C H S , OMMUNITY EALTH YSTEMS B C ARSTOW OMMUNITY H F OSPITAL AND ALLBROOK H P C OSPITAL ATIENT ARE R EPORT This patient care report was compiled from documents written by registered nurses employed in direct patient care at CHS Hospitals: Barstow Community Hospital in Barstow, CA, and Fallbrook Hospital in Fallbrook, CA. All incidents reported herein are believed to be not only accurate in their particulars but also representative of common or typical assignments. All reporting is consistent with HIPAA guidelines National Nurses Organizing Committee Contents Key Findings: ................................................................................................................................. 2 About this Report .......................................................................................................................... 3 About Community Health Systems ............................................................................................ 3 Medicare Fraud .......................................................................................................... 4 CHS Mission Statement and Goals ........................................................................... 4 Chronic Patient Safety Concerns at CA CHS Hospitals ......................................................... 5 CHS Responds with Hostility ...................................................................................................... 7 Solutions......................................................................................................................................... 8 Unit-Specific Patient Safety Concerns ..................................................................... 8 Women’s Center: Labor and Delivery / Post Partum / OB GYN ............................ 11 Acute Medical /Telemetry/Step-down ..................................................................... 12 Critical Care (ICU) .................................................................................................... 14 Works Cited ................................................................................................................................. 18 Appendix ...................................................................................................................................... 19 A. Selected ADO Reports ..................................................................................... 20 B. AACN Criteria for 1:1 Nursing Care ................................................................. 23 C. AWHONN Staffing Guidelines .......................................................................... 26 D. Scientific Research Linking Safe RN Staffing to Patient Safety .................... 26 1 C H S , OMMUNITY EALTH YSTEMS B C H ARSTOW OMMUNITY OSPITAL AND F H P C ALLBROOK OSPITAL ATIENT ARE R EPORT Key Findings:  High Nurse turnover, reliance on registry RNs, and inadequate skill mix between experienced and newer RNs at both hospitals compromise patient safety  Inadequate staffing levels are routinely present, placing patients at risk of harm on a daily basis  Patients who are most vulnerable, requiring the most nursing care, are at the greatest risk of harm  Staffing patterns are in violation of the California Nursing Practice Act  Nurses are forced to work in conditions that do not allow them to practice in accordance with the California Nursing Practice Act  Nurses are harassed, bullied, intimidated and threatened when reporting unsafe patient care conditions 2 About this Report Community Health Systems (CHS) nurses at Barstow Community Hospital in Barstow, CA, and Fallbrook Hospital in Fallbrook, CA should be commended for their commitment to the safety of their patients, for fulfilling the legal duties placed upon them by the California Nursing Practice Act, and for adhering to professional ethical standards requiring them to advocate for their patients. As a condition of their licensure, RNs must object to any assignment that the nurse determines to be unsafe or potentially unsafe. It is the legal and ethical duty of registered nurses to ensure safe, competent, therapeutic and effective care for every patient at all times. This patient care report is a representative summary of unsafe staffing reports submitted by CHS nurses over the last 14 months. The unsafe staffing report form, or Assignment Despite Objection (ADO) form, is a tool for nurses to identify and track professional practice issues within the hospital when a nurse objects to an unsafe, or potentially unsafe, patient care assignment. ADO forms are signed by the nurse or nurses who file them and shared with the supervisor on duty. CHS management in both facilities has refused to accept these forms. In every case, however, nurses have communicated their objections verbally. Under protest, registered nurses then attempted to carry out their assignments under adverse circumstances. CHS nurses have been struggling to resolve of unsafe working conditions, particularly dangerous staffing levels, which have resulted in the filing of nearly 50 ADO reports from May 2012 to August 2013. (Appendix A) These reports specify instances where patient safety was compromised. However, not every incident of short staffing or unsafe patient care is documented. Nurses fear retaliation and reprisal by supervisors or administrators for reporting unsafe conditions. In addition, some reports have been suppressed to protect patient privacy as required by HIPPA. Therefore, the number of actual unsafe situations is significantly higher than reported. Nevertheless, the number of unsafe staffing reports continues to grow, reflecting that, the quality and safety of patient care in both CHS facilities remains severely compromised. While high RN turnover affects patient safety at both hospitals, each has a core of RNs who are lifelong residents of communities