are not
doing as well.  And there is a little gray
area in the middle but there's not a
phenomenal amount of overlap, actually.
And so hold on to the blue, blue is good.
And so that's cluster one.  So the cluster
one nursing homes, which are about sixty
percent of the total, they have a higher
employee satisfaction, higher retention
annual retention of nursing aides also
by the way of LPNs and RNs, they have
higher staffing ratios which has been
shown to be associated with both quality
of patient care and other outcomes in
healthcare.  They had lower rates of
pressure ulcers, falls and medically
unexplained weight loss and they had
higher resident family friend
satisfaction and higher survey ratings
which is one of the scoring scores
that's produced by the Center for
Medicaid/Medicare Statistics.  And then we
did a post-hoc comparison looking at all
the other variables we hadn't put into
the cluster analysis because we were
worried about waiting and and things
like that.  And again, as I said higher
retention rate of the other clinical
staff lower so a bigger change in the
workers compensation claim rate relative
to baseline.  So cluster one, the claim
rate went down clustered to the claim
rate went up; so remember there were some
centres that didn't have a benefit from
this program?  A higher rate of return
while a positive return on investment
from the safe resident handling program,
whereas, the cluster two basically did not
see a return on investment.  Better this
is another one of the CMS ratings and
then also interestingly they were more
likely to be unionized centres.  So a
whole range of organizational factors
coming into play that are associated
with the literal day-to-day experience
of the aides handling patients in their
rooms; getting them on and off the toilet
and in and out of the bathtub.  So again,
just such a great place to be having
this conversation because I know that
some of these issues are often under
discussion here as well.  So summing up so
so we we found that resident handling
equipment use increased, exposures
decreased, compensation claim rates and
costs decreased, overall turnover rates
decrease.  So overall, the really good news
for the company; yes, your investment was
very worthwhile look at all of the
different ways in which the the physical
work was improved and the costs to you
as the employer were improved and look
at all this variability among these
different facilities all belonging to
the same company.  So so these
characteristics of centres, which can be
improved upon.  The first four at least you
think of as kind of predictor variables
you could think of these as leading
indicators these are things we could try
to improve and we could expect to see a
better return on investment separate
from whether you bought the right
equipment, right.  This is kind of the
context in which that equipment is being
used.  And then the the latter two are
more like lagging indicators, I think.
Maybe not.  It's a little bit hard to tell.
But certainly, they ought to be quite
motivating to top leadership in terms of
where they put their resources.  And then
lastly the the variability among workers,
how do you use that?  Are there ways that
we can provide training in different
areas that can help to address some of
these issues?  Is there is some of the
between worker variability a function
of individual supervisors and their
supervisory styles?  Are there ways that
we can improve supervision quality to to
address some of the differences that we
see among workers even within the same
nursing facility?  And then as some other
things I'll just note quickly in terms
of room for improvement.  So the the lack
of the what happened what happened to
the low-tech slip sheets and transfer
boards?  The problem of devices and
equipment not being fully available even
though supposedly the right number was
purchased for every resident in each
facility.  The issue of adequate staffing
which directly impacts time pressure
which as I mentioned is already has been
highlighted quite a bit in research on
health care worker health and safety.  The
issue about residents not liking the
devices, so there are nursing homes where
when you bring in a new client actually
part of the education of the resident
and/or their family members is to say, "we
have this program, this is to protect our
staff and you get a benefit too.  This way
your mother or your grandmother is
always going to have a consistent
caretaker that person isn't going to
need to take time off for injury they
can be fully there and feel confident that they are doing
their job in taking care of your beloved
family member without putting themselves
at risk."  And this company, for reasons
that I really am ignorant of, isn't hasn't made that one of the features of
their program, but I think would probably
be well advised to because it remains an
obstacle to devices being used.  And then
the issue about assault because we've
we've found in here it so this is an
epidemic in healthcare workers in the
United States I don't know if it's as
big an issue in Canada but it's it's
huge in the United States in every kind
of setting outpatient inpatient it's
it's quite common in nursing homes it's
we could have a whole sociological
conversation about that but it's quite
common in nursing homes, its associated
with back pain its associated with with
nursing aides being afraid to use
lifting devices and there's apparently
something about the the proximity of the
physical contact between staff person
and resident that puts them at risk of
being lashed out at by someone who's
unhappy or angry or frustrated or you
know just doesn't like the fact that
they no longer live at home or they're
paralyzed or they can't do some of the
things that they used to do.  So that's a
that's a piece also that I think needs a
lot more attention and the connection
between these two between resident
handling or patient handling and assault
I think really deserves a lot more
attention.  So why don't we have public
policy about this?  If there's all this
evidence, what do we need to do to get
that evidence translated into protection?
