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Should Supervisors Perform Bargaining Unit Work?

15 Jan

Mat Keller headshot

By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist

It’s happened to just about every RN at some point or another. Your unit is short staffed, and you’re doing the best you can — but you’re stretched too thin, and your patients aren’t getting the care they’re paying for and deserve. So you call your nurse manager. What happens?

Staff-nurse supportive nurse managers do their best to avoid these situations in the first place by staffing appropriately. However, sometimes it’s just not possible to prepare for unexpected events and changes in acuity. That’s why top nurse managers, when confronted with these situations, advocate for their units in order to get another bedside RN called in to lend a hand.

Some nurse managers may also offer to help out themselves. In limited circumstances, this may be acceptable. If the nurse manager is competent to perform the work, if there was no way the nurse manager could have anticipated the staffing needs in advance, and if the nurse manager is performing the work only in limited emergency circumstances, then MNA is unlikely to pursue a grievance for a supervisor performing bargaining unit work.[1] In such instances, the needs of our patients come first.

If, however, the nurse manager precipitated the staffing crisis through purposeful unsafe staffing, if the nurse manager is not competent to perform bedside RN care, or if there is a continuous pattern of unsafe staffing and supervisors performing bargaining unit work, then MNA can and will take action. As above, in such instances, the needs of our patients come first.[2]

A continuous pattern of supervisors performing bargaining unit work indicates a greater underlying problem—unsafe staffing. As Carrie Mortrud, RN, MNA Safe Patient Staffing Specialist, puts it:

We appreciate nurse managers who step up to the plate and help the team in emergency circumstances that could not have been anticipated. When nurse managers continuously do this, however, they are covering up a larger systemic and often chronic problem — unsafe staffing. They are putting a Band-Aid on an arterial bleed. Clearly a tourniquet is needed — with a temporary Band-Aid.

In those instances, nurse managers need to step up to the plate in another way: by staffing appropriately and hiring more nurses. This protects our licenses, our jobs, and more importantly, our patients.”

Are you experiencing a situation where your nurse manager is continuously performing bargaining unit work? We want to know!  Please let your steward, labor representative, or MNA’s Regulatory and Policy Nursing Specialist Mathew Keller know right away.

 


 

[1] See, for example, Essentia Health Virginia Contract p. 4: “Except in cases of emergency (an unplanned immediate need) or an unavoidable situation where patients would be deprived of needed nursing care, non-bargaining unit personnel shall not be used to perform bargaining unit work.”

[2] Please note that, in rare instances, smaller hospitals have negotiated language allowing supervisors to perform bargaining unit work.  See, for example, Deer River Contract Article 3.1: “Due to the relatively small number of RNs employed at the HealthCare Center and the relatively small size of the facility, the HealthCare Center has working managers who perform bargaining unit work in addition to their management duties.  Any significant expansion of managers doing bargaining unit work beyond that typically done at present shall be open to negotiations between the parties.  The minimum staffing for acute care at the facility will include two bargaining unit RNs if one RN is ER capable and one RN is charge capable.”

Minnesota Hospitals Reduce Charity Care, Increase Profits

30 Sep

Mat Keller headshot

By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist

We all knew big insurers would benefit as more individuals sign up for health insurance under the provisions of the Affordable Care Act. What is surprising to me, at least, is just how much Minnesota hospitals are profiting as well.

In the latest sign of sickness in the corporate healthcare world, the Minnesota Department of Health reports that our hospitals have reduced the amount of charity care they provide to our sickest and poorest citizens by 22.4 percent.

Much of this decrease is driven by a sharp increase in the number of patients with health insurance across the state — up to 94.1 percent, an all-time high.

Hospitals, as they reduce their charitable care, should pass those cost savings on to their patients and communities. They should allow more patients to qualify for charitable care. They should increase the quality of care they provide through appropriate nurse staffing. They should engage their communities in public health outreach.