in which CHS hospitals provide services; some have worked at their hospital for their entire career. These RNs have noticed a dramatic decrease in standards since CHS took over operation of their hospital. The emphasis has changed from providing quality patient care to “doing more with less.” It is evident after reviewing the reports from nurses that the rationing of nursing care has had a detrimental effect on patient care and safety. About Community Health Systems Community Health Systems (CHS) is a national, publicly traded for-profit hospital corporation. “The organization's affiliates own, operate or lease 135 hospitals in 29 States, with an aggregate of approximately 20,000 licensed beds. In over 55 percent of the markets served, CHS-affiliated hospitals are the sole provider of healthcare 3 services.”1 CHS is the second largest for-profit hospital chain in the United States, and one of the wealthiest. Over the past five years, CHS reported over $1.5 Billion in profits to the Securities Exchange Commission. CHS has carefully crafted a marketing scheme that masks its corporate identity from the communities where they do business. In most cases, the corporation takes over a community hospital that has an excellent reputation for quality care but keeps its corporate name carefully hidden. Shortly after acquisition of a community hospital, CHS’s first step is often to eliminate unprofitable services even though they are needed by the community, such as women’s health, pediatric care, and labor and delivery units. The CHS business model eliminates needed healthcare resources from the community. In addition, CHS is under investigation for fraudulently draining monetary resources to enhance corporate profits. Medicare Fraud CHS is the subject of a U.S. Department of Justice (DOJ) investigation into allegations of Medicare fraud. A brief history: 2005: Whistleblower Robert Baker files lawsuit against CHS alleging improper donations to state leading to inappropriate federal Medicare funds 2009: The DOJ joins lawsuit against CHS alleging $47.6 Million Medicare fraud in New Mexico 2009: Former employee at CHS affiliated Lutheran Hospital in Indiana files lawsuit alleging millions in Medicare fraud 2011: The DOJ consolidates multiple probes of illegal practices by CHS into one Federal investigation. CHS is alleged to have admitted patients who did not meet the Medicare standards of admission 2013: The DOJ subpoenas two high ranking CHS officials as part of its ongoing investigation CHS Mission Statement and Goals Each CHS hospital has prominently displayed mission statements and goals in its marketing materials. By contrast, CHS corporate materials tout its return on investment and valuable stock price. CHS owes a duty to Wall Street but RNs owe a professional duty to their patients. Nowhere does CHS state that its objective is to provide safe care to patients. RNs at both facilities support the mission statement of their respective hospitals and seek to hold the company accountable to these mission statements. Mission statements are described on each hospital’s website as follows:  Fallbrook Hospital RNs support the mission to “strive to exceed patient expectations, while delivering compassionate, quality care.”  Barstow Hospital RNs support the hospitals stated mission as follows : 4  We aspire to earn a reputation among patients as offering high quality, technologically advanced and compassionate medical care in a safe and clean environment.  We aspire to earn a reputation among the medical staff as being responsive, proactive, open and trustworthy in support of physicians who practice evidence-based medicine, employ best practices, and commit to achieving optimal patient outcomes.  We aspire to earn a reputation among staff as an employer that recruits and retains the best employees; fosters teamwork, respect and professional growth; and rewards and recognizes employees for their individual and collaborative contributions.  We aspire to earn a reputation among the community-at-large as a vital and valued community resource, the preferred hospital provider, and a civic-minded community leader. Chronic Patient Safety Concerns at CA CHS Hospitals Staffing Nurses are ever present with their patients. In fact, the primary reason that patients are admitted to hospitals is to receive nursing care. When RNs do not have enough time to care for patients, patients are put at unnecessary risk of adverse outcomes. One such risk is the so-called “failure to rescue.” “Because nurses are often the first to detect early signs of possible complications, their vigilance makes timely rescue responses more likely.”2 California Health and RNs at both CHS facilities have serious concerns for the Safety Code Section 1276.4 safety of their patients. Inadequate RN staffing, lack of (b) states, “These ratios shall support staff, inadequate training, high RN turnover, over- constitute the minimum number reliance on registry, traveler and new graduate RNs, and of registered and licensed nurses inadequate equipment all contribute to higher RN that shall be allocated. Additional workloads. Higher nurse workloads are associated with staff shall be assigned in more patient deaths, complications, and medical errors.3 accordance with a documented When RNs are unable to follow the laws guiding nursing patient classification system for practice, it not only jeopardizes patient safety but also determining nursing care each nurse’s state license. California’s Title 16, the requirements, including the regulations for the Nursing Practice Act, clearly states the severity of the illness, the need for standards of nursing care. Thus, in CHS hospitals nurses specialized equipment and are accountable for the care they provide but are technology, the complexity of powerless to influence the decisions that surround nursing clinical judgment needed to