If it's so obvious that this is the
right direction to go?  So there are a
number of national organizations in the
United States that have been way out in
front that have provided detailed
guidelines for what patient handling
programs should look like, including, FGI.
Facilities Guidelines Institute is
actually a branch of the American
Hospital Association which has published
minimum standards for the design and
construction of hospitals and outpatient
facilities and and long-term care
facilities to make it easier to use lifting devices and and
and as well specifically occupational
health and safety professionals.  And and
actually, a national federal bill was
introduced in 2009 and then again in
2013 and then again in 2015 and if you
are aware of what's going on in our
Congress, you won't be too surprised in
here hasn't gone anywhere.  But there has
been an attempt to create federal
legislation that would protect health care workers.  But since that's not
happening, some of the states have moved
ahead with their own laws or regulations
most of them understanding that it's not
enough just to buy equipment and stick
it in the back of a linen closet that
you really need a comprehensive program
that ensures that the equipment will be
used and that you also need to be
collecting data and evaluating how well
it's working and finding out if there
are things you need to fix.  So we don't
have a law like this in Massachusetts
yet, where I come from, but I was
privileged to be on a task force for a
couple of years that tried to do some
data gathering and generate some of the
local evidence for this.  And you might be
aware we have some world-class hospitals
in Massachusetts, but we also have a very
high rate of health care worker injury.
So what what is what is going around
going on specifically within the state
of Massachusetts was was of interest was
of concern.  So one of the things that we
did was to survey all of the hospitals.
So hospitals are actually licensed by
the Department of Public Health, so when
DPH sends out a survey, you get a good
response rate, they pay attention.  So we
got a very good response rate on this on
this survey of hospitals within the
state and I tried to just pull out a few
bits of the findings, although I think I
put too much on these slides.  But sort of
the bottom line is, forty-four percent
said they had a written safe patient
handling policy that was actually in practice.
Another twenty-two percent, they were in the process of developing one.
Thirty-four percent just said no.  Of them,
some actually had a safe patient
handling committee even though they
didn't have a written policy but 16 that
is about twenty percent of the total
number of hospitals who responded didn't
have either a committee or a policy
which was really surprising to us
because we like to think of
Massachusetts as being kind of state of
the art in terms of health care.  The the
hospitals that had programs were
doing a pretty good job of getting staff
input on the selection of devices.  They
did a better job of assessing events
when there was a patient impact, if the
patient fell during handling they were
more likely to go investigate and
understand what had gone wrong.  They were
a little less likely to follow up if it
was only the worker who had been injured.
There was a lot of variability in the
this says safe patient handling policy
component, so there was a lot of
variability in what elements each
hospital had within their policy.  Mostly
they were pretty strong on the clinical
practice side, they were a little bit
weaker with regard to making sure the
equipment was always available and
working, there was not such a good
reporting of near-misses or incidents
that could have led to injury but
happened not to in a particular
situation.  Similar to the nursing home we
worked with, there wasn't as much in the
way of patient and family education as
would have been desirable.  And there was,
this is, kind of an interesting problem.
So so actually, minors under federal law
minors aren't allowed to do certain
kinds of jobs that are hazardous and
using hoisting equipment is one of those.
