With Survey Results on Patient Deaths, Nurses Hatched a Non-Cause Celebre

Friday, July 18, 2014

I’m still wondering why the nurses’ union didn’t get traction with its survey alleging thousands of patient deaths caused by inadequate nurse staffing.

I thought something would happen after the Massachusetts Nurses Association (MNA) announced on June 4 that one in four nurses were personally aware of patients having died in hospitals because there weren’t enough nurses around.
But nothing really happened that I could see.  The survey was a one-day blip on the news radar.   It didn’t make the front page of the Globe or Herald.  It didn’t dent the evening news broadcasts.  The Massachusetts Hospital Association barely lifted a finger to refute it.  And no government bigwig, caught in anguished surprise, declared her intention to launch an investigation.

The headline on the MNA news release touting the survey said: “Nearly One in Four MA Registered Nurses Report Patient Deaths That Are Attributable to Unsafe Patient Assignments.”
Under that was a long, explanatory paragraph in bold face, italic type:

78% of RNs agree that the quality of patient care in Massachusetts hospitals is suffering due to unsafe patient assignments including 59% of RNS who are aware of patient complications and 46% who are aware of patients who have been injured or harmed because hospitals are forcing nurses to care for too many patients at one time.

Here’s the scary list of particulars from the body of the news release:

·         …nearly one in four nurses (23%) report patient deaths directly attributable to having too many patients to care for at one time.

·         46% report injury and harm to patients due to understaffing;

·         51% report longer hospital stays for patients;

·         56% report readmission of patients due to unsafe patient assignments;

·         57% report medication errors due to unsafe patient assignments;

·         59% report complications for patients due to unsafe patient assignments;

·         68% report RNs don’t have the time to educate patients and provide adequate discharge planning;

·         82% report RNs don’t have the time to properly comfort and care for patients and families due to unsafe patient assignments.
The release ended with: “The 2014 survey respondents were all nurses currently working in Massachusetts hospitals randomly selected from a complete file of the 92,000 nurses registered with the Massachusetts Board of Registration in Nursing.  According to the researchers, the survey results can be assumed to be representative of the 92,000 nurses to within plus or minus 7% at a 95% confidence interval.”

In a June 6 blog post, I took a stab at translating that last sentence.  I said that, if you could somehow ask each of the 92,000 nurses if they were personally aware of a patient having died because there weren’t enough nurses to care for all of the patients needing care, you could be confident that between 16% and 30% of them would answer in the affirmative.  (Sixteen percent of 92,000 is 14,720; 30% is 27,600.)
I also said that, assuming just one witnessed patient death per surveyed nurse, the MNA is suggesting that at least 14,720 and as many as 27,600 hospital patients died because of inadequate staffing during the working lives of those 92,000 nurses.

Maybe the survey fell flat because the nurses’ union bought and paid for it.  That gave everyone a ready-made excuse to dismiss it.  We could say, “The nurses got the numbers they paid for; that’s what you do these days,” and move on to other news.
Maybe the survey got swamped by all of the other things happening in our world that day.  The torrent of news, or what passes for news, never lets up in the Internet age, even for a second.    Too much stuff competes for our attention.  How much of what comes before our eyes on a typical day can be remembered, never mind acted upon?

Or maybe it failed to achieve loft because the nurses’ union tried to accomplish too much with too little.  The news release said the results “can be assumed to be representative” of the experiences of 92,000 nurses.  It did not say how many nurses were actually surveyed by the union’s research firm, nor how much the union spent on the survey.  Skeptical minds could infer that: (a) the total number of respondents was not impressive, and (b) the project was done on a slender budget.
I’m being a little unfair when I say nothing happened as a result of the survey.  Later in June, after all, the legislature passed, and the governor signed, a bill mandating nurse staffing ratios in hospitals for the first time ever, House Bill 4228, An Act Relative to Patient Limits in All Hospital Intensive Care Units.  The survey might have nudged HB 4228 an inch closer to the goal line, but I think the legislature was ready to do something on this issue in any event. 

The new mandate is limited to hospital intensive care units.  It stipulates:  “…in all intensive care units the patient assignment for the registered nurse shall be 1:1 or 1:2 depending on the stability of the patient as assessed by the acuity tool and by the staff nurses in the unit, including the nurse manager or the nurse manager’s designee when needed to resolve a disagreement.” 
Literally for years, the MNA has been working on Beacon Hill to get a comprehensive nursing staff ratio bill passed.  While HB 4228 is truly a significant piece of legislation, it falls miles short of what the union was aiming for when it began its latest round of lobbying on this issue, way back in January, 2013, at the start of the current legislative session.

