There are many things to worry about in this world. For instance, right now in my hometown of Seattle, the Alaskan Way Viaduct is sagging a bit due to the large-scale drilling going on in the downtown area. The Alaskan Way Viaduct is built on ‘reclaimed land’ from Puget Sound that would most likely turn to liquefaction in our next earthquake (similar to what happened in the Christchurch earthquakes). But OK—state officials say it’s nothing to worry about.
As I write this post I am sitting on a ‘somewhat active’ series of volcanoes, on land that was covered in a hot mud eruption only ten years ago. Rotorua, on the North Island of New Zealand is a hot mess. The youth hostel we are staying in has fire action directions in each bedroom, but no information about what to do in case of an earthquake–or a volcanic eruption.
Disaster preparedness and effective disaster messaging are important components of public health. In the U.S., disaster preparedness communications specialists came up with the Zombie Disaster Preparedness Campaign. Supposedly this campaign started out as a joke by a CDC communications specialist frustrated over the lack of public interest in their traditional disaster preparation information. But then the Zombie Campaign became so effective they’ve continued to use and expand upon it. This shows that with the ‘Chicken Little’ dire warnings of impending doom, a little levity can help.
Last week in Wellington, we talked with Sara McBride, a PhD candidate at Massey University at the Joint Center for Disaster Research. (The photo here is of the inside of their Emergency Operations Center where they coordinate disaster response for the university and conduct trainings). Her area of expertise is as a risk communicator, work which she was doing in Christchurch before the earthquakes. She told us that disaster communication is tricky because too much emphasis on doom and gloom results in people becoming fatalistic. Ms. McBride is currently doing research and work on earthquake/disaster preparedness and messaging in Washington State (where she grew up). As Professor Timothy Melbourne writes in his guest editorial in today’s Seattle Times, the Seattle area is at high risk for major earthquakes and tsunamis on the scale of those in Japan three years ago (“What Our Region Has Not Learned from the Japan Earthquake and Tsunami, 2-25-14). He points out that Washington State needs an honest and transparent assessment of building safety (and other structures such as our dams and bridges). This is an excellent ‘health in all policies’ topic for nurses to get involved with.
On the red eye this week from Seattle to NYC I was reminded of Washington State’s Whooping Cough (pertussis) epidemic. It was a full flight and at least ten people seated near me had deep hacking coughs the entire flight. It’s likely that at least a few of them had untreated pertussis and have now spread it to susceptible people. There were a few small infants on the flight and they are the most vulnerable to getting severe pertussis and dying of it. Adults with pertussis can have a cough that is so forceful it can cause them to vomit. A milder form of the cough can last for months. And pertussis is highly preventable with appropriate vaccination.
In Washington State we are in the midst of a pertussis epidemic. Mary Selecky, the Secretary of Health at the Washington State Department of Health, officially declared an epidemic on April 3, 2012, even though epidemiologic data indicate that pertussis cases exceeded the epidemic or outbreak threshold in late December, 2011. Declaring an epidemic allowed Governor Christine Gregoire to mobilize state emergency funds to provide more pertussis vaccinations to uninsured people in Washington State. It also allowed her to call on assistance from the federal government in the form of CDC investigators to monitor and advise intervention strategies.
According to the Washington State Department of Health website, through the week of May 19th, a total of 1,738 cases of pertussis have been reported in Washington State for 2012, compared to 146 cases for the same time period in 2011. Since January 114 infants less than 12 months have been hospitalized with pertussis; 23 of those were under three months of age and presumably were the sickest and probably required the longest hospitalizations. No deaths have been reported from this year’s pertussis epidemic in the state.
Current US recommendations for vaccination against pertussis include the usual combination childhood vaccination series starting at two months of age, then a booster shot for adolescents ages 11-12 years. A more recent recommendation is for an additional booster shot for adults who are parents or caregivers of infants less than 12 months of age—the idea being that if the adults are vaccinated they are less likely to get pertussis and pass it on to susceptible infants in their care. Health care providers, especially the front-line staff of nurses, are included in this recommendation. This approach of targeting pertussis vaccination to the main caregivers of infants is called cocooning.
I’ve been monitoring the news coverage of Washington State’s pertussis epidemic. The Seattle Times published an article, “Whooping cough epidemic declared in Wash. State” (Donna Gordon Blankenship, 5-10-12). In her article, Ms. Blankenship emphasized the need for adults to get vaccinated as a way to protect infants, and quoted a CDC official calling this a “cocoon of protection.” She also quoted this same CDC official as stating that Washington State’s current pertussis epidemic has nothing to do with the anti-vaccination movement, and instead attributed it to better disease surveillance, the cyclical nature of pertussis infections, and an aging population with waning immunity as the vaccine wears off. That all made sense to me—except for the matter of it not being related to the antivaccination movement. How could it not be at least partially responsible for the current epidemic?