So sort of paradoxically, employees under
18 actually shouldn't use patient handling devices because that falls
under this big category of hoist equipment which is potentially dangerous.
So the the optimal solution is to say those
young workers shouldn't be doing patient
handling shouldn't be putting their
backs at risk either but but that is
something that most of the hospitals
weren't aware of and weren't weren't
addressing.  And then I think maybe I'll
wrap up here.  But so that so this kind of
pulls it back to some of our nursing
home findings.  So these were questions in
the same survey about why what what do
you see is barriers to addressing
patient handling within your facility.
And the respondents were not frontline
workers; they weren't the nurses or the
nursing assistants they were, well we
actually didn't know in many cases, but
it could have been the HR director who
filled out the survey or it could have
been an employee health nurse so it
could have been someone with knowledge
of the program but not necessarily.  And
so you can see, perceived increase in
time required to use appropriate
equipment was actually the top
vote-getter.  Now in our survey, that was
in nursing homes, so maybe that's
different from hospitals but we actually
didn't find over time that that really
was a big problem.  But it was from
these hospital administrators or whoever
the respondents were, they did see that
to be a very big issue.  So whether that's
actually grounded in fact or not, we
aren't certain of.  They also thought it
was very hard for staff to break habits
again our data would suggest that over
time that's really not such a big
problem, that's an initial hurdle but you
can definitely get through that.  Cost of
course was was of concern; again return
on investment is pretty good so you do
have the initial outlay but if you're
going to make it back within a couple of
years you probably could manage that
unless you're a very small community
hospital that has cash flow issues.  And
storage space and room size are also
understandable issues, so where are you
going to keep the lift devices?  Are they
going to be easily accessible or buried
behind other things?  Is the room big
enough to bring a portable whole body lift
into the room?  How does that impact your
patient census if you have to have fewer
beds in a room in order to have room for
the lift devices?  And of course, you're
going to have less income so so it is an
economic issue very much as well and
it's again hard to fix unless you're
designing or renovating a facility.  So we
made a bunch of recommendations to the
hospitals about implementing programs
and doing surveillance and evaluation, we
made recommendations to workers
compensation insurers and consultants
and the architects who design facilities and
people who provide training.  We made
recommendations that we the task force
made recommendations to the Department
of Public Health about staying on top of
this issue following through and in fact
now there is a working group with many
different stakeholders involved and
we're actually doing focus groups of
different parties.  So we're doing focus
groups of hospital administrators and of
employee health nurses and of frontline
nurses, trying to understand from each
party's point of view, again, what are the
obstacles that they see and and then
we're going to compare and see how do
those line up and what does that mean in
terms of activities that the Department
of Public Health should promote in order
to move forward with prevention.  So
that's that's it.  I know I covered a lot
of ground very quickly a fair amount of
this has been published and I'm
certainly happy to provide reprints to
anyone who's interested.  I thank you very
very much for your attention through
that long saga and would welcome any
questions.

Thank you, Laura.  We will let you handle questions.
Sure.
Questions from the floor?
If you can remember anything I said.  Jack.
Yes, thanks Laura.  That was a lovely, comprehensive showcase
of how simple physical interventions can have financial impacts.  It becomes this big, multifactorial issue.
It's lovely.  Especially when it's successful.  That's always lovely to see.
Yes.  You're always happy to write
to have a good to have a basically good
story to tell, yes, fortunate.
There were some weird flips in the graph at your 3 month period, right?  For both
the weights handled in your low back scores.
They all went up at three months and then
tailed off.  Why do you think that is?  I don't know.  I think that
some of the, so if you remember the reasons for
not using, the "not enough time," "too
much effort," "my co-workers don't use them."
Those were the first survey where we
included those items were at the 3-month
point and those all were notably higher
than they were later on.  So so this is
where I feel reasonably comfortable
saying, you know, you just have to tough
it out through that learning process.
