Patient Protection LAW!

pickledpepperRN · Nov 22, 2003

Original law:

http://www.leginfo.ca.gov/pub/99-00/bill/asm/ab_0351-0400/ab_394_bill_19991010_chaptered.pdf

pickledpepperRN · Nov 22, 2003

Hospital industry seminars advise administrators how to evade RN ratios

http://www.calnurse.org/102103/hospindustry.html

California's hospital industry has been holding seminars across the state in recent weeks advising hospital administrators on how to undermine and avoid compliance with the new RN staffing ratios that go into effect on January 1, 2004.

While some hospitals are hiring hundreds of RNs to meet the ratios, and some are promising to fully cooperate in implementation, the seminars indicate that a number of industry executives are seeking to evade the regulations and overturn the law - regardless of the consequences for patient safety, and the likelihood of driving more RNs from the bedside.

The seminars are hosted by the California Healthcare Association, CHA, (the union for hospital officials) and the Association of California Nurse Leaders, ACNL (the nurse executive association, a CHA affiliate). Seminars have been held in Fresno, Chico, Fremont, Long Beach, Los Angeles and San Diego, attended by hundreds of nursing supervisors and other hospital officials.

Presenters have included top officials of the CHA, hospital management attorneys, and nurse executives, such as Carol Bradley, the new chief nursing officer for Tenet Healthcare Corporation and the former editor of NurseWeek.

Among the industry plans:

'Close beds and cry wolf'

Voluntarily close or downsize beds or units, citing an inability to "find" sufficient RNs to meet the ratios. The goal is to fan hysteria in hopes of softening public support for the ratios, winning regulatory exemptions to compliance, and generating political support for legislation to repeal or suspend the ratios.

Delay elective surgeries, declare healthcare "emergencies," both to force RNs on staff to work more hours and to engage in a PR war to subvert the ratios.

To ratchet up public pressure, some hospitals may close units or suspend operations every day, and will meet with legislators to place the blame on the ratio law. The officials concede that hospitals may in some cases have difficulty receiving permission to reopen beds or units that have been temporarily or permanently shut down.

Seminar packets provide:

1. Detailed information on temporary and permanent closures of units and suspensions of beds

2. Sample letter to DHS requesting bed suspension

3. Sample letter to employees and medical staff announcing unit closures

4. Sample press release for participants headlined "(Facility/System Name) Closes XXXX Unit Because of Lack of Nurses. Despite Recruitment Efforts, Hospital Unable to Hire Enough Nurses to Meet New State Law."

Hospital officials are told to view their PR department as their new best friend, and that the "CHA PR will help as well."

Keep the doctors in line, on all the strategies, from avoiding the ratios to downsizing, closing units, and suspending surgeries. Physicians are also seen as vital in public and legislative campaigns to reverse the ratio law.

Attacks on RN practice

Use LVNs to comprise up to 50% of the ratios, doubling the RN work load.

Hospital industry officials hope to distort the intent of the law by assigning patients directly to LVNs, rather than have LVNs be assistive to, and under the supervision of, the RN. Under the final AB 394 regulations, hospitals must use RNs because of scope of practice and patient acuity, based on a hospital's patient classification system.

Hospitals hope to expand LVN scope of practice to permit direct assessment of patients. Some also project expansion of "team nursing" to sharply expand the role of LVNs from data collection and med administration to performing more nursing care functions. The hospital industry is meeting with the LVN Board on the issue of assessments, presumably to encourage ongoing efforts by the SEIU-dominated LVN Board to expand LVN scope in assessing patients.

Additionally, many hospitals project using LVNs for meal and break relief for RNs.

SEIU has also promoted 50% LVN ratios. Click here for more on SEIUs role

Eroding the ratios at the bedside

Distort the use of acuity systems or other tools to reduce staffing. According to ACNL in one seminar, acuities are no longer a factor in staffing.

Some Tenet hospitals are employing a pilot staffing program borrowed from Tenet hospitals in Texas. The tool monitors labor efficiency in census driven units. In order to meet "production goals," managers can flex the number of hours of care to make staffing adjustments to meet budget targets. Managers are told to input acuity ratings to use the tool as a patient classification system to preclude the appearance of violating the staffing law.

Manipulate triage and work flow in the Emergency Department.

One non-CNA hospital in Southern California uses "operational flow redesign" of patients presenting to the ED to reclassify some patients as "office level" so they will first be seen by a Physician Assistant rather than by an RN, along with the expanded use of an EMT to reduce the amount of triage performed by an RN.

Quicker discharge of patients so staffing can be reduced.

Layoff non-RN staff thereby increasing the RN work load and violating the intent of AB 394.

Challenge or ignore ADOs and other RN efforts to monitor and protest violations.

The industry officials concede that ADOs are not illegal, but also tell the hospitals there are no legal regulations covering the use of ADOs. Hospital officials worry that ADOs and other reports by RNs to object to unsafe assignments and document unsafe staffing pose civil liabilities for hospitals that violate the law.

They advise managers to ignore or not respond to the reports, and recommend hospitals develop their own, in-house reporting tool, like an incident report, which staff are required to use, instead of forms developed by CNA.

Subverting the DHS

Continue to use existing, even expired, "program flexibility" waivers from the Department of Health Services to avoid compliance with the ratios and hope that no one notices.

According to one seminar speaker, DHS has said it will not grant new waivers for the ratios, but if a hospital has an alternative method for meeting the "spirit" of the law, it will be reviewed. Seminar packets include program flexibility request forms. Hospitals are advised to carefully document the "need" for waivers.