Instead, our non-profit hospitals are pocketing the money, giving it out as bonuses, spending it on advertising and branding, building the latest and greatest waterfall in the lobby. Enough is enough.

Charitable care forms the backbone of our societal contract with our non-profit hospitals — we grant them tax exemptions, and in return, we expect that they will strive to help the sickest and poorest among us in a charitable manner. It might be time to re-examine that contract.

 

Minnesota hospitals’ income soars

18 Sep

Mat Keller headshot

By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist

In yet another sign that Minnesota Hospitals are using the myth of a Minnesota “nursing shortage” in order to avoid appropriate nurse staffing, the Star Tribune recently reported that our 10 largest hospital systems “saw operating income jump by 38 percent in fiscal 2014 compared with the previous year.”

These healthcare systems reported sparking income growth by “putting the brakes on hiring.”

In particular, North Memorial Medical Center saw its highest net profit margin since 2006 (and yet is currently laying off RNs); the Mayo system reported a 1 percent decline in salary and benefit costs while experiencing a 36 percent increase in revenue (complaining of a nursing shortage and cutting pensions the whole time); Sanford reported eliminating positions through attrition (while also reportedly purposefully staffing 10 percent under grid in order to cut costs); and HCMC, a 472-bed facility, added the equivalent of only 38 full-time positions.

Meanwhile, nurses continue to report unsafe nurse staffing in record numbers.

Since August of last year, MNA nurses have submitted 2,802 Concern for Safe Staffing forms, indicating situations in which staffing is so bad patient safety is at risk.

Minnesota Hospitals: bragging about enormous jumps in profit obtained through unsafe staffing all the while jeopardizing the safety of our patients.

The time for a Safe Patient Standard law is now.

The Problem with Observation Status

4 Aug

Mat Keller headshot
By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist

Last fall, my grandmother was admitted to the hospital after a TIA that left her oriented only x1.  Or, more correctly, we thought she was admitted.  As it turns out, she was in the hospital for several days in an outpatient status, known in Medicare parlance as “observation status.”

Unfortunately, what “observation status” meant for Grandma was that she did not meet the Medicare requirement for a 3-day inpatient stay at the hospital in order to qualify for discharge to a skilled nursing facility.  Thus, despite the fact that Grandma was certainly not in any shape to discharge home; and despite the fact that she had entered the hospital from a nursing home, she was not able to go back to the nursing home.

Such situations occur more frequently than you might think: according to a 2014 report by the Medicare Payment Advisory Commission, 1.8 million observation claims were submitted in 2012, an 88 percent increase from six years earlier.  While observation status was originally implemented to allow hospitalists to determine whether or not patients should be admitted, it has grown into a kind of purgatory that allows hospitals to reduce penalties from the Hospital Readmission Reduction Program (since observation status patients are not technically readmitted) and shift services to more profitable outpatient areas of the hospital.

On top of not counting toward the 3-day requirement for discharge to a skilled nursing facility, observation status stays are charged on an outpatient basis (i.e. under Medicare Part B). This can often mean higher out-of-pocket costs for Medicare beneficiaries—for example, Medicare Part B services have a deductible and 80/20 cost sharing (80 percent Medicare/20 percent beneficiary) that is applied to all services provided and does not cover the cost of pharmaceutical drugs used in the hospital.

So what can nurses do? The first step is to advocate for our patients.  Ask the hard questions – why are our patients in the hospital being charged for services if the physician is unsure whether or not a hospital admission is medically necessary?  Equally important is communicating with the patient.  Our patients deserve to know whether or not they are on observation status.  Furthermore, they absolutely must understand what “observation status” entails: they will be charged for services under Medicare Part B (80/20 cost sharing and a deductible), the cost of medications will not be covered, and the patient’s time in the hospital will not count toward the 3-day requirement for discharge to a skilled nursing facility.