The hospitals seemed glad, having ceded only their ICUs, to leave the battlefield.  Said Lynn Nicholas, president of the hospital association, “The legislation focuses on the intensive care unit where there is a collaborative role for staff nurses, for nurses who manage care for all patients in an ICU, and for an acuity system to help determine the severity of an ICU patient’s illness.  Importantly, the legislation leaves flexibility throughout the rest of the hospital to properly address every patient’s needs.”
The nurses’ union vowed it would be back next session, trying to get a bill through to set mandatory nurse-to-patient ratios in all hospital units.   Many legislators no doubt have severe nursing-staff-ratio fatigue.  But every rep and senator who’s there for the 2015-16 session will hear the union out.  Nurses are respected, rightly so.  There’s a lot of them. They vote.


When Pondering the Wreckage in Probation, Don't Ignore 'Minimum Qualifications'

Friday, July 11, 2014

The other day, while thinking about the trial of the three former big shots in the Massachusetts Probation Department, which is mercifully drawing to a close at the Moakley federal courthouse in Boston, I remembered that the Ethics Commission had issued an advisory on the making and receiving of recommendations for jobs in the public sector.  I went to the state government web site, clicked on Ethics Commission, and easily located the document in question: Advisory 13-1, dated January 18, 2013.

Under the heading of “Recommendations of Constituents,” it said, in part:
“To comply with the prohibition against giving unwarranted privileges imposed by Section 23(b)(2) (Chapter 268A of the Massachusetts General Laws), an elected public employee should have some reason to believe that the constituent possesses the minimum qualifications for the position  for which he is being recommended.  The elected public employee may already be familiar with the constituent’s qualifications for the desired position.  If not, the elected public employee should obtain sufficient information to satisfy himself that the constituent possesses the minimum qualifications for the position before making the recommendation.”

There are problems in advancing the candidacies of job applicants possessing only minimal qualifications, as any unit of state government with more than a few minimally qualified persons in its ranks is bound to defeat the hopes of the citizens in need of its services, but there are bigger problems, in the first place, in having elected public employees, especially legislators, who are supposed to be making laws and deciding on public expenditures, routinely involved in the hiring and promoting of public employees.
Yes, I know it’s always been that way, and, yes, I understand that legislators have taken on the burden of facilitating hiring and promoting in the public sector at the behest, nay the insistence, of we the public.

(One member of the House, called to testify Wednesday at the Probation trial, said he had often joked that his State House office was “the Eighteenth Suffolk Employment Agency,” suggesting how thoroughly the demand for job placement services had overtaken the agenda of the representative from the 18th district in Suffolk County.)
But that doesn’t mean it’s a good idea or that there are not superior alternatives to arming our lawmakers, de facto, with inordinate powers in the realm of human resources.  The trial in federal court of John O’Brien, the former Probation Commissioner, and two of his former deputies, Elizabeth Tavares and William Burke, on charges related to an allegedly fraudulent hiring system, has served, if as nothing else, as a sorry reminder of how a vital public safety function in a democracy, i.e., the supervision of criminals ostensibly travelling a path to redemption, may be drained of vitality by too much politics.

It would be asking too much, it would be aiming too high, it would be contending too strenuously with human nature, to propose that elected public employees be prevented by law from providing any help whatsoever to constituents aspiring to the public payroll.
I’d settle for changes in our general laws stipulating that no more than 20 percent of the employees in any unit of state or local government at any time could possess only minimal job qualifications, and that at least 20 percent of those employees be maximally qualified.

Going back to the Probation trial, did you see that the defense attorneys declined today to present any of their own evidence?  They obviously believe their clients will be acquitted. 
If O’Brien, et al. are found not guilty, as now seems quite likely, make no mistake, they still will have lost a great deal.  And those losses may prove irreparable.   Having your reputation continuously assailed over a period of years and losing your life savings, if not your home, to lawyer’s fees is but the half of it.

While it does not always have the ability to convict, our government is always able to destroy.

Bottle Bill Expanders Have a Problem: the Law's a Cash Cow for the State

Wednesday, July 9, 2014

The longest, continuous battle in Massachusetts politics has to be the one over the expansion of the bottle bill.

For as long as I can remember, every year in the legislature, there’s been a serious-but-ultimately-unsuccessful push to have the 5-cent-per-bottle deposit go beyond beer and soda to bottled water, sports drinks, iced tea, juices and the like. 
In May of this year, for instance, the Massachusetts Senate passed a Fiscal Year 2015 state budget with an amendment seeking to expand the Bottle Bill.  Because the House budget, passed one month earlier, had no such amendment, it fell to the six-member House-Senate budget conference committee to decide if the measure would remain in the final version of the budget. In conference, the House viewpoint prevailed: the amendment was ditched.