That things are awkward, there's maybe
some resistance the three-month point
was the deadline for every nursing aide
to pass a kind of a competency
evaluation for using the equipment so
there was a lot of hands-on instruction
but you had demonstrate that you knew
how to use all these devices to keep
your job.  So, whether that meant that
people were working more slowly or more
awkwardly up until that point, you know, I
don't actually, I don't know.  We, you know,
there's always there's always data points you collect that you don't use
and then there are other things you say, I wish I had been prepared to study that
in more detail.  And I wish we had been able to
mount some focus groups right around
that time period and see what people
thought later, with what the frontline
workers thought then and later about
what that was about.  You may have ideas and I'd love to hear them.
Yes.  It's fascinating, your answer because I then go back to Richard and Bob and the paper that showed
the increased time and increased cumulative load when they're using these devices.
Right
How long was that?
That was a snapshot, it wasn't too long.
So I wonder if it's just that learning phase of using it.  That they're slower and once you  get over that
3 month hurdle, then they become efficient at using the devices.  Almost has a skill component or something.
Yes I know, I know.  We asked if there was
any way to assess that and we were told
no, you know.  People either pass it or
they don't.  And if they don't, then they
don't stay.  So there wasn't really, you
know, the comparison group is gone
the control group is gone, so we didn't.
In fact, they couldn't, I also
asked could you please tell us who the
trainer was at each facility so that we
could group on trainer because I can't
believe that every trainer is equivalent.
Even if you put this I mean right you
have different teachers and even if
they're covering the same material some
people are just better at explaining
things and helping you grasp the
concepts and the skills.  And so, even
though it was the same curriculum, I
couldn't believe there was no difference
among trainers but they wouldn't let us
have that information so we we couldn't
look and see whether one trainer was
better than another and they just kept
saying, "Oh no, of course not. That can't be."
Yes.
Thanks for your talk.
At several points you say that you further look into the evidence on
the potential importance of resident characteristics, so I wonder if you've done
anything to do some risk adjustment at the facility level for the types of residents the facilities are serving?
Because you probably want to be sure you can control for that because its almost certain the case mix will
vary across the organizations.
Yes, that's a really excellent question.  So we
we did several different things, one is
that for the centre-level analysis, so we
have to do all this at the centre level.
That's one thing because of issues about
confidentiality of resident data we
don't have one resident at a time
information we have pooled at the centre.
So we have the proportion of residents
who are whose stay is reimbursed by
public funding, Medicaid or Medicare so
we adjusted for that in all the central
level analyses that I showed.  We were we
have downloaded data on activities of
daily living scores and those also we're
in the process of computing kind of
centre-level indices, I think.  For example,
how much assistance residents need to
ambulate? Right?  To move that would be
presumably extremely important for for
this particular topic.  So we are going to
put that into the mix and see if it differs.
Yes, so I think nursing home compare does have  data.
They do, exactly. That's our source of right.
Probably also has  which will give you a good
comprehensive case mix, if that's something you could use.
Perfect. Thank you.
Great.  Good.
Other thoughts? Yes.
This project has been fairly long and too often, you want to get funding for these long studies where
the effects have become obvious but the second
piece is perhaps because of the earlier
date and you didn't mention ceiling
devices which are used more frequently now
perhaps.  Was the was this company not
using those?  Or have they moved to those? Or was there any idea of moving to those?
Yes, this company,  I think it's fair to say, didn't buy the Cadillac
devices.  And and that's and that's even
within the range of the portable devices
I had a picture at the very beginning,
didn't I?  The portable devices that are
I guess I maybe.  Yeah, the portable
devices that roll around from room to
room.  That's what they had.  So these are,
this as you can see, is a device that
rolls under the bed and then you roll it
away again so you move someone not from
an overhead track.  So even among this set
of devices I think there are better ones
but the ceiling lift systems are
definitely more reliable.  They'll not
there there I think, they last for much
longer and they don't pose some of
the same problems about how much space
you have within the room because you
aren't having to bring this thing in
around the bed or the chair or the
toilet or what have you.  So, but, the
company didn't make that kind of outlay
and they aren't they haven't and to the best
of my knowledge they're not planning to.