As of July 1, such communication with a patient is in fact required under state law — but in order to properly communicate with and advocate for our patients under observation status, we must first understand it ourselves.  Read more about the issues with observation status here or here.

Is this the End of the Charge Nurse as We Know It?

12 Jun

Mat Keller headshot
By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist

It is with growing concern that MNA has received reports of increasingly ineffective charge nurse utilization in our hospitals.  If you’ve been in nursing for more than a few years, you’ve seen the trend yourself: charge nurses have quickly gone from having no patient assignment, to having a few admits or discharges as needed, to always having half of an assignment, to always having a full assignment… to having two floors?

This alarming new trend is to assign the nurse variously described as a given unit’s “resource,” “foreperson,” and “air-traffic controller” to two units at once. This disastrous model stretches already thin nurse staffing even thinner while eliminating an essential resource for both routine and emergency nursing care. Furthermore, it requires the charge nurse to be in two places at once while making safe, accurate, and timely staff assignments without knowing half the staff being assigning.

When a hospital requires a charge nurse to take on a full patient load, or to be in two places at once, that hospital is putting its bottom line ahead of patient safety. This is dangerous for both the hospital and the charge nurse. In fact,  many experienced nurses are now turning down charge nurse assignments due to their unwillingness to take on the legal risk such unsafe assignments entail.

Charge nurses are essential tools to ensure the right nurse is assigned to the right patient, to help navigate crisis situations, and to ensure care that would otherwise be missed is performed. As one researcher put it, the role of a charge nurse is a “skillful balancing act.” But how can one perform a skillful balancing act on two floors at once?

Is this the end of the charge nurse as we know it? Maybe. It’s up to nurses to stand strong together: do not accept unsafe charge nurse assignments. Do not enable your facility to cut corners and put patients at risk. Do not perform your skillful balancing act with a full patient load on two floors at once. Our patients deserve better.

Are you ready to administer marijuana?

29 May

Mat Keller headshot

By Mathew Keller RN JD, Regulatory and Policy Nursing Specialist

With Minnesota’s medical cannabis law set to take effect on July 1, Minnesota nurses will likely be asked to administer medical marijuana in the hospital setting.  But are you ready to do so?  Here’s what you need to know about the new law.

  • Patients will not receive a medical marijuana “prescription” from a physician or APRN. Instead, a patient’s provider will certify that the patient has a medical condition that qualifies for medical cannabis use.  The patient will then need to register with the Minnesota Department of Health in order to be eligible to utilize the medication.
  • Patients will not be able to pick up medical cannabis from the local pharmacy. There are eight locations in the state that are licensed to dispense medical marijuana.
  • Patients will not be able to smoke their medical cannabis.  Raw leaf, flowers, and edibles are not allowed under the Minnesota law: only pills, oils, and liquids are allowed.
  • Your facility may ask you to administer medical cannabis. Each facility will surely have its own policy and procedure on patients who are admitted and bring their own medical cannabis.  It is possible that your facility may ask the patient to turn the medications over to the hospital pharmacy, which would then ask you to administer the medical cannabis.
  • You and  your facility are protected under state law while administering or providing care to someone who is taking medical cannabis.  Minnesota recently passed an amendment to the medical cannabis law.  Per the MN Department of Health:

    The amendment extends protections and immunities to employees of health care facilities to possess medical cannabis while carrying out their employment duties. These protections include providing care or distributing medical cannabis to a patient on the Minnesota medical cannabis patient registry who is actively receiving treatment or care at the facility. The amendment also allows health care facilities to reasonably restrict the use of medical cannabis by patients. For example, the facility may choose not [to] store or maintain a patient’s supply of medical cannabis or that use of medical cannabis may be limited to a specific location.

  • Federal law still prohibits the distribution and use of medical cannabis. Under federal law, medical cannabis remains a Schedule I drug.  Given state law protections, however, the potential liability and level of concern for individual nurses who are asked to administer medical cannabis per hospital policy should be low.