A New York Times article “Cutbacks hurt a state’s response to whooping cough” (Kirk Johnson, 5-12-12) emphasized Washington State’s budget crisis and recent cuts to the public health infrastructure as contributing factors to our states’ current pertussis epidemic. He pointed out that changes in the vaccine to make it have less side effects have also made it less effective over—immunity tends to wane faster. He included quotes from a school nurse (yeah school nurses!) in Skagit County, north of Seattle, which is the hardest hit county so far. He referenced the fact that Washington State has the highest percentage of parents who voluntarily exempted their children from vaccines out of fear of side effects or for philosophical reasons. Studies have shown that vaccine refusers tend to cluster, are often middle-class, college educated white people with antigovernment, anti-establishment views. They like living in the Eco-topia of Puget Sound.
A related topic I find fascinating is the seemingly rising trend of antivaccination sentiments among nurses—and the fact that an astonishingly low percentage of pediatric nurses get the booster vaccine for pertussis, despite CDC recommendations for them being part of the ‘cocooning’. I’ll deal with that issue in a follow-up post next week—unless I come down with pertussis thanks to my airplane seatmates. (I have had the pertussis booster so am counting on it working.)
I love nurse midwives and tried to have one deliver my son a quarter century ago. But since I lived in the south—and did I mention it was a quarter century ago?—and had an extremely benign heart arrhythmia and maybe had been exposed to TB by a homeless patient, I was deemed too high risk to rate a midwife. In labor, I went to a birthing center to have my son and was doing just fine with the nurses there and with no real medical intervention—until some uptight female OB/GYN who I’d never met came clicking down the hallway in insanely high heels, yelled at me not to push until she returned—she had to go park her car—and clicked back down the hallway. I wanted to kick her or at least fire her. I’m sure it would have been a better birthing experience if I’d had a nurse midwife.
I’ve worked with nurse midwives in a variety of community-based health settings and they provide wonderful women-centric primary care. It will be interesting to see what emerges in the continuing—hopefully public—debate over the fate of nurse midwives at the University of Washington.
All nurses should be required to take college-level micro/macro economics. Trying to teach nursing students the basics of health policy is almost impossible if they are not comfortable with economic terms and concepts.
I was reminded of this recently, when in a fit of fall office cleaning, I finally gave away my copy of Samuelson’s economics textbook. It was stuffed full of class notes, health economic diagrams and highlighted paragraphs. Two quarters of economics were required for my public health degree, and both were taught by a passionate German economist who waved dollar bills around his head for effect. I begrudgingly signed up for his course, found it—and him—fascinating, and it has been the single most useful class I’ve ever taken in any of my health care programs. That and a water and sanitation class: the basics of health care.
Economics of health care finds its way into my mailbox. My home mail these days mainly consists of utility bills and glossy medical newsletters by local hospitals. The cover of the latest one (photographed here) is oh so Seattle, showing two smiling but scary looking roller derby women. I’ve met one of the women (off rink thankfully) and she is quite nice in person. Inside the hospital newsletter/magazine is a two page article about the women’s roller derby team, the various sports injuries team members have endured, their team orthopedist and the orthopedic surgical ‘cures’ performed at the hospital. I get similar hospital newsletters from two other local hospitals I’ve been a patient at. All three highlight the hospital cash cows of cardiac surgery, cancer care, and orthopedic surgery (none of which I’ve been there for). I’ve been successful getting off the mailing lists of most all major catalog/merchandise companies, but have not been able to stop getting these hospital newsletter/magazines. It is oh so NOT Seattle, being decidedly un-green and tree/salmon-killing.
I know that I am bombarded with these hospital newsletters because: 1) I have decent health insurance, 2) I’m getting towards the age when cardiac/cancer/ortho surgeries may be needed, 3) I might be crazy enough and able to afford to make a monetary donation to a certain hospital unit/program, and 4) perhaps because I am a health care provider and can recommend certain hospitals to my friends and relatives.
Most experts on hospital advertising agree that the main purpose of such advertising is brand recognition—and that hospital advertising increases (as do the costs obviously) as competition increases for insured/affluent/paying customer-patients. If you ask hospital PR people (I have), they will say their newsletters are an important patient education/health literacy effort—a public service of sorts. But when you analyze the content of articles and print ads, this claim doesn’t hold up. Most are not written or reviewed by clinically-knowledgeable people, they play up emotional content (her heart was fixed and she can now play with puppies and kittens and grandchildren!), and they exaggerate benefits/leave out adverse effects of surgeries and other treatments. Hardly real health education. Most industrialized countries ban or severely restrict health care advertising.