Pressure or cajole DHS to not enforce the law.

Seminar speakers note that DHS, already understaffed, is facing another 20% funding cut - and may face further cuts under Gov. Schwarzenegger. Hospital officials are also encouraged to cozy up to local DHS officers, and explain that the nursing supervisor is the expert for their unit. The officials are advised that they need to "educate" DHS.

Re-introducing anti-ratio legislation

Reintroduce AB 847, the hospital industry bill CNA helped to defeat last year. The bill would have required indefinite delays in implementation of ratios until iron clad studies prove there are sufficient numbers of RNs and that ratios improve patient outcomes.

Cover your tracks

RN supervisors and hospital administrators are advised to carefully record all their efforts to recruit RNs and comply with the law.

Industry officials advise hospitals to systematically keep track of all their efforts to find RNs to meet the ratios, from contacting all their own staff and registries to time and money spent on ads, travel and other recruitment efforts. The purpose: to have a record to justify decisions to close services and seek repeal or revisions in the law.

Hospitals are encouraged to "self-report" their violations of the law, because they can control what is reported rather than waiting for RNs or CNA to report the violation.

Seminar packets also include a sample "Documentation of Nursing Service Assignments" to demonstrate to the DHS or JCAHO the staffing plan on a day-to-day, shift-by-shift basis for every unit, and the specific number of RNs, LVNs, and PTs assigned.

Geeg · Nov 25, 2003

Is there any way to get this into a mainstream newspaper? Or will the AHA pay the LA Times and the SF Chronicle off, so that they won't print it?

sanakruz, ADN · Nov 25, 2003

But SEIU is not the enemy here. SEIU has plenty of Rns in its ranks. It wants to see its members stay employed. (I must defend my union on the internet):chair:

Geeg · Nov 25, 2003

SANAKRUZ, isn't the SEIU trying to expand the role of the LPN to include assessments, etc??? In an effort to make RN's obsolete?

sanakruz, ADN · Nov 25, 2003

No that is not what's happening.

The Hospital "unions" wants the board to do this by appealing to DMH, which opposed the ratios that are now law

I will go back under my chair now.

Havin' A Party!, ASN, RN · Nov 25, 2003

If what was quoted above is accurate, it sounds like an open conspiracy to evade or undo the intent of the law. Is this prosecutable or must the Attorney General wait for a party to actually undertake these steps before going forward? Seems the legislature has deemed the ratios to be of critical significance.

Perhaps this needs to be brought before the legislators that sponsored the original bill for tweaking.

sanakruz, ADN · Nov 25, 2003

I meant to post DHS (Dept of Health Services)

Not DMH (Dept of Mental Health)

Nor DSS (Dept of Social Services)

... fodder for another thread

There is a feud going on between SEIU and CNA.

Nuff said.

This is not our problem today. LarryG is correct, its an attack on the law. Hardly a conspiracy cuz we see where its coming from.

The CHA is powerful and well funded. Yes, consumers need to know what is going on.

Sekar · Nov 27, 2003

OH MY GAWD! What is the world coming to?!? LPN's doing assessments! What's next, IV Medications? How horrible! The next thing you know they might insist that LPNs be considered NURSES instead of glorified aides! IS NOTHING SACRED? :uhoh3:

California is supposed to be one of the most progressive states in the union, unless you're an LPN. Then it's mideval times! LPNs doing assessments, administering IV meds, have their own ASSIGNED patients, and in general being the nurses they are trained to be, are a fact of life in North Carolina. Seems like California has a looooong way to go.

Why is it that expanding the scope of practice of LPNs is seen as a threat to RNs out there? It's been done here over the last 10 years and amazingly, RNs aren't losing their jobs to LPNs. True some RNs are distraugt to see LPNs no longer as sub-servient and lowly they used to be. Even more amazing, the predictions of higher patient mortality and morbidity rates secondary to increased LPN scope of practice has failed to materialize. Go figure.

Y'all are barking up the wrong tree if you think an expanded LPN scope of practice is aimed at pushing RNs out of jobs. Get a reality grip. It didn't happen here and it won't happen there. LPNs and RNs are all Nurses in the eyes of administration, a cost to be contained. This outraged attitude is exactly the divide and conquer technique that they have used for years to keep nurses down and those of you complaining about the increased LPN scope of practice are playing right into their hands. Good Job, keep it up. :rolleyes:

When are nurses going to realize that we need to unify as a group to achieve our goals?

sanakruz, ADN · Nov 27, 2003

The issue here is not lvn vs rn

It's the CHA- The well paid lobbyists for the hospital industry attempting to subvert a law that they see attacking their profit margin.

pickledpepperRN · Nov 27, 2003

Originally posted by sanakruz
The issue here is not lvn vs rn
It's the CHA- The well paid lobbyists for the hospital industry attempting to subvert a law that they see attacking their profit margin.

So correct.

I was a CNA and an LVN before earning my RN.

Now I am priviledged to work with LVNs who are excellent nurses. We are a good team. Not working tele or M/S every night I really need a competent co worker who knows the floor and often knows the patients too.

There is a big difference between working with an experienced LVN whose abilities are known to me and a new grad, float, or registry whose competency is not known to me.

See in this state the responsibility for the nursing care is that of the RN.

If I work with an RN who causes harm to apatient it is just as terrible, but if I am clinical supervisor for the LVN I can lose my license if I delegate the assessment or care plan to the LVN.

Also I can lose my license if I do not consult with the LVN working with me. I MUST take his or her observations and ideas into account.

If you are interested in this topic there is much more on the US/CA forum.