 

Practice Alert: Should nurses be filling the Pyxis?

20 May

Mat Keller headshot`

By Mathew Keller RN JD, MNA Nurse Practice & Policy Specialist

In a cost-cutting move, many Minnesota hospitals are asking registered nurses to take on more pharmacy duties. Where there may have once been pharmacy staff available 24/7 to answer questions, compound pharmaceuticals, and dispense medications, many nurses are finding that such coverage is now limited to 9-5 with an outsourced pharmacist in another city (or state) available by telephone after hours to answer questions and certify prescriptions. This can lead to potentially dangerous situations for patients as well as nurses’ licenses when nurses are asked to dispense and/or compound medications in the absence of a pharmacist.

One disturbing trend we are tracking is nurses being asked to fill the Pyxis or other automatic dispensing machine on the overnight shift. Non-pharmacy staff filling a Pyxis is unacceptable pharmaceutical practice. Furthermore, it is outside the scope of RN practice.

Under state law, only pharmacists are legally qualified to dispense medications, although they may be assisted in the task by up to two pharmacy technicians at one time.[1] Dispensing is defined as “delivering one or more doses of a drug for subsequent administration to, or use by a patient.”[2] When a nurse fills a Pyxis or other automatic dispensing machine, that nurse is delivering doses of drugs for subsequent administration to a patient.

While nurses may legally administer medications, they may not legally dispense them. Filling a Pyxis is outside the scope of RN practice and can lead to discipline against one’s nursing license as well as charges of practicing pharmacy without a license. In addition to scope and licensure issues, a nurse who fills a Pyxis assumes legal liability for any and all errors or patient harm resulting from improper dispensation (e.g. putting the incorrect medication in a Pyxis drawer).

Another common issue involves nurses being asked to mix IV medications in the absence of pharmacy coverage. The propriety of this practice is situationally dependent: reconstituting medications is acceptable nursing practice; compounding medications is not. Compounding is defined as mixing, packaging, and labeling a drug for an identified individual patient’s use.[3] The determining factor in whether or not you are compounding medications is whether the medication is for immediate use or not.  If a medication is being mixed for immediate use, it is acceptable reconstitution.  If the medication is being mixed for storage and later use, it is unacceptable compounding.

Lastly, many nurses are being given pharmacy access for after-hours care.  Under Minnesota rules[4], after-hours nurse access to the pharmacy should fulfill the following guidelines:

  • Withdrawal of medications must be limited to “emergency” situations, interpreted broadly by the Board of Pharmacy to include any time a necessary medication is needed but unavailable;
  •  Only one designated RN on a given shift may have emergency access;
  • The standard of practice is that narcotic access is limited to a locked narcotic drawer with a small supply of available medications, not full access to the narcotics safe;
  • The designated RN must properly document medications removed from the pharmacy;
  • The designated RN should have proper training from the pharmacy staff in pharmacy policies and procedures, as well as specific training regarding after-hours access.

MNA has and will continue to work with the Minnesota Board of Pharmacy in order to ensure that our patients are protected through proper pharmaceutical and nursing practice. Have you been asked to fill a Pyxis or compound medications? Please let us know at Mathew.keller@mnnurses.org.

[1] MN Statute §151.01 Subd. 27 (2)
[2] MN Rule 6800.7100
[3] MN Statute §151.01 Subd. 35
[4] MN Rule 6800.7530

Proposed Law Would Revoke Licensure for Medication Errors

11 May

Mat Keller headshot

By Mathew Keller, RN JD, MNA Nurse Practice & Policy Specialist

“Samuel’s Law,” under consideration in the South Carolina Senate, would require the South Carolina Board of Nursing to revoke a nurse’s license “upon the board’s finding that a licensed nurse misreads the physician’s order and overmedicates or undermedicates a patient.”