A fascinating underlying reason for hospital/physician advertising (as I learned from Paul Levy’s blog post on this topic), is that it strokes the egos of physicians and senior executives of hospitals. The doctor egos need stroking because they make money for the hospitals and doctors are free agents and can move to a different/higher paying hospital. Funny how there aren’t too many hospital ads or newsletter articles highlighting nurses.
The final reason that health care economics is on my mind is the excellent article in today’s Seattle Times by health reporter Carol Ostrom: “ERBuilding Boom is Wrong Prescription, Experts Say.” In this article she discusses the economic and regulatory issues behind our Seattle-area resort-spa-emergency department craziness—a problem not unique to our region. If you want to understand health care, take or review Economics 101.
The following is an essay I recently wrote about the health professions regulatory system in the US. It is written in the format for Narrative Matter’s “narrative policy” essay, and as such is longer than my typical blog posts. Please share widely, with proper attribution, of course…. I want to thank Morris M. Kleiner for reviewing drafts of the essay for accuracy.
One evening this past April, I was sitting on the floor of O’Hare airport, near a packed gate, waiting to board my flight back home to Seattle. Headphones on, working on my laptop, I clicked on the Seattle Times news site. “Nurses’ Death Follows Tragedy,” was the title of the lead story, with the byline summary, “The suicide of Kimberly Hiatt, a nurse who accidentally gave an infant a fatal overdose last year at Seattle Children’s hospital, has closed an investigation but opened wounds for her friends and family members.” (Carol Ostrom, The Seattle Times, 21 April 2011)
I read the brief article, and then stared at the ubiquitous overhead TV screens in the waiting area, wondering why her death wasn’t included in the endless loop of news. Kim’s story seemed weighty—national in scope. Kim was 50 when she died from hanging herself. She had miscalculated a medication dosage for a medically fragile infant, and immediately reported her mistake. This was the first serious medical error Kim had made in her 25-year career. An official medical report stated it was unclear that the medication error contributed to the infant’s death. But the hospital fired Kim. And the Washington State Nursing Quality Assurance Commission—the sate nurse licensing unit—fined her $3,000 and placed such severe restrictions on her nursing license that she could no longer find employment as a nurse.
In the weeks following news of Kim’s death, I was left wondering how this could have happened—not the medical error—but the cascade of negative consequences for Kim. I thought I knew how health systems worked; I had a doctorate in health policy. And I was convinced that Washington State had a progressive health professions regulatory system—that things like this couldn’t happen here—or now.
The week after Kim’s death hit the news, the topic of my health policy class was quality of care. I planned to talk about just culture: having open, fair, and just organizational cultures supportive of patient safety. There is strong evidence indicating that just cultures are more effective at ensuring patient safety than are traditional punitive health care work climates. Kim was an alumnus of the nursing school where I taught. Most of my nursing students were graduating in a month and would obtain their Washington State nursing license. Our class discussion was no longer at the theoretical level.
But I had a more personal connection with the news of Kim’s death: I was seeking closure to an investigation of my own nursing license by a health regulatory board. I was seeking both emotional and literal closure. For the past year, I had been writing a book about my work as a nurse practitioner providing health care to homeless people in the 1980s. Back then, my life and my career had been derailed by a collision with a state licensing system.
Early in my career as a nurse practitioner, I had my nursing license investigated by the Virginia Health Regulatory Boards of Medicine and Nursing. At the time, I was the sole provider at a clinic for Richmond’s homeless population. I was working within written protocols with a supervising physician available for telephone consultation. This was in compliance with the practice regulations in Virginia. In my second year of working at the clinic, I had an unannounced visit by an investigator for the Health Regulatory Board. I remember the day—and him—vividly.
I noticed an older man walk into the waiting room of the clinic. His shoes were what I noticed first: beige puffy comfort shoes with Velcro straps. He pulled out a business card and handed it to me.
“ I’m doing an investigation of a complaint made to the Boards of Medicine and Nursing about your practice.”
I was stunned. My mind raced through worst-case scenarios: had I killed a patient?
“What complaint? And where did it come from?” I asked.
“I can’t tell you that information. It was requested to remain anonymous. I’m just gathering information for my supervisors.”
He asked to see my patient files and medication dispensary. He stayed for several hours, interrupting clinic.
The health regulatory board investigation of my nursing license sent destructive tentacles—like mold hyphae—throughout my life. The process of the investigation remained unclear to me. I was told they were investigating my scope of practice, including prescribing of medications. Fear was the first thing I felt: fear verging on terror. The most immediate threat was the potential loss of my nursing license. This would have devastating effects on my family since my salary supported all of us. My husband was still in seminary, and I was paying for childcare for our then five-month-old son so I could work and my husband could finish school. An additional threat was the loss of my professional reputation: people assume there are valid reasons for an investigation.