practice. Neither of these CHS facilities takes into design, implement, and evaluate consideration the individual needs of the patient when the patient care plan and the deciding the amount of nursing care that they will receive, ability for self-care, and the as is required by California Health and Safety Code licensure of the personnel Section 1276.4 (b) (see inset). required for care.” 5 In addition to inadequate RN staffing, nurses report that there is inadequate support staff, such as nursing assistants, unit secretaries, transporters, and environmental service employees. This creates additional strain on the quality of nursing care that patients receive because the RN then becomes responsible for these additional duties. Nurses have repeatedly brought these concerns to the attention of administration and have been repeatedly ignored. In many cases, RNs face hostility when they bring these concerns to the attention of CHS management. Such hostility is misplaced; nurses seeking to fulfill their professional duties are merely advocating for quality care for their patients. Dangerously high patient loads cause delays in nursing assessment, delays in the administration of tests and medications, significant changes in patients’ hemodynamic status which go unnoticed and uncorrected, poor patient outcomes, patient falls due to lack of available assistance with ambulation, and increased infection risks. In addition to safety concerns, basic human dignity is being neglected. For instance, patients are left in soiled beds until staff can address these basic human needs—sometimes hours after they should have been taken care of. The ADOs submitted by RNs at these CHS facilities document unsafe near misses, attempted suicide, and patients removing their breathing tubes and IVs. All of these incidents would have been prevented if CHS had responded to nurses’ safety concerns and provided adequate staffing. It is evident from the ADOs that patients are being harmed by CHS’ refusal to act. RN understaffing is dangerous and unacceptable. It “Nurse satisfaction with many contributes to hospital morbidity, mortality, and medical errors. aspects of work increased It is outrageous from a patient safety standpoint, and drives up significantly between 2004 and healthcare costs. Most importantly, adverse patient outcomes take a significant emotional and economic toll on those who 2006. The largest changes in are harmed. Research studies show that poor staffing satisfaction, in percentage terms, contributes to millions of preventable complications for patients were with adequacy of staff (a and causes tens of thousands of preventable deaths each 12.95 % increase), providing year. patient education (+7.3%), clerical support (6.9%) and satisfaction CHS in these two hospitals has willfully engaged in practices with the job overall (5.9%)." - that place patients at risk of harm while inflating corporate Nurse Satisfaction and the profits. Its practices violate National and State standards of Implementation of Minimum nursing practice. When these concerns have been brought to Nurse Staffing Regulations, the attention of CHS administrators by registered nurses, they Joanne Spetz, Ph.D, Policy, have been dismissed, or ignored, and the nurses retaliated against. Based upon review of ADOs, the most vulnerable Politics & Nursing Practice, April patients, those who require the most nursing care, are at 3, 2008 greatest risk. 6 RN Turnover, Over-Reliance on Registry / Traveler RNs and Inadequate Skill / Experience Mix Adequate staffing is the most important factor in reducing RN turnover (see inset). RN turnover is both a “bottom line” barometer for RNs’ collective satisfaction with their ability to provide safe care in a given hospital, and a variable that has in itself a negative effect on the quality of care delivered to patients. A statewide survey of nurses in California found that nurses perceived a significant improvement in their working conditions and were more satisfied with their jobs in the two years following implementation of the landmark California staffing law in 2004. The aggregate RN turnover at the two CHS Hospitals is more than twice the national average for similar hospitals.5 At Barstow Community Hospital turnover is almost three times the national average, with 23 of 81 RNs who have been hired in the last year alone – a 29% turnover. Fallbrook Hospital RN turnover in the past year has been close to twice the national average for similar hospitals, and almost 50% in critical units like ER and the Women’s Center.6 One third of Fallbrook RNs have been hired in the last two years. With area hospitals already recognizing RN Professional Practice Committees (See “Solutions” below), two new acute care facilities opening in the next year, and many of their colleagues expressing a desire to move on, long-term Fallbrook RNs fear an acceleration of this already alarming trend. CHS Responds with Hostility When RNs report their concerns to hospital administration, they are met with responses ranging from blatant disregard to overt hostility. This pattern has been uniform and systematic in both these CHS facilities demonstrating an institutional practice of ignoring threats to patient safety. Nurses are not only ignored but also bullied, intimidated, and threatened with retaliation when they report unsafe conditions. These responses are clearly unprofessional and disrespectful but in a healthcare setting they can be detrimental to patient safety and outcomes. According to the Joint Commission, “intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.”7 CHS promotes a culture of hostility rather than adopting a “zero-tolerance” for such disruptive behavior as is recommended by researchers and patient safety advocates. 