While the circumstances surrounding the introduction of Samuel’s Law, involving the fatal overmedication of a 7-year old, are tragic, the bill is an inappropriate response and does nothing to correct the systems-level failures that are often the basis of medication errors.

As a systemic review of 54 studies on medication errors puts it, since “nurses find themselves as the ‘last link in the drug therapy chain’ where an error can reach the patient, they have traditionally been blamed for errors. However, the reality is that the conditions within which the person responsible for the error works, as well as the strategic decisions of the organization with whom they are employed, are often the key determinants of error.”[1] 

Therefore, any law that purports to reduce the incidence of medication errors ought to focus on systems-level failures that can lead to medication errors, including inadequate communication pathways (e.g. illegible prescriptions, poor documentation, lack of transcription), problems with pharmaceutical supply and storage, unmanageable workload, availability and acuity of patients, staff fatigue and stress, and interruptions or distractions during drug administration.

Correcting or addressing the above issues, rather than punishing unintentional errors with the loss of one’s livelihood, will go a long way toward addressing the root cause of medication errors Samuel’s Law seeks to address.  It also fits with the model of “just culture,” widely accepted and adhered to in both the medical and aviation industries, which seeks to create an environment that encourages reporting mistakes so that precursors to errors can be understood and systems issues can be fixed.

As Lucian Leape, MD, member of the Quality of Health Care in America Committee at the Institute of Medicine and adjunct professor of the Harvard School of Public Health, said in testimony before Congress, “Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes.” (Leape, 2000).

Samuel’s Law, while well-intentioned, uses the wrong approach to prevent medication errors.  How would you change the language to better prevent errors?  Share your thoughts in our comment section below.

[1] Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Causes of Medication Administration Errors in Hospitals: a Systematic Review of Quantitative and Qualitative Evidence. Drug Safety, 36(11), 1045–1067.

Minnesota nurses oppose MNCare repeal

5 May

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By Mathew Keller, RN JD, MNA Nurse Policy Specialist

When cuts are made to public insurance programs, we all end up paying more.  Just the other day I heard the story of Mary*, a young woman who found some unusual lumps in her breast.  Having already had her preventive care exam for the year, she could not afford the high cost of following up with her physician.  When she was finally able to get her next annual exam, Mary got the heartwrenching news that she had Stage 4 breast cancer.

MinnesotaCare, a public health insurance program for the working poor, is under threat from state legislators in the House of Representatives. In the long run, gutting MinnesotaCare is a losing proposition for our patients, our hospitals, and our state.

MinnesotaCare is a program for those who earn between 133 percent and 200 percent of the Federal Poverty Line (FPL), which is $11,770 for an individual and $24,250 for a family of four this year. MinnesotaCare currently serves 105,000 individuals and families who work hard and yet don’t have employer-provided insurance and can’t afford coverage on the open market.  The program requires enrollees to pay premiums of $15-$50, depending upon income, and to share in some of the costs of coverage.

If MinnesotaCare is repealed, its current enrollees will be forced to enroll in a private insurance plan, which will cost more and deliver less. For example, a 2015 silver plan would cost an individual earning $16,243 annually a $46 monthly premium, while only covering 70 percent of medical costs. That same individual would pay a monthly premium of $15 while receiving 98 percent coverage under MinnesotaCare. For the working poor, this is a huge difference.

As nurses, we know that the high price of healthcare is often a barrier to the working poor receiving adequate care. According to a Harvard study, unpaid healthcare costs cause more than 60 percent of  bankruptcies in America, and one in five American adults struggle to pay their medical bills.  The rate of unpaid medical bills is even higher among working poor earning between 133 percent to 200 percent of the FPL.