For several months after the investigator’s initial visit, I couldn’t sleep well. I lost so much weight that I had to stop nursing my baby before he was six months old, and that made me feel even more guilt as a working mother. My husband and I got in spats. Due to the ongoing investigation, I was forced to work at the clinic in reduced capacity. The Health Regulatory Board kept threatening to close the clinic, and they finally did for several weeks in the eighth month of the investigation.
The Board of Directors for the clinic where I worked responded to the investigation by increasing their efforts to hire a full-time physician. No physicians were clamoring to do this work. The clinic Executive Director enlisted the help of a volunteer lawyer who talked with lawyers at the Virginia Office of the Attorney General, who advised the Health Regulatory Board. No one seemed to know what nurse practitioners could and couldn’t do. I was told it was a contested area of state law, and that they had never had a nurse practitioner as the only health care provider for a clinic. Even at the time, I knew I was a pawn in the grand political game of professional turf battles.
I was treated as if I were guilty until proven innocent. Investigators and lawyers told me not to talk to anyone about the situation or it could make the outcome worse—effectively issuing a gag order and isolating me from seeking help. More recently, I’ve asked myself why I didn’t get my own lawyer back then. No one advised me to and I couldn’t afford one. There were large gaps of time of not hearing anything about the investigation, but I was always aware that it was unresolved, like a large noose dangling above my head that could come down around my neck at any time.
The stress of the investigation contributed to the dissolution of my marriage, loss of my job, and my own spiral into homelessness. I seriously contemplated suicide on several occasions during the investigation. It was such a painful chapter of my life that I had not been able to look at it before—or talk about it.
Twenty-five years later, as I was writing a book about my work with people experiencing homelessness, I wanted to include the investigation of my license. I realized I had no documentation on it. When I read the news of Kim’s death in April of this year, I was awaiting a reply from the Virginia Board of Nursing to my written request for a copy of my case file. I had expected some resistance, but was confident I would eventually see copies of the investigation. I asked for redacted records: I was not interested in knowing who had ratted on me.
Jay Douglas, the Executive Director of the Virginia Board of Nursing, refused my request. In a telephone conversation with me in late February, she stated that they were confidential records, “Board property, and besides, Virginia’s Freedom of Information Act doesn’t apply to people who are not state residents.” This made me angry: confidential records on me by a government agency that I wasn’t allowed to see? This wasn’t a matter of national security; I wasn’t a terrorist. And freedom of information—the right to a transparent and accountable government—only applies to certain citizens? I studied the relevant laws and wrote a polite rebuttal based on the Code of Virginia. While I waited for her reply, I began to do more research on health care workforce regulatory systems. Between my own experience and that of Kim Hiatt, I wanted a better understanding of how these systems worked.
Health Care Workforce Regulation
All states in the US license health care professionals, as well as an increasing number of other occupations ranging from architects to wrestlers, and even frog farmers. These are labor market institutions, administrative agencies with executive, legislative and judicial powers, ostensibly under public mandate to protect public health and safety. According to economist Morris M. Kleiner in Licensing Occupations: Ensuring Quality or Restricting Competition? (Upjohn Institute Press, 2006), they are self-policing, self-regulating bodies, and have been identified as state-sanctioned monopolies. The most autonomous units of state health care licensing systems—medical boards—have been formed by powerful professional associations and their lobbying arms which make large campaign contributions to state legislators. Many state legislators who serve on health subcommittees, which make the health care workforce regulations, are themselves health care providers and members of the professional organizations “funding” state regulatory systems.
But do these state health regulatory systems really protect public health? While there may be the perception of protection from ‘charlatans, quacks, sexual predators and drug abusers,’ it is not supported by data. Kleiner points out that there are no data to support improvement in overall quality of health care by state health regulatory systems. There is some indication that higher-income people gain from stricter health professions licensing, but there is no measurable impact on overall quality of health care for the population as a whole. There is robust evidence that by effectively limiting supply, licensing of health professions increases overall health care costs, and creates longer wait times for health care services. This worsens health inequities in the US. In addition, licensing laws that standardize health care services effectively restrict innovation and improvements in the health care system. Health care workforce regulatory systems in all states are notoriously inefficient, with many taking over two years to investigate and resolve even the most serious of cases. There are wide inconsistencies between the different health professions licensing boards in how they discipline individual health care providers for similar infractions, as well as inconsistencies between states.
The Pew Health Professions Commission Taskforce on Health Care Workforce Regulation—a national, nonpartisan panel of experts—issued a series of reports in the late 1990s’. They called this a significant public health policy issue that flies under the radar. They stated there is a lack of oversight and accountability of the state regulatory systems, as well as a lack of effort to provide consumers access to information on health care providers’ practice histories. They called for national scope-of-practice standards, as well as consideration of changing from licensure to certification of health care providers, which is more likely to improve overall quality of care while not driving up health care costs. According to the reports, the next best alternative to a certification system would be to appoint more neutral parties as the decision makers on licensing boards, with members of the profession available to advise board members on technical issues.
