Sunday, August 04, 2013

A misguided initiative petition

One of the problems when you criticize a union proposal is that you are at risk of being tarred as "anti-union."  I'm not.  But I'll take the risk of that response in criticizing one union's plans for a referendum here in Massachusetts.

The Massachusetts Nurses Association, which represents about 20% of the state's nurses, is preparing a petition that would impose nurse staffing ratios on the state's hospitals. This kind of proposal, akin to one in place in California, has been rejected many times by the state Legislature, which realizes that such matters are best determined by the clinical and administrative folks in hospitals rather than by regulation.  California is the only state that has these kind of rules, based on a 1999 law, and there have been many unintended consequences.

The folks at the MA Hospital Association have correctly noted:

The arcane concept of applying ratios is especially disturbing in the rapidly evolving Massachusetts reform environment that is centered on rewarding hospitals and other providers based on quality of care delivered and patient satisfaction. Integrating care across the care continuum depends on continually changing patient care and assessment decisions arrived at by a full care-giving team, and not by inflexible, government regulation.

Here's a copy of the instruction sheet being handed out to the MNA members.  It is interesting to note that nurses are instructed not to collect signatures from other bargaining units (i.e., other unions) in their hospitals.  Might that be because a rigid nurse staff ratio could cause other unionized clinical assistants--who are valued members of the care delivery teams--to have fewer jobs?


Anonymous said...

Not only that, but to title it 'safe staffing ratios' is misleading at best, and self-serving at worst. Not to mention that if payment is to be based on quality and outcomes, then the staffing ratios will become a natural part of that - i.e. whatever ratios are needed to produce the desired result will be naturally incentivized.
Not, mind you, that I trust hospital administrators to not be self-serving themselves in staffing a hospital. I spent much of my professional life as a hospital-based physician countering their desires to cut, cut, cut.
However, nurses in particular seem dead set on rigid staffing ratios as 'the only' solution. Now, more than ever, the incentives are geared to take care of this issue without mandated ratios.

nonlocal MD

Barry Carol said...

I wonder if there is any consensus either nationally or within states as to what constitutes a safe and efficient nurse staffing ratio within an ICU, CICU, NICU, telemetry floor or regular room. Some hospitals CEO’s are also likely to be more profit driven than others to maximize their bonus compensation and would thus have an incentive to skimp on staffing.

The other issue that troubles me is the difficulty in measuring care quality for the medical inpatient cases as opposed to the surgical cases. Quality encompasses following evidence based guidelines and protocols (process), outcomes, preferably risk adjusted for patient age, frailty and co-morbidities, minimizing infections, avoidable readmissions and other harm (safety) and patient satisfaction. The surgical cases lend themselves better to outcomes measurement but, overall, meaningful quality measurement is easier said than done though that doesn’t mean we shouldn’t try hard to quantify it.

Finally, how does care quality, to the extent that it can be measured, in CA stack up against other states’ experience? How many more nurses are employed in CA than likely would be employed in the absence of the regulation and has it had any impact to speak of on patient safety?

Anonymous said...

Rigid nurse staffing ratios don't take into account the acuity of the patient, additional assistance from unlicensed staff, and the "churn" on the unit. Having an RN care for 5 patients who are mostly Category 2 (essentially ready for discharge or self-care patients) or caring for the same patients classified as Category 4 (because you can't have a Category 5 patient on a med-surg unit) can be very difficult by yourself on a medicine ward (think of all those 9 o'clock meds!). But, if you throw in an LPN/LVN to assist and maybe a CNA to help bathe those patients, it becomes very doable. Let's think about the floor where the net number of patients is 14 at the beginning of the shift and is 14 at the end of the shift. Yet, there were 2 transfers to the ICU due to code or RRT, and 3 discharges home, and 2 transfers to rehab units. That churn (and communication to other units and the associated paperwork) makes the shift so hectic (and things get lost or left undone, which is why I'm a huge proponent of checklists!) even when staffing is fat.

I'm not a believer in nurse ratios and I know there are hospitals that try to get by with the bare minimum in order to trim costs. But I also know nurses who don't want to work. They want a paycheck, though.

Bob said...

The nurses union is a bane of progress in health care organization, and a primary cause of the rise in health care costs. They will not be satisfied, ever. They are a terrible, hypocritical union.

The hopes for progressive unions in the US died years ago. It's one thing to oppose terrible management, as in the mines or in the fields. It's another to push an industry to the brink of disaster for one's own betterment, damn the public good. Adhering to the union causes is often an exercise in sentimentality. My mother said, "Never cross a picket line." That was in the 40's, not now.

In unions, each case must be looked at individually. Farm Workers - good, terrible employers. Teachers union - not so good, self-interested to an extreme. Government workers - bankrupting the cities and states. Nurses union - terrible.

Better not to be sentimental.

Anonymous said...

As you suspected:

Just came from an HR meeting in California and they all say this is a nightmare! In order to do this you have to eliminate Phlebotomists, dietary personnel, environmental services, CNA's etc to afford this.