Tag: Nursing

Head of Investigations Unit Resigns


The head of investigations for California’s Department of Consumer Affairs has resigned, continuing the fallout from a Los Angeles Times – Propublica investigation into lengthy delays in disciplining nurses accused of egregious misconduct.

According to a spokeswoman for the California State and Consumer Service Agency, the decision by Lynda Swenson to quit was tied to revelations by The Los Angeles Times and ProPublica about problems at the Board of Registered Nursing. Most investigations of errant nurses are handled by the Division of Investigation, which Swenson headed.

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Op-Ed: No Need for Alarm Over Need for Foreign Nurses

Recent news coverage (“Amid Nation’s Recession,
More Than 200,000 Nursing Jobs Go Unfilled,” Reuters, March 8th) validly
and vividly calls attention to a nursing shortage in the U.S. healthcare system that
“threatens the quality of patient care even as tens of thousands of
people are turned away from nursing schools, according to experts.”

That article adds, “The shortage has drawn the
attention of President Barack Obama. During a White House meeting on Thursday
to promote his promised healthcare system overhaul, Obama expressed alarm over
the notion that the United States
might have to import trained foreign nurses because so many U.S. nursing jobs are

Importing internationally-trained nurses is no cause for
alarm.  The fact is, at least in the short term, the U.S.does have to
import these nurses, and plenty more of them, if we are to meet our rapidly
growing healthcare needs.  Don’t understand why?  Consider the

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Op-Ed: Let’s Pay Nurses Minimum Wage!!

Every morning I wake up and thank God that we still have some Republicans in Congress. Representative John Shadegg (R) from Arizona, is one of those blessings. He has introduced a bill in Congress called the Nursing Reform Act of 2009. The bill calls for increasing work visas for foreign nurses (and their spouses). When passed, it will eliminate the nursing shortage!

This bill is great on so many levels. For one, everyone knows that healthcare is costing us an arm and a leg (pun intended). The biggest causes are obviously nurses and nursing unions. Nurses are way overpaid, but unfortunately the healthcare corporations have not been able to break the nursing unions because of the shortage of nurses. By bringing in lots of foreigners, they can flood the market with labor, break the unions, and get nursing salaries down to where they belong — somewhere around what retail pays. If only there weren’t that law capping the number of foreign nurses we allow in the country… As a side benefit, the bill allows for nurses’ spouses to get unrestricted work visas as well, so it will help bring down salaries in all sorts of other industries as well!

The true brilliance of this bill (thank you Mr. Shadegg!) is in the way it is written. It doesn’t bring them all in at once. It starts out with 50,000 new visas the first year, which is a low enough number that people will “buy it” and the bill can get passed. Supporters of the bill have had to go to great lengths to say that nursing salaries will be unchanged, which of course will be true at first. However, the genius in the bill (evil grin) is that the number of allowable visas automatically goes up 20% per year, so it will be 60,000 visas in year two, 72,000 visas in year three, 86,400 visas by year four, 103,680 by year five, and a whopping 124,416 by year six! The bill states that “According to the Department of Labor, the current national nursing shortage exceeds 126,000.” Therefore, the nursing shortage will be solved in about six short years, and healthcare companies can get back to earning the kind of money they deserve! Incidentally, this is just the approach that was so successful in cutting the salaries earned by information technology workers about 10 years ago. Corporate profits were getting impacted by high IT costs, so our brilliant Congress increased the number of H1-B visas, and companies were able to hire cheap workers from India and other places. Thank you, Congress! Later, many of these foreign workers returned to their homelands and brought the work with them. Now, corporate America doesn’t have to pay high salaries, and they don’t even have to look at the foreigners anymore — they can just write a little check to India. Bravo! Fortunately, information technology salaries have never rebounded to the levels where they were.

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The Hospitalist as Bed Czar: Indispensability, But At What Cost?

In last week’s Annals of Internal Medicine, Eric Howell and colleagues describe an innovative experiment in which the hospitalists at Johns Hopkins Bayview became the institution’s bed czars. It worked.