None of the major Pew Commission recommended changes have been made. Instead, there have been incremental reforms, including improved websites, and uniform sanctioning guidelines, which sound good in theory, but have not proven to be effective in practice. According to Kleiner and the Pew Commission experts, powerful professional associations that helped create the licensing system in the first place, benefit from its continued existence. Higher income health professionals benefit from limiting supply by restricting competition, thus boosting their own salaries. Administrators at universities and technical schools support its continuance, since their institutions benefit financially from licensing requirements tied to entry and continuing education. And the current state licensing system continues because the risk-averse voting public has been repeatedly told it is an effective system protecting them from harm by sorting out the “bad apples” of incompetent, impaired, immoral health care providers.
Ms. Douglas informed me that without a court order she refused to provide a redacted copy of my individual case file. It took hiring a lawyer to convince her to provide a copy of the Case Decision Memorandum for the investigation of my nursing license. Dated February 13, 1989, the memo stated that if I continued consulting with my supervising physician as reported, no further action would be taken. It concluded, “There have been no further complaints or problems and the case is closed with no violation and no sanctions.” The memo confirmed that it had been a scope of practice issue, and that the Medical Board had wanted tighter reign on my nursing practice. What surprised me though was the date of the memo. While I had remembered the investigation as being a painfully long process, I hadn’t realized it took 16 months. My husband and I had separated a few days before the official closure of my case. And by that time I was disillusioned with nursing and with our health care system.
Ironically, the same week I received the one-page Case Decision Memorandum, I received 1,500 pages of redacted, detailed information on the case of Kimberly Hiatt from the Washington State Health Department. I requested Kim’s files in order to better understand the current decision-making process of the Nursing Commission in a state where I am responsible for teaching nursing students health policy. And in a state where I maintain nurse and nurse practitioner licenses. Reading through Kim’s records only deepened my distrust of the health professions regulatory system. The Washington State Nursing Commission refused the request by Kim’s lawyer for copies of their investigative reports in order to adequately advise his client.
I remind myself that Ms. Douglas and others in the health regulatory system are well-intentioned people who believe their work promotes public health and safety. But the system they work within is not part of a just culture. The current regulatory system is not working to protect public health and safety. It is not working for the majority of health care providers, who justifiably view it as capricious, punitive, and with little oversight or accountability. If we are to have a higher quality and more equitable health care system in our country, it is essential that we reform the byzantine health professions licensing system.
This week I reviewed Washington State Nursing Care Quality Assurance Commission records for Kimberly Hiatt—the 1,500 pages allowed under public disclosure. I had requested these records in order to look at the primary sources unfiltered by journalists or people close to the case. I also requested them as data for a journal article I am preparing on health workforce regulatory systems. Kim’s story continues to disturb me. I won’t repeat her story here, since it has been told in many other places (and most completely/accurately in my opinion by JoNel Aleccia/MSNBC). Instead, I will share my main impressions, thoughts, and unanswered questions.
My overarching impression is that the entire cascade of events contributing to Kim’s suicide could have been prevented. A secondary impression is just how complex our health care system is—how prone to errors of all sorts, not just medical errors, but errors of judgment by people in various levels of the healthcare hierarchy. It is not any one person’s—or one institution’s—fault. However, all along the way, individuals with power could have significantly altered the course for Kim. And nurses were turning on other nurses within this cascade of events. Not only nurse administrators, but also nurse colleagues of Kim’s. (I should note that there were also nurse colleagues who were quite supportive of Kim–and these show up in the record as well.)
But some of Kim’s colleagues were making unsubstantiated accusations, including a sophomoric and trumped-up sexual harassment charge by seemingly homophobic co-workers (and from the record, not handled well by hospital HR). This sexual harassment charge by a female nurse against Kim involved the fact that Kim was openly gay. That this could happen in a modern-day US hospital is dismaying. That this could happen in a US hospital in a city with the highest per capita population of lesbian-identified women is appalling. Then there was the more recent charge (by an ICU nurse) of Kim abandoning a patient. An investigation of this charge found that physicians had called Kim into help with a difficult parent conference, and Kim had arranged coverage for her patient.
Nurses could have prevented the negative outcome: shame on us.