The coalition of groups working to expand the bottle bill was ready with a good fallback: it had gathered more than enough signatures on petitions to put the expansion on a statewide ballot, which is where it will be -- as Question 2 -- on Tuesday, Nov. 4.
Proponents are confident of victory.  Says Janet Domenitz, executive director of MassPIRG: “Every poll shows that over three-quarters of the public support updating the bottle bill.”

Opponents are ready to fight. And they have the resources to fight long and hard.  Nicole Giambusso, a spokesman for an anti-expansion group, told the Boston Herald the other day:  “We’re going to run a campaign that’s statewide and highly visible.  We definitely want to get our message out that there’s a better way to recycle.”
I may be a tree hugger from the Sixties, and I may be a lock to vote yes on Question 2, but that doesn’t mean I don’t see trouble up ahead for Bottle Bill expanders.

Their Achilles Heel, I believe, is the bulging state account that holds unclaimed, or “abandoned,” bottle deposits.
According to reliable estimates, between $37 million and $38 million will have accrued in that account by the end of FY 15, on June 30, 2015. 

That’s one awesome pile of nickels.
A windfall for the state in unclaimed deposits is not a new phenomenon.  Almost every year since the enactment of the Bottle Bill in 1982, the state has raked in tens of millions of dollars this way.

I think the voters of the Commonwealth will also have difficulty swallowing this number: if the Bottle Bill were expanded, it has been estimated that the unclaimed deposit account could grow by as much as $20 million per year. 
When Bottle Bill foes complain that the law is outmoded, and that it has created an everlasting, hidden tax and a spending crutch for the legislature and governor to quietly lean on, it’s hard to dismiss those arguments out of hand.

Now consider Charlie Baker, the Republican candidate for governor, who's running partly on a platform of economic growth and job creation.  He says he wants to promote small businesses; make state government more affordable, accountable, and business-friendly; and give the people of Massachusetts a government “that’s as thrifty, creative, and hard-working as they are.”
It’s no stretch to see Baker joining the fray against the expansion of the Bottle Bill and using it as an example of the government’s dead thumb on the economy.

First, of course, the Baker campaign will conduct internal polling on Question 2 and all of the other November ballot questions.  If that polling shows support for expansion is soft and trending softer, Baker could leap to exploit the issue.
In that scenario, I imagine him saying something like: “Tell the leaders of the Democratic Party we know how to spend our money better than they do.  It’s our money!  Let’s use it to stimulate the economy, not maintain the government status quo.”

BAKER POSTSCRIPT:  Late on Wednesday afternoon, July 9, Charlie Baker told the State House News Service he would oppose Question 2.  The service quoted Baker as saying, "I view the Bottle Bill expansion as mostly a money grab by the state, and I think there are far better and less expensive ways for us to continue to recycle and to be effective."  His comments were reported several hours after this blog item was posted.

The Great Northeast Casino Glut and Other Disparate Attention Grabbing Items

Thursday, July 3, 2014

IS A CASINO RESCUE BILL IN OUR FUTURE?  A new poll by WBUR indicates that the citizens of Massachusetts favor casino gambling by a wide margin, 56 to 38 percent, although 40 percent said casinos “are a net negative, driving out existing businesses and bringing social ills like crime and gambling addiction.”  This addiction talk reminded me of a study released last fall by the Council on Compulsive Gambling, which said that problem gamblers are more likely to use alcohol and drugs, smoke cigarettes, shoplift, report sex addiction and drive too fast.  The Council study asserted: “With the legalization of casinos, large scale legal gambling in the Commonwealth of Massachusetts is about to radically change.  The introduction of up to four casino-resorts in Massachusetts, a state which has the most lucrative lottery system in the country, will likely generate significant social and economic changes.”   On Friday, June 20, the Wall Street Journal ran an article -- “Casino Glut Pinches States” -- on how the oversupply of casinos is eating into state tax yields from gambling.  “Racetrack casinos used to contribute as much as $240 million a year to Delaware’s tax coffers,” the article said.  “But as the Northeast becomes saturated with gambling venues, the state’s casino revenue has tumbled, prompting a new industry request – for a tax break.”  Five years hence, can we say we’re surprised when a bill is introduced in the Massachusetts legislature to cut taxes on casinos to save all those casino jobs?