I guess for the study makes it a little stronger; that even with fairly minimal
set of devices, you were still seeing effects.  Yes.  I mean, I don't know if I'd
call this minimal because they purchased
quite a lot of them, it wasn't just you
know, one per centre kind of thing it was.
But but yes they could have done better
and they probably would have seen even
greater benefits so so for them they're
satisfied with what they achieved but
but from a larger context I think that's
right if you spent more money on better
devices I think you would probably have
a greater return on investment.  You might
have to wait a little longer but I think
you would realize it within a relatively
short period of time.  I wanted to say two other things about this sort of
maturation thing.  Where it's always nice
when your findings converge with
somebody else's.  So we have a postdoc
who's just done a meta-analysis of
safe patient handling programs in
hospitals, Erin Teeple.  I think it's
in press now.  And in the meta-analysis, they showed that the programs that had
been in effect for the longest when they were evaluated had the greatest return
had the greatest reduction in injury
rates.  And there was also a paper a
couple of years ago that some European
colleagues worked on, Svend Erik
Mathiassen and a couple of other
people I want to say.  I can find the I
can find the reference list later but
they did a kind of a Markov simulation
and they predicted that it would take
six years for the maximum benefit in
terms of reduction in low back pain.  So
well both of those quite reassuring.  Yes.
Laura, thanks for the great talk, appreciate that.  Laura, given this is in this total worker health program,
total worker health program, the health
promotion piece I didn't see a lot of.
What's the feeling, I guess in the group of
what's happening there and how do you
sustain a total worker health program
given health promotion isn't seen widely?
Ya, I didn't tell that part of the story so much so
we did we did analyze, I showed
you one slide that had the centres that
were running the company-sponsored
workplace health promotion program.  That
was a pretty low resource effort and it
wasn't one that the company sustained
for a terribly long time.  So as I said, we
didn't see a lot of benefits in terms of
personal health behaviors where you
would have expected.  A little bit but a
little bit of a reduction in smoking but
really, not much but a good program
really takes a lot of resources and this
one didn't have those kinds of resources
invested.  The other, there was actually a
third arm to this study which was that
the company, in addition to, I have to say,
providing us with enormous amounts of
data as you can see and phenomenal
access for observations and surveying
and answering dozens and dozens of
questions every year they also permitted
us to to pull out three facilities where
we actually implemented a participatory
what what they ended up calling, Health
and Wellness Teams but which were really
kind of founded on participatory ergonomics
principles.  And where we put in
front of the workers the idea of, you
know, your health is impacted by so many
things things at work things outside of
work let's talk about that whole range.
And the workers found this a very
natural idea not in, I mean, they
weren't hung up on disciplines about, you
know, health promotion and occupational
out they were like, yes let's talk about
the whole mix there's this and this and
this.  And they were very enthusiastic
actually.  They started out was kind of
easy things, well what we thought would
be easy, like getting healthier food in
the vending machines and then they moved
on to sort of scarier stuff about
quality of communication and quality of
supervision and whether their
supervisors respected them and whether
they could really have some input into
how things were done.  And then they
got closed down basically as we backed
off which was which was in the plan that
eventually we would back off and we
would try to support them from a little
bit farther away they all got re-purposed
into other committees.  So we have now a
whole different protocol for kind of
bringing bringing a program like this
into effect.  We've had much greater
success in my colleagues within the
centre have been doing an intervention
study in corrections sector, which is,
that's another hour but that's a really
challenging setting to work in.  And
they've had phenomenal reception by both
the union and management by both
corrections officers and their
supervisors.  And from that we've actually
packaged up what we call the Healthy
Workplace Participatory Program, which is
on our website in user friendly form
with a toolkit and little training
videos.  And that's that's been
developed with an eye to how do you keep
it how do you help people embed it
within the ordinary day-to-day
operations so that there's some hope of
it being sustainable when the when the
researchers go away.  And the new study
we've just been funded to start in
health care is going to be, a sort of
like, a cluster randomized trial except
it's only six facilities but three pairs
of facilities where we've got a control
group and we're going to be evaluating
this program that's on our website.  We're
going to be evaluating it in that design.
