Countryside Care Nursing Home (A)¹
April 2005

Craig was a management consultant in the mid-west and had been for the past several years. When the director of Countryside Care Center called seeking his consulting services to improve safety, he initially disregarded her concern. How dangerous could a nursing home be? He soon learned. According to the Bureau of Labor Statistics, in 2000, the average nursing home injury and illness rate was 14.2 per 100 full time employees. Comparable rates include: coal mining (6.2), construction workers (10.8), and truck drivers (13.8). Craig still had his doubts about how effective his management consulting skills could be in improving safety, but he decided to look into the problem further.

Countryside Care Center is a 207-bed nursing home facility in Aurora, Illinois that employs 65-70 nurse aides to work with residents (total staff: 160 employees). Nurse aides assisted residents in many day-to-day tasks with one of the most hazardous to the aides being moving individuals to and from beds, chairs, and the toilet. These nurse aides were taught "safe" lifting techniques and to use a "two-person" lift whenever handling residents. Despite this training and the adoption of what most consider the industry's "best practices," nurse aides were continuing to experience a high rate of injuries, especially back injuries (see Exhibit 1 for common types of injuries). In the first eight months of 2002, Countryside Care had 74 injury cases with 31 OSHA reportables where 15 of those directly involved lifting a resident. Their worker's compensation claims were approximately $67,500 for that portion of 2002.

The director had two requests for Craig: 1) she needed a more effective program to reduce the injuries, and 2) she needed a cost-benefit justification for any recommended capital expenditures.

In preparing a plan for Countryside, Craig reviewed the ergonomic program developed at Wyandot County Nursing Home in Upper Sandusky, Ohio. He had been hearing that the "no-lift" policy adopted at Wyandot was considered an unqualified success, but would another facility be able to justify the capital expenditures that Wyandot made and how easily could the program be transferred to other facilities?

Wyandot County Nursing Home:

Wyandot was located in Upper Sandusky, Ohio. It was a 100-bed, county-run facility with 90 employees, 45 of whom were nursing assistants. The nursing staff ratio was 2.4 hours per resident per day. Before Wyandot implemented its ergonomics program, the workers' compensation costs averaged almost $140,000 per year from 1995-1997 (see Exhibit 2) and the turnover rate among nursing assistants averaged over 55 percent (see Exhibit 3).

Wyandot's administrator approached the employees for ideas for reducing injuries and slowing the turnover rate. More than 30 workers volunteered to examine the tasks of moving and repositioning residents. From this evaluation, he and his staff felt that there was no safe way to lift a resident other than with a mechanical lift.²

In 1996 a safety committee of volunteer employees was formed and charged with solving the lift problems at the nursing home and decreasing injuries to employees. Initial lift equipment chosen by the committee was in place by January 1997. This included five sit-to-stand lifts and four other mechanical lifts. Later on, an ambulatory lift was introduced that allows residents to walk once they were supported on the rolling frame. Nurse aides could move each of these lifts from room to room as they worked with individual residents.

An initial challenge facing this new program was convincing the employees that manual lifting and other tasks involving the residents were associated with an increased risk of pain and injury to caregivers, particularly to their backs. Many aides did not realize the hazards associated with the large amount of weight involved, the awkward postures that may result from leaning over a bed or working in a confined area, and the shifting weight that may occur if a resident loses balance. The second challenge they faced was getting workers to overcome their insistence on doing things the old way. In many cases, workers said that it took too long to use the mechanical lifts. A time study was undertaken which showed it took about five minutes to use the mechanical lift. To perform a manual lift, a nurse aide had to find someone to help and that was almost never accomplished in less than fifteen minutes.

As the nurse aides became more familiar with the use of mechanical lifts, more money was invested in the products. In April 2000, 58 electric adjustable beds were purchased in an attempt to reduce the number of cumulative trauma disorders (CTDs) especially those associated with stooping to crank the mechanical beds to the appropriate level.

During October 2000, ceiling lifts were initially installed in two resident rooms with a shared bath. The ceiling lift let staff members move the residents anywhere in the equipped rooms (e.g., bed, bathroom, or chair). The ceiling lifts were so helpful moving residents with significant physical limitations that the number of lifts was extended to cover 18 beds (2 private rooms and 8 double rooms).

Wyandot implemented a complete "no-lift" policy effective October 31, 2000, and the new program was showing tremendous benefits. Worker's compensation claims averaged about $6,750 from 1998-2001 and turnover in nursing assistants were only 3% in 2001. OSHA recordable rates of employee injuries decreased from 9 in 1995 to 5 in 2001 with no back injuries since 1997. (See Exhibit 4 for a cost-benefit financial model.)

Clearly this program was successful for Wyandot, but should Craig propose an identical program for Countryside? What key characteristics of Countryside should he factor into his decision?

Exhibit 4 - Cost and benefits:

Wyandot projects that total costs for lifting equipment will approach $280,000. As of August 2003, the total investment is $155,000.

• Ceiling lift: $12,000 per room (for a double room with private bath)
• Sit-to-Stand lift: $1,800 to $3,000 per lift
• Hydraulic lift: $700 per lift
• Ambulatory lift: $5,500 per lift

In benefits, the nursing home estimated that they saved $55,000 annually in payroll because of reduced overtime and absenteeism, and more than $125,000 in turnover costs (i.e., hiring, training, etc.)