IT DEPENDS UPON WHAT YOU MEAN BY ‘PENDING.’ On June 30, the Massachusetts Department of Fire Services issued a press release noting the upcoming anniversary of a tragic rooming house fire in Beverly, and drawing attention to a bill that would give cities and towns the option of requiring sprinkler systems in new one- and two-family homes.  “This July 4 will be the 30th anniversary of the Elliott Chambers Rooming House fire in downtown Beverly that killed 15 residents and injured nine others,” the release said.  “This tragedy led to swift passage of legislation allowing communities to choose to require sprinklers in boarding and lodging houses…leading to a decline in rooming house fires and especially fatal rooming house fires.  It is one of the great fire prevention success stories.”  State Fire Marshal Stephen C. Coan was quoted as saying there’s legislation “pending right now” in Massachusetts that would give communities “the ability to choose to require sprinklers when new homes are built.”  He was apparently referring to House Bill 2121, An Act Relative to Enhanced Fire Protection in New One and Two Family Dwellings.  The legislature’s Joint Committee on Public Safety and Homeland Security sent that bill to “study” on March 20, meaning it was for all intents and purposes killed at that point. Now bills can be recalled from study and acted on, but they almost never are.  Opposed by many in the construction and real estate fields, H2121 will not be resurrected from study before the legislature ends formal sessions on Thursday, July 31.   
THE ACTUAL DOCUMENT CONTAINER ARRIVED LATER, OF COURSE.  At the Democratic State Convention in Worcester, Juliette Kayyem gave a wonderfully passionate speech about why she wanted to be the party’s nominee for governor this fall.  According to the official text of the speech released by the Kayyem for Governor Committee, she said, in part: “This is no time for caution.  We can’t simply dream of a Commonwealth that might be.  We must plan for the Massachusetts that SHOULD be.  My inspiration and optimism about this journey comes from my grandmother, my Situ.  She moved here from Lebanon in 1938 and raised 9 children on her own.  She could barely read English.  But she achieved the goal of educating all her children. She carried the proof of her journey with her in a Ziploc bag: birth certificates, citizenship forms, her American Passport.”    According to the Dow Chemical Co. web site, the first Ziploc bags were test-marketed in 1968.  (Kayyem came in fourth in the convention balloting for the nomination, with 12.1 percent of the votes.  She needed at least 15 percent to qualify for the September primary.)

BARNEY AIN’T BUYING LIZ’S ‘NOT ME’ ROUTINE.  Elizabeth Warren is almost single-handedly maintaining the bottom lines of three different airlines.  Her speaking obligations beyond Massachusetts seem to be without end.  Everywhere she goes, Warren is asked if she intends to run for President in 2006, and everywhere she denies having any such intention.   Retired Congressman Barney Frank was asked recently by the State House News Service if he thought Warren, despite her disclaimers, is inclined to seek the presidency.  “Oh, I think yes,” Frank said.  “In the first place, why would you want to get into a profession and have no interest in rising to the top of it?  I don’t know anybody who has that.”  Frank is eager to see Hillary Clinton run.  “I’m a great admirer of Hillary Clinton,” he said.
MOULTON COMES UP WITH INVENTIVE LINE OF ATTACK.  Several months back, the Boston Herald asked former Massachusetts Senate Minority Leader Richard Tisei about candidates he had recommended for jobs in the Probation Department.  Apparently, there’s at least one letter of recommendation from Tisei in the files.  Tisei, who’s running again for Congress in the Sixth Massachusetts District, reportedly told the Herald that “a letter from me I don’t think was very helpful,” and that he had “never talked to O’Brien.  I don’t think I ever met him the whole time I was in (the Senate).”  O’Brien is former Probation Commissioner John O’Brien, now on trial in federal court for allegedly rigging the hiring system.   Tisei’s exchange with the Herald inspired Seth Mouton, an Iraq war veteran running in the Sixth District as a Democrat, to issue a press release under the headline, “Richard Tisei to Boston Herald: I’m Ineffective.”  Moulton was quoted in the release as saying: “At issue isn’t that Richard Tisei sent a letter to a now disgraced ex-department head making a job recommendation.  The issue is that Richard Tisei has proven time and time again to be just another Republican who stands for the status quo.  It’s not something to brag about that, after 20 years in the state senate, a letter with his name on it ‘wasn’t very helpful.’ Nor is it impressive that, 20 years into his tenure, he hadn’t met with the head of a major department.  How many other department heads did Richard Tisei not meet.”  Think how worked up Moulton could get if it was revealed that Tisei got someone a job.