Kim had worked at Seattle Children’s Hospital for 24 years on several different units. This was her first major medical error. The Cardiac Intensive Care Unit where Kim worked had just offered her a permanent position. Her last performance review dated 8-24-10 signed by the Director of ICU rated Kim’s performance as a 4/5 “Leading Performer.” Annual job performance reviews going back to 1994 are similarly high, with a peer writing, “Without a doubt, Kim is one of the most skilled nurses on our ICU.” Then, immediately after the medication error, in a report to the Nursing Commission, this same Director of the ICU (and a nurse herself) expressed concerns about Kim’s nursing practice—that she “failed to partner with leadership and work to correct the situation that could have caused her to make the failure.” Kim had immediately reported her medication error—had helped the medical staff remedy the situation—had disclosed her error to the baby’s parents with the support of the lead physician—then had been escorted off hospital property/put on administrative leave, and soon after was fired. Where exactly was Kim’s failure to partner with hospital leadership?
The initial report of an adverse event sent from Children’s hospital to the Nursing Commission stated: “an overdose of medication to an infant, who died as a result” even though it was not clear (and remains unclear according to the medical examiner’s final report) that the overdose contributed to the baby’s death. It was also reported this way in a memo by the CEO of Children’s hospital—that was then picked up by KOMO News and the Seattle Times. Guilty until proven innocent. The Nursing Commission member’s e-mails/memos acknowledge this “heavy media attention” as pressuring them to make Kim’s ‘case’ high priority. How might this have prejudiced the Nursing Commission’s decision-making process for Kim? The Nursing Commission member in charge of Kim’s investigation is herself a Chief Nursing Officer of a hospital. How might that lens have affected the Nursing Commission’s decision-making process for Kim?
The Nursing Commission refused Kim’s lawyer’s repeated requests for copies of their complete investigative materials—including the final medical examiner’s report—so that he could adequately advise Kim on her options before she was required to sign the final Stipulation of Informal Disposition (the final disciplinary action/sanctions). Why was his request denied?
The Stipulation sanctions included a $3,000 fine, 48-month probationary period where Kim needed supervision for giving medications, Commission approval of any future jobs, and reporting of her discipline to the National Practitioner Databank—as well as made public on the Department of Health website. The Department of Health staff attorney assigned to this case wrote in an internal e-mail “Talking Points” prior to the final settlement, “Tell (Kim’s lawyer) his client may take it or leave it…” Kim signed this Stipulation. A week later she killed herself. Upon being notified of her death, the Staff Attorney for the Nursing Commission advised closing Kim’s case as “a unique closure.” As of today, Kimberly Hiatt shows up in the Washington State Provider Credential Search Database as having an expired nursing license and having had no disciplinary actions.
What does all of this say about the deficits in our health care system? What can nurses—and others—do to prevent this sort of treatment of a nurse? Can anything be done to reform the health professions regulatory system? Can anything be done to hold hospitals accountable for their treatment of nurses?
I realize that it is easy for me to say that nurses need to speak up more about injustices to other nurses, to stop petty in-fighting and not so petty back-stabbing. I am–as spokespersons for Children’s hospital refer to us–an “armchair safety expert who doesn’t know the details of Hiatt’s case.” Except I do know 1,500 pages of details of Hiatt’s case. It now makes less sense to me than it did before. There is no suitable closure–not even a unique closure–for Kim Hiatt’s case.
This past week our local public radio station, KUOW, ran a series on workplace safety in Washington state. For those of you not familiar with Pacific NW-specific high-risk jobs, these include loggers and commercial fishermen, including scuba-diver harvesters of geoducks (world’s largest clams/highly priced aphrodisiac in China and Japan—when you see a photograph of one you’ll understand why). Then there are the non region-specific high-risk jobs of police officers, corrections officers and security guards.
But the highest risk job category of all in Washington state is that of nurses’s aid, followed closely by RN. The highest risk place to work is Western State Hospital. Nurse’s aids, nurses, and other frontline workers at Western State Hospital are assaulted on the job 60 times more than the average worker in Washington state. Western State is the largest psychiatric facility west of the Mississippi and houses criminal defendants when they are found mentally incompetent to stand trial. So it is in effect a combination correctional and psychiatric facility with highly volatile and violence-prone patients.
Nationwide, nurses working in Emergency Departments (EDs) are at high risk for workplace violence, generally in the form of physical violence from patients, family members or other visitors. EDs and urgent care centers are where people go for violence-related injuries stemming from domestic violence or gang violence. EDs and urgent care centers are where people go who are intoxicated or having acute psychiatric emergencies—usually accompanied by police. Waiting room overcrowding, long wait times to be seen by a provider, lack of visible security systems, lack of staff training on de-escalation techniques, and understaffing, all contribute to increased risk of violence. Reports from around the country indicate a steady increase in ED violence, most likely stemming from weakening primary care safety net services, forcing more desperate and frustrated patients into EDs for basic health care needs.