So should my program and yours take this one on? If you looked up “Thankless Task” in the dictionary, you might see “Active Bed Manager.” So how did they do this?  And why?

Hopkins Bayview is a 335-bed teaching hospital affiliated with Johns Hopkins. The Chief of Medicine, David Hellmann, is an old friend and a gem, a graceful and eloquent man who is constantly looking for improvement opportunities. Under his guidance, several years ago the hospitalist group, led by Howell, agreed to become the medical center’s “Active Bed Managers” for medical patients. The ED sees 54,000 patients a year, and admits about one-quarter of them, three-quarters of these to Medicine.

One hospitalist at a time serves on the ABM service, in 12-hour shifts. During this shift, the hospitalist has no other responsibilities, freeing him or her up to act as a full-time air traffic controller for all medical patients. This involves keeping up to speed on the bed status of all medical, step-down, and intensive care units, “prediversion” round in the ICU, evaluating (by phone or in person) all new admissions, expediting ED-to-floor transfers, and sundry other tasks.

After a few years of doing this during the days, in 2006 they began providing ABM around the clock, 365 days a year. When all hell breaks loose, the ABM hospitalist notifies the “Bed Manager” – Eric or another senior hospitalist leader – who has the authority to activate resources or knock heads to free up beds or expedite transfers.

The results were truly impressive. ED length of stay for admitted patients fell by 98 minutes (458 minutes in control period to 360 minutes after the intervention), a tremendous improvement, particularly when multiplied by 10,000 patients a year. The time that the ED was on full divert – which costs the hospital both money and good will (and probably costs a few lives as well, as patients are shunted to less appropriate or more far flung hospitals) – went down by a staggering 87% (from 31% to 4% of the time)!

I spoke to Howell last week to find out more, since I was reasonably sure that I – and my fellow hospitalist leaders around the country – would receive “why don’t you do this?” calls from our CMOs within minutes of the publication of these results. “I watched for years as the hospital tried to improve throughput and stay off ambulance diversion,” he told me. “Nothing worked, but we knew that we could help fix this. After a while, we decided that it was worth trying.”

A short fiscal primer for those of you who don’t traffic in DRGs and bed-days-per-thousand: Hospitals that run full spend staggering amounts of money on efforts to improve throughput. They hire consultants (which never works, but their PowerPoint presentations are pretty to look at), they tweak admission criteria, they shop eBay to buy second-hand electronic tote boards discarded by the Hyatt. These interventions rarely make a significant dent, because to make a real impact you need someone to make scores of tough, contentious decisions in real-time, preferably someone with the negotiation skills of Richard Holbrooke.

Most hospital ultimately throw up their hands and solve the problem of throughput by – you guessed it – building more beds, at a cost these days of 1-2 million dollars per bed, depending on whether you have to meet earthquake standards (the cost is even higher for ICU beds). But hospitals can’t afford to leave their bed shortage problem unsolved – not just because they need to dis-impact the ED, but more importantly (for the bottom line) because they need to free up beds upstairs for elective surgeries. Canceling such surgeries because of bed shortages is intensely expensive and demoralizing to the C-suite folks. Plus it makes the surgeons very unhappy, a bad job retention strategy for most COOs.

I wanted to know how the ABM intervention had affected Howell’s hospitalists’ relationships – with the ED, the nurses, and the residents. He told me this:

“All relationships got better. The ED loves us – the ED chief sits in medical board meetings and asks for more hospitalists. The ICUs like us, maybe love us, because we got rid of ambulance diversion. The nursing supervisor loves us, because we help them enforce stuff, or can override policy if needed (when common sense dictates). The residents? First they were reluctant, now they love it.  But it does put the hospitalist in the middle of resolving conflicts between two house officers, house officers and the ED, sometimes house officers and the nurses…”

This intervention can’t be done on the cheap: having dedicated hospitalists on this service 24-7-365 (not performing billable activities) would likely require about 4-6 FTEs-worth of hospitalists, or close to a million dollars a year (Eric and I didn’t get into the precise numbers at Hopkins Bayview, but the math is pretty straightforward). And, in order to motivate Eric’s group to do this, the hospital anted up some additional salary support for both rank-and-file hospitalists (who saw an increase in academic “protected” time) and for leadership positions. The latter was particularly important, since the junior hospitalists were instructed to bump issues to a senior hospitalist leader (the “Bed Manager”) when the disputes got too difficult or new resources were required. At first, this was just Eric and one colleague who were always on call for this purpose; by the end, four leaders were sharing this difficult but crucial role.