7 Every nurse is entitled to a workplace that is free from hostility. Every patient has a right to a care environment that promotes a culture of safety. Solutions Nurses at both of these facilities seek interventions that would remedy the dangerous care conditions and hostile work environment. In the spring of 2012 nurses from each facility voted for representation by the California Nurses Association (CNA), National Nurses United (NNU), so that they could collectively bargain with CHS. The vote in favor of union representation was driven almost entirely by patient safety and RN- retention concerns. It is the desire of the RNs to form Professional Practice Committees that will examine ADO reports and make recommendations to improve patient care in their hospitals. Further, RNs seek enforcement of RN-to-patient ratios based on patient need as determined by the individual professional judgment of the RN. These recommendations are consistent with the California Nursing Practice Act. At CHS facilities, critical care RNs are often required to respond to emergencies in other units. It is well documented that understaffing in the ICU can cause serious harm to patients. For example, “adding just one full-time RN on staff per day resulted in 9 percent fewer hospital-related deaths in intensive care units.”7 Unit-Specific Patient Safety Concerns Emergency Care In facilities like Barstow Community Hospital and Fallbrook Hospital where there are no other acute care hospitals in town, emergency care is particularly critical. “… threats to patient safety are theorized to arise, in part, because temporary staff Turnover and Skill Mix are less familiar with a nursing unit and a Turnover in these critical units is particularly high. At health care organization’s overall Fallbrook 39% of the ER RNs were hired in the last structure, policies, practices, and year, at Barstow 35% hired in the last year – both over personnel—including information three times the national turnover average for similar systems, facility layout, critical hospitals. This number greatly underestimates the need pathways, interdependency among work for experienced staff RNs in the Barstow ER night shift, components, ways of coordinating and where at one point the staff consisted of approximately 2/3 registry or traveler RNs.9 managing its work, and other work elements. This can be compounded when Examples from ADOs of over-reliance on registry RNs temporary workers do not receive and/or failure to orient registry RNs (see sidebar): the same level of orientation and training from the organization in which they  On one shift a traveler RN discharged a patient provide care as do the organization’s who had not received all ordered medications. employees.” - 2004 IOM Report Keeping Patients Safe: Transforming the Work Environment of Nurses. 8  A registered nurse reported that traveler RNs who have neither received sufficient orientation to the ER nor had their competency validated by the hospital are repeatedly assigned to patients in the emergency department This winter’s mass exodus of staff RNs from the Barstow Community Hospital is more than just a “bump in the road.” Barstow Community Hospital ER has been forced to – or decided to – rely on new graduate RNs to fill the holes in full time ER staffing positions. A study of new graduate RNs who were given full patient loads found: “More than 55 percent reported that they had to “Novice nurses still honing their work too fast; 33 percent reported having little time to get skills in patient care and time things done and nearly a third of new grads reported they management will be particularly had too many patients to get their job done well. Not vulnerable, but an excessive surprisingly, as a result of these conditions, more than 37% patient load can overwhelm even of the new nurses say they plan to leave their current job in the most experienced nurse. On the next two years, and more than 41% say they, if free to do units with novice nurses, the more so, would take another job immediately.” The authors of the experienced nurses serve as study concluded that the data “raises the concern that “safety checks” by being available employers will not be able to retain them in the acute care settings where they start out."10 Barstow Community for consultation and, perhaps even Hospital’s management practices have set the stage for an more importantly, by looking over ER staffed by a revolving door of inexperienced and/or the novice’s shoulder and registry RNs, compromising patient care. observing her patients for early signs of distress. When a nursing Emergency Staffing unit has too few experienced The maximum staffing ratios in an Emergency department is nurses relative to inexperienced 1:4, 1:2 for RNs caring for Critical Care patients, and 1:1 for nurses and when those RNs caring for critical trauma patients. RNs have experienced nurses are documented nearly constant understaffing in the Barstow ER, overburdened, it become less including misuse of charge and triage RNs, and lack of likely that complications will be support staff detected in a timely manner. - Sean P. Clarke, PhD, RN, CRNP, Examples of ADOs documenting violation of acuity based CS, and Linda H. Aiken, PhD, RN, staffing ratios: FAAN, FRCN “Failure to Rescue”  Due to the unit being staffed mostly by registry RNs, AJN January 2003 the only regular staff RN on duty was assigned to four high-acuity patients - two critical care patients with orders to be admitted to ICU and two with orders to be admitted to Med/Tele with continuous cardiac monitoring. Patient safety was compromised despite the RN missing her meal and break periods and working overtime.  An RN reported being assigned a trauma patient with multiple stab wounds with an extreme acuity level. The patient required continuous modification to the plan of care based on the RN assessment. It was not possible for the RN to provide care for the other 3 patients she was assigned. Other RNs with their own 4 9