The KUOW episode “Violence in the ER” and the accompanying Seattle Times article “Most violent job in Washington? Nurse’s Aid” highlight ED workplace violence in Tacoma General Hospital in Tacoma, and Harborview Hospital in Seattle—the state’s two biggest hospital EDs. Tacoma General Hospital ED uses a metal detector at all times to screen patients and visitors. Harborview Hospital only uses a metal detector in the ED at night, and at other times security guards use a hand-held metal detector on patients and visitors they deem high risk. Harborview Hospital administrators, like many for hospitals across the country, have chosen not to install permanent metal detectors for fear of slowing down emergency care. According to the KUOW report, on a recent Saturday night a man got into the Harborview ED with a backpack containing a large knife, two cans of pepper spray, a cap gun, and bullets.
Third behind ED and psychiatric hospital settings for workplace violence for nurses is home care/home hospice. Work in these settings is usually done solo, with possible exposure to domestic violence or drug activity.
The Occupational Safety and Health Administration (OSHA), the federal agency charged with ensuring safe and healthful working environments for US workers, has failed to issue federal standards on workplace violence in health care settings. So far, they have only published voluntary guidelines on this topic. California, Washington, Florida, Illinois, New Jersey, Tennessee, and Nevada have passed state laws requiring further protection for health care workers. For instance, in Washington state, all health care settings are required to develop and implement plans to protect employees from violence. State law now makes it a felony for anyone to attack a health care provider—including verbal threat of assault. Washington state law requires all health care settings to keep records of any violent act (including verbal threats) against an employee, patient or visitor.
According to Jeaux Rinehardt, president of the Washington State Emergency Nurses Association, the felony assault charge is mainly enforced for attacks on doctors—rarely for attacks on nurses or other health care providers. He also echoes many nurses around the country in stating that nurses are actively discouraged from reporting and documenting workplace violence by managers or hospital administrators. (KUOW News: Violence in the ER, 7-13-11)
I worked in home health in Richmond and Baltimore for seven years during the height of the crack cocaine epidemic of the late 1980’s/early 1990’s. I worked in a large downtown Baltimore hospital urgent care center for six years. If you have watched any episodes of “The Wire” that’s what it was like to work and live in Baltimore at that time. The worst thing that happened to me during those years was that an intoxicated patient peed on me during a pelvic examination right when we had a power outage. She got scared she said, so it’s not like she meant any harm. The urgent care center I worked for was well staffed, had excellent relations with the community it served, and had a visible, well-functioning security system. We had panic buttons we carried in our pockets at all times, but I never had to use it. All staff received regular training in violence prevention techniques.
By contrast, working at various community health centers in and around Seattle for 15 years, there were at least ten times when patients seeking narcotics verbally or physically threatened me. These clinics were usually poorly staffed, served large numbers of impoverished people, had no security systems in place, and did not have clear protocols or “pain contracts” for use of narcotics. I remember front desk staff calling for police in several of the cases, but I think in only one case was I encouraged to complete an Incident Report.
An aspect of workplace violence in health care settings I had not even thought of appeared as a spin-off of a KevinMD.com guest blog. In 2007 Patricia Allen, RN wrote “Violence in the Emergency Department and how to promote ER safety.” It is a short blog post, mainly advertising her book. What I found more interesting was a reader’s comment. Steve Parker, MD: “Here in Arizona, hospitals are gun-free zones. Most physician and healthcare providers will not carry their guns into the hospital. Risk of getting caught is too high.” I had to read his comment twice before I understood it, because it never occurred to me that health care providers would carry concealed weapons to work. I thought that was confined to really bad TV shows.
Washington State is among the best states for nurse practitioner scope of practice. I knew this, of course, and it is one of the reasons I moved here 16 years ago. Therefore, I assumed that Washington State had to be that much better than Virginia when it came to the regulatory system for health professions. However, according to the results of the 2007 Performance Audit Report, Department of Health, Health Professions Quality Assurance Report by Brian Sonntag, Washington State Auditor, this is not the case. Governor Christine Gregoire requested this audit, largely as a result of media coverage of sexual abuse of patients by Washington state licensed health care providers. In 2005/2006 The Seattle Times published a investigative reporting series by Mike Berens called “License to Harm,” and in it he concluded that Washington State had a deficient health regulatory system that fostered abuse through weak and inefficient regulation.
One of the main problems as pointed out in the Performance Audit Report is the confusing government structure for Washington State health professions regulation. Whereas most all other states in the US have independent agencies regulating health professions, Washington State has an umbrella structure. Within the Department of Health there is Health Professions Quality Assurance (HPQA), which directly oversees 23 professions, but also provides support to 16 other boards and commissions. These boards and commissions are authorized by law to adopt their own rules and standards. Although HPQA is responsible for overseeing credentialing and discipline of health care professionals, it does not have responsibility or authority to direct boards and commissions in matters relating to case resolution and disciplinary actions. The report states that this divided governance structure does not provide for clear lines of performance management and accountability with regard to operations of the boards and commissions. In addition, it results in significant inconsistencies in disciplinary practices across professions.