Finally, I asked Eric – given what must have been Too-Numerous-To-Count political challenges – whether he was glad he did it. I also asked how he’d rank this intervention against alternative uses of the same dollars (such as surgical co-management or proceduralist services), most of which would cause less loss of hair and gastric mucosa. He responded this way:

“Yes, I am glad I did it. It put my group on the map at Johns Hopkins. Before hospitalists were largely considered “non-essential” by other faculty. Now they see us as equals, because we fixed something that they could not… for years. Also the hospital LOVES us; the president introduces me as the man who runs the entire hospital (not true but flattering)…”

I’m going to give this intervention a very high degree of difficulty – in the Hospitalist Olympics, I’d rank it as a reverse one-and-a-half somersault with three-and-a-half twists, with a good chance for a Belly Flop if it isn’t skillfully executed. In other words, Active Bed Management is not for the faint of heart, nor something to take on if you have staffing challenges elsewhere.

In part because of that, although you might get a warm and fuzzy feeling about improving throughput and decreasing diversion for your hospital, there is no way a group should take on this role simply to have its costs recouped. If you do ABM and see Eric’s results, you have created several millions of dollars of value for the average hospital (and many hundreds of thousands for the surgeons), and some of this needs to be allocated to the hospitalist program itself, in the form of more protected time, higher salaries, or other items on its wish list.

But my premise from the moment this field began was that hospitalists – because of their near-universal dependence on outside (usually medical center) support – had to constantly be looking for opportunities to add value. Particularly in tough economic times, the opposite of being Indispensable is being Dispensable. That’s not a good thing to be right now.

I haven’t told my group this (or perhaps I just did) but, assuming we have sufficient staffing, I think we should begin looking at ABM in the not-so-distant future, probably starting with a daytime service to see whether it is do-able before taking on the much more challenging task of nighttime coverage.

The American Hospital Association just released its 2008 estimates, and the number of hospitalists is now pegged at 27,000, which makes the field larger than cardiology or emergency medicine – the largest non-primary care field in Internal Medicine, and the fastest growing field in the history of medicine. This is staggering (next time, please remind me to trademark a term when I coin it), and owes to the fact that when most docs are running in the other direction, hospitalists step up to the plate and fix problems that need fixin’.

So a shout out to Eric Howell and the Hopkins Bayview crew for adding one more arrow to the hospitalist Quiver of Indispensability.

Communication 101: Shedding power imbalances to protect patients

Katie Fiebelkorn Westman is a registered nurse at an acute care hospital in the Minnesota Twin Cities. She is working toward a clinical nurse specialist degree, focusing on improving patient care quality.

The Joint Commission’s recent sentinel event alert on the detrimental affects of ineffective communication between caregivers prompted me to examine the communication I see daily in the hospital.

The dearth of effective communication skills is not limited to the health care profession — we just have bigger consequences when we get things wrong. Someone in another profession may run a report incorrectly and be annoyed to have to redo it, but in health care, we can take off the wrong body part, give the wrong medicine, or send someone home with the wrong discharge instructions.

These mistakes are big deals. We need, as healthcare providers, to respect each other, our different points of view, and learn how to talk. 

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Overcoming the challenges facing rural health care

Kensington, Minn. is barely a dot on the map. This small grid of concrete, where fewer than 300 people live, is a brief interruption amid the sprawling acres of green corn, soybean and wheat fields that cover Minnesota’s western plains.

Similar tiny villages exist every seven or so miles along the Soo Railroad route. These once busy agricultural hubs are now skeletons of commerce with rapidly aging populations.