So, I'll come back in five years and tell
you how that went. Amin. Great presentation, I really enjoyed it. Thank you.
Just to follow up on that, do you think the companies that they had those health
promotion programs they had a structure
in place they have perhaps some
experiences of work groups but doesn't work
that help your program to be more
successful in those organizations I mean achieving more return on investment.
Do you think those companies with bad experience in that
system in place or will not be affected
but will help to facilitate your approach, your program to be more effective.
Would, I'm sorry.
Would help to facilitate our
participatory program?  Well we did it in
centres that didn't already have a
workplace health promotion.  So so the
three arms were; centres with no
workplace health promotion program at
all, centres that were using the
company-provided materials and then
three that would have been in the "no"
group, but they let us come in and make
trouble.  So I don't know, maybe.
I don't know.  Something good was
something good was going on in the
centres that had the workplace health
promotion programs.  But I think it was more
kind of in the general work climate so,
yes, that might have been fertile ground
for doing some other things.  But
certainly we saw that they had more
effective safe resident handling programs,
which was really, really interesting.  Yeah.
Yes, and anybody who needs to leave if
you have another class or whatever you
obviously, you can go, it's fine.  Yes,
question. Yes.
Just going back to the actual training program itself,
so what was composed of that training program and why do you think that program was successful?
Yeah, that's a really great question.  So
so I showed this very fast and I went on,
so it was more than just training.  So
first of all, the third party company
came in and assessed the residents their
their ADL levels, their their medical needs and their weight because
if you have heavier clients you need
stronger devices that can support their
body weight.  So the the third party
company said to the nursing home company,
facility X needs this many of the whole
total body lifts and this many of the
sit stand lifts and this many of the
slide boards wherever they went I don't
know and this many of the oops this many
of the total body lifts that can support
a resident weighing 400 pounds and so on.
So that was that was kind of the first
step.  But then they also had a set of
protocols for sort of all the things
that they had observed that could go
wrong.  So you they came and inspected the
facility and they asked, "what was the
physical space where the batteries were
going to be put out every night to be
recharged?"  Like they required enough
storage space for the number of
batteries that correspond to the number
of lifts that were being purchased and
then the same thing for the slings they
actually required to see where was the
space where the slings would be hung to
air dry after they were laundered.  So
they were very, very particular about
kind of all the things that could
interfere with their because it isn't
just the devices itself you know you
have to launder a sling after one
resident has used it, and if you're using
a device all day the battery is going to
run down.  So so all of these things had
to be attended to and they were they
were very particular about you know show
me where are you going to do this that's
not enough room you're not going to be
able to fit all the batteries you're not
your lifts aren't going to be working.
And then this part about label on each
resident's chart, so each resident, their
chart was stickered, "this person
needs a sit stand lift," "this person needs
a total body lifts that can support 400
pounds."  So every chart that you didn't
and they were color-coded so even if the
nursing aide didn't have a high level of
literacy he or she could look at the
sticker and know what device they needed
if they were going to get that person
out of a chair and back to bed.  And then
there was, as I said, there was the
training there was a training about how
to use the devices and each staff person
had to demonstrate that they could in
order to hold on to their job.  So it was
really quite multi-faceted and a lot of
it was about the larger environment it wasn't only training.
I'm really happy you brought that up, coming from the healthcare sector and implementing this exact
kind of thing right now.  It's critical that it's just not training
and I think that's one of the biggest impacts right now
to this program.  It's, you can't just
train someone and expect them to go back to their unit and use these techniques.
If they don't have the equipment or accessibility, etcetera.
Exactly, yeah. I'm really glad you asked about
that. Yeah good thanks. We're going to have to cut it off here.  But, first of all,
I'd like to thank Dr. Punnett.