Also, workers' compensation payments went from $140,000 (in 1995, 1996, and 1997) to below an average of $4,000 (in 2000-2002)

Countryside Care Nursing Home (B):

After reviewing Craig's recommendations, the administrator at Countryside Care Center decided to adopt a "no-lift" program to minimize manual resident lifting tasks using mechanical devices whenever possible. Countryside initially spent $24,000 for lifting devices, slings, and transfer disks in 2002. Their program focused around a lifting committee⁴ of approximately 10 aides that met 45 minutes each week to plan improvements and develop training materials. Also, the committee had a team leader who spends approximately 1 hour per week on administrative tasks.

For comparison, Countryside's worker's compensation claims for January through August 2003 were $1,215 rather than the $67,500 for the same time period in 2002. Also, injuries decreased from 74 cases (31 reportable, 15 lifting injuries) in the same time frame to 27 injuries (4 reportable, 2 from lifting⁵) in 2003.

Countryside's administrator identified several success factors for their no-lift program:

• Select the right personalities for the lifting committee (someone with the power to lead a group, with an ability to motivate, with some budgetary authority, and with some excitement about the project)
• Evaluate equipment at your facility to ensure that it fits in your environment - test in bathrooms, showers, and at beds
• Get nurse aides to test equipment and provide feedback prior to purchase
• Set date for zero lifting policy and make it no more than three months out
• Consult with residents and family about implications to patient care
• Complete one-on-one training with each employee using lifts, and have each employee competency checked on each piece of equipment
• Develop an assessment sheet to identify the type of equipment needed for each resident
• Enforce a 3 day suspension for not using lift policed by lifting committee members
• Routinely inspect equipment and perform preventive maintenance
• Develop a sling inspection program and disinfect all slings once a week
• Meet with lifting committee every three months to evaluate progress and get suggestions for improvement

In addition to the reduction in injuries to nurse aides from the no-lift policy, other positive factors included:

• Reduction in injuries to residents from dropping
• Better public relations translated to improved admissions
• Reduction in the risk of OSHA inspections and penalties
• Better employee morale
• Better resident care

Craig learned several important truths from his involvement in the project:

• Financial cost/benefit cases for safety must include the "true costs", e.g., hidden costs, indirect costs (such as from high turnover rates), and costs avoided.
• People are inherently biased when it comes to evaluating risks, and safety managers correctly communicating the risks are important in altering employee behavior and engaging senior management commitment.
• Leadership and employee empowerment are keys to creating a proactive safety culture.

Countryside Care Nursing Home Teaching Note:

Craig is a fictional consultant, but Countryside faced this dilemma and used the OSHA Consultation Service. This service is 90 percent funded by OSHA but delivered by state governments. By using this no cost, confidential service, small employers in high hazard industries can learn about potential hazards at their worksites, improve their occupational safety and health management systems and even qualify for a one-year recognition program, which includes an exemption from routine OSHA general schedule inspections. Information about the Consultation Service and the state offices that administer the program can be found by going to OSHA's homepage and clicking on the "Consultation" link that appears at the top of the blue navigation bar on the right side of the page.

Interesting points for case discussion:

Cost-Benefit Justification

In justifying a decision based on a cost-benefit analysis, the challenge is always what data to use to support the benefits. Referring to Exhibit 2 for example, the workers' compensation costs do not necessarily support the no-lift policy. 1996 was lower than 1998, 2000, and 2001. 1995 and 1997 were just particularly bad years. But this kind of variance is also to be expected with such a low sample size. All they need is one claim to skew the data trends. Therefore, you need to look at various business dimensions in order to see the full impact of an effective safety program. For example, lower turnover rates in some instances may be a better justification of benefit.
Using the data provided in Exhibit 3, if you believe the nursing home's estimates of $55,000 savings in payroll and $125,000 in turnover ($180,000 total), then the pay-back period on the current $155,000 investment is one year, and it is one-and-one-half years for the total $280,000 investment.

Injury Perception

Why don't the nurses aides recognize the risks of lifting and moving the residents and if they do, why don't they alter their behaviors?

One theory could be that the nurse aides are considering multiple objectives such as convenience, comfort of resident, etc. and that when they consider their values, the risk of injury is outweighed by other factors. Anyone not wear a bike helmet when riding a bike or sports goggles when playing racquetball?

A possible communications exercise at the end of the (A) case is to have the students prepare a memo or an oral presentation for what Craig should tell Countryside.

¹This case is based on publicly available information from OSHA regarding experiences at two nursing homes located in Ohio and Illinois. This case was prepared as part of an Alliance between Georgetown University's Center for Business and Public Policy, OSHA, and Abbott. Participation in an Alliance does not constitute an endorsement of any specific party or parties' products or services. This case was prepared as the basis for class discussion in the "Business Value of Safety." The decision maker and his associated thoughts and actions are fictionalized.

²Based on the National Institute of Occupational Safety and Health lifting guideline, the recommended weight to be lifted for women in the 90th percentile of strength is 46 pounds (note that this is for a static load held close to the body).

³Injury data for the first six months of 2003 provided by Life Services Network Association, a provider of Workers' Compensation insurance for the non-profit long-term care members of its network

⁴The Countryside Care Nursing Home was set up to serve as a coordinator of Countryside's "no-lift" program and not to perform residential lifts.

⁵Of the two from lifting, one was before the zero-lift policy was in place and the other was from an employee that only worked at the home for two days.