Another interesting fact mentioned in the Audit Report is that since 2005, HPQA has taken steps to address public demand for more severe sanctions against health care providers. They do not specify how they have addressed this public demand for more severe sanctions, except by highlighting Governor Gregoire’s mandate to promptly investigate—without—exception—all allegations of sexual misconduct by all health professionals. They note that between 1995 and 2006, there was an 83% increase in the number of all complaints filed against health care providers in Washington State. The authors of the report recommended ways to increase public awareness about their right to file complaints against health care providers; however, the written response of HPQA to this recommendation was that they didn’t want to do this since they were inadequately staffed to handle the increased number of complaints.
So, in the past four years since this audit was done and recommended changes given to the Department of Health, the Governor and the State Legislature, what progress has been made? Since there was no follow-up report available on the HPQA website, I decided to call and e-mail them to find some answers to my questions. I’m happy to report that I got further with this line of inquiry than I did with comparable government personnel in Virginia. I spoke with Steve Hodgson in the Assistant Secretary’s Office of HPQA. He told me he had forwarded on my list of questions to Kristi Weeks, Director, Office of Legal Services, HSQA, and that they would get back with me with the answers by the end of the week this past week. In response to my ‘easy’ question, “What’s the difference between a board and a commission within HPQA?” he said that it boiled down to a difference of payment structure. That the board members of the four health professions’ boards (medicine, nursing, dentistry and chiropractic) receive $250/day in compensation for their board duties, whereas all commission members only get $50/day.
Here are some updates. There have been no changes in the umbrella/divided government structure of the health professions regulatory system in Washington State. In May 2006, the Secretary of Health adopted Uniform Sanctioning Guidelines as a tool for all of the boards and commissions to consistently impose similar sanctions for similar violations. The various health regulatory boards and commissions were not mandated to adopt these guidelines, and voluntarily adopted them at different times. As of this year, all boards and commissions have adopted them. However, as the results of the 2007 audit found, interpretation and implementation of such guidelines varies widely by professional group commission/board. All of the boards and commissions are now annually reporting performance measures to the HPQA. A planned follow-up audit of the health regulatory system in 2010 was canned due to lack of funds. However, Kristi Weeks writes, “The Legislature has mandated a report by December 15, 2013 that will evaluate, among other things, medical and nursing’s regulatory activities, including timelines, consistency of decision making, and performance levels in comparison to other disciplining authorities.” She did write that this is all subject to public disclosure and said I should feel free to share it.
A lingering question: Assuming the 2010 health regulatory system audit had been funded, what, if anything, would have been different in the cases of Kim Hiatt and the other Children’s hospital nurses recently charged by the Nursing Commission for misconduct?
The topic of my last post “To Err Is Human” hit a raw nerve for many people. Since the post, I have heard directly from numerous former co-workers and parents of NICU patients of Kim Hiatt’s who are devastated by the news of her suicide. Many other people who did not know her personally are distressed over her death, and seek to understand what went wrong at a systems level—what we can do to prevent this from happening to other nurses. I am struck by the inadequacy, irony, and inaccuracy of the Seattle Times article last week, “Nurse’s Suicide Follows Tragedy.” Her suicide is part of the tragedy; her suicide does not follow the tragedy. The role of local media—not only the Seattle Times but more importantly KOMO News—in this tragedy is a topic I do not possess the psychic distance to be able to address. Of course, we the news-munching public are also culpable, since we engorge ourselves on ambulance-chasing, witch-hunting, tabloid-line blurring ‘news’ stories.
I try to keep my personal blog separate from my life as a faculty member at the University of Washington School of Nursing. But on this topic the lines blur. I listened to some of my current nursing students, as well as some very wise local nurses outside of the UW, and—with the blessing and assistance of many of my UW colleagues—we are offering a forum/panel discussion on Tuesday May 10th, 3-5pm Hogness Auditorium, UW Health Sciences Building. It is open to the public, so please join us if you can. The tentative title is the title of my last blog post, “To Err is Human: Medical Errors and the Consequences for Nurses” because—well, that is what the panel discussion will be about. So far for the panel we have top-ranking representatives from the Washington State Nursing Care Quality Assurance Commission, the Washington State Nursing Association, an area suicide prevention program for health care professionals, and Joanne Silberner from the UW Department of Communications (to discuss the role/responsibilities of the media). For those of you who don’t know, May 10th is during National Nurses Week.
As I told my students this week, the news of the suicide of Kim Hiatt has re-opened wounds of my own. The topic of a future post (and a chapter in a book I am writing), I experienced the fallout in my own life of an investigation/threatened suspension of my nursing license early in my career. It was due to a (still) anonymous complaint about the scope of my practice back when the