About one-fifth of Americans live in rural areas, and providing health care to them is a challenge financially and logistically. Only 10 percent of the nation’s doctors practice in rural areas, and rural residents tend to be poorer and less likely to have employer-based insurance than urban dwellers. The list of challenges is long.

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Advice to future nurses: ask questions, be proud

It’s that time of year when nursing and medical students shed their label (and protection) of student and head out to the workforce with their new licenses. Over at Emergiblog, veteran emergency room nurse Kim McAllister shared advice with new nursing graduates.

Here are her words of wisdom.

To the new nursing classes of 2008:

Your first year will be the most difficult as you acclimate to your new role as a professional nurse. Hang in there! Keep your focus on why you went into nursing to begin with.

Keep your eyes and ears open. Watch the nurses around you. You will be surrounded by role models. Take the best of what you see and incorporate it into your own practice. It may be hard to believe, but by the time the next class enters the profession YOU will be the role model they look up to.

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Snooping at Britney’s Chart: Why Should Docs and Nurses Have Different Rules?

Robert_wachterShould doctors and nurses be subject to different penalties for
precisely the same infraction? Of course not. Are they? Sure. Just ask
Britney Spears.Britney was hospitalized at UCLA at least
twice in the past few years –
once when she gave birth to her first son in 2005, and again in early
2008 for psychiatric care. Both times, dozens of UCLA staff members
peeked at her medical records, despite having no clinical reason to do

This voyeurism, of course, is hard wired into our DNA, and
we aren’t about to purge our inner paparazzis any time soon. But even
celebs have a right to keep their medical records private. Although the
Health Insurance Portability and Accountability Act
(HIPAA) has caused some real mischief, one of its beneficial effects is
that it put the issue of medical record snooping on our radar screen.
Whether the victim is a Hollywood starlet or your next-door neighbor,
it is just plain wrong.

Most organizations have hired HIPAA
police and done extensive HIPAA training with their staff.
Nevertheless, all the UCLA snoops were documented to have passed an
on-line HIPAA tutorial. When Britney hit the door, Inquiring People
just wanted to know.

Lest you think this is a UCLA thing, we had
a similar situation (with another famous actress) a few years ago, as
have dozens of other hospitals. In fact, human nature being what it is,
I can’t imagine this not happening – unless the rules are clear, widely disseminated, and strictly enforced.

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Careseek CEO Gale Wilson Steele writes in to comment on the ongoing controversy over physician ratings:

"It’s not surprising that physicians are uncomfortable with the idea of others "rating" them.  After all, what do others know about how well they provide healthcare?

This, actually, is very similar to the reactions professors first had on RateMyProfessors, where professors protested that students only cared about whether their tests were fair, and scoffed saying that the “kids” knew nothing about the professors’ degrees, research projects, etc.  In the minds of those who stood at the lectern, it was about academic qualifications; for those in the seats, it was about staying awake.  Today, professors are much more comfortable with the fact that they can be listed on a website and reviewed, and in fact, are somewhat insulted if no student has taken the time to list them.  Secretly they even hope to receive a few “chili peppers”, meaning that they are “hot” professors!

Ultimately, a few professors responded in kind and created, a sort of RateMyStudents site.  By now it has turned into a cynical professorial rant about teaching.

So with new physician rating and review sites coming online nearly every week, how are doctors going to handle being rated by their patients?  Physicians also complain “What does a patient know about how well I practice medicine?…Patients don’t know about my years in school, my research, my etc.” 

Will doctors ultimately create a site called RateMyPatients, where they can rant over the injustices of healthcare and the assaults they take daily from their patients?  Or will they praise these sites as a place to learn how to improve their practices or as sources of patient testimonials to their excellence? 

The latest twist on who rates whom is eliminating the issue of reviewer qualification, namely  No one will deny that this population of over 3,000,000 trained medical professionals has a keen insight into the practices of physicians, their bedside manners and clinical competence.  It will be interesting to see if this trusted group of patient advocates will have the willingness to share what everyone wants to know…who are the best doctors?"


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