Consider, for example, the price of an emergency appendectomy. Assuming the patient gets to the emergency room before the appendix ruptures, the procedure costs upwards of $20,000. For a working-class individual earning $16,243 annually on a silver-level private insurance plan (with 70 percent coverage), the out-of-pocket cost is still an unmanageable $6,000. When that individual is unable to pay the $6,000, the hospital absorbs the cost under “charitable care,” but the hospital has to raise prices on every other patient to balance the books.  Rather than cut healthcare costs, eliminating MinnesotaCare actually raises costs for all Minnesotans.  It’s a gimmick that budgeters try to make it look like they’re doing a good job.

When individuals and families are afraid to go to the doctor because of what it might cost them in the long run, they put off necessary treatment.  This harms our patients’ health while costing them, the hospital, and all Minnesotans more in the long run. Mary didn’t make it; let’s make sure the 105,000 working-class Minnesotans who use MinnesotaCare don’t need to face the same choices she did.

*Name changed to protect confidentiality

Proposal protects healthcare workers from workplace violence

13 Mar
MNA members testify about S.F. 1071, workplace violence prevention bill on March 11

MNA members testify in favor of a proposal by Sen. Chuck Wiger to reduce workplace violence against healthcare workers on March 11

By Mathew Keller, RN JD, MNA Nurse Policy Specialist

As a result of the assault against staff at St. John’s Hospital last November, the hospital removed bedside poles that could be used as weapons.  While this action may prevent future violence, it’s too late to help the nurses who were attacked that day.

Meanwhile, there’s a bill in the Minnesota Legislature that could lead to better prevention and preparation for healthcare workers caught with a violent patient. HF 1087 and SF 1071 are bipartisan bills aimed at preventing violence against health care workers, require that hospitals:

  • Develop preparedness and incident response action plans in collaboration with health care workers;
  • Provide adequate security staff;
  • Allow healthcare workers to request additional staff due to concerns over possible violence;
  • Provide training to all health care workers on safety guidelines, the incident response plan, how to properly de-escalate situations and request additional staff, and the worker’s rights regarding acts of violence.

In addition, HF 1087/SF 1071 prohibit hospitals from interfering with a healthcare worker’s right to contact law enforcement or the Minnesota Department of Health regarding an act of violence, and establishes an electronic violence prevention database, which will allow the state to track trends in violence against healthcare workers at a hospital level.

The violence against healthcare workers bill could go a long way toward preventing potentially violent or abusive situations we have all experienced as bedside nurses.  Furthermore, it will prohibit hospitals from preventing or discouraging nurses from reporting abuse from patients or visitors, which we know is a common problem.

Unfortunately, the Minnesota Hospital Association would rather enact harsher punishments on perpetrators of such violence rather than prevent the violence in the first place.

MHA claims that nurses can already report safety lapses to the Office of Health Facilities Complaints, but this argument displays little understanding of how healthcare workers can interact with state agencies.  Both MDH and its commissioner tell MNA that OHFC investigates only complaints against facilities that are violating current law; when a patient assaults a worker, the facility has not violated current law, and therefore a complaint against the facility would fall outside the jurisdiction of OHFC.

The hospital association also claims that the violence prevention bill is a ploy to enable nurses to report safety issues to the Minnesota Department of Health; but as MHA itself stated in a letter dated August 13, 2014, to MNA President Linda Hamilton, they view nurses as statutorily obligated to report unsafe staffing to the Department of Health and state that “allowing hospitals, the Board of Nursing, or the Office of Health Facility Complaints to actually address any legitimate concerns” is of paramount importance.  Thus, on one hand MHA views the violence prevention bill as a ploy to enable nurse reporting to MDH, but on the other hand views such reporting as mandatory and of paramount importance.

MHA needs to take a hard look in the mirror and accept some responsibility for a flawed system, which does little to nothing to prevent violence in the healthcare setting, ignores nurses who ask for resources to help prevent a brewing problem from exploding, and discourages nurses from reporting violent or abusive situations to the relevant authorities.  Instead of punishing sick and delusional patients even more for their abhorrent actions, let’s prevent them in the first place.  Let’s remove the pole before it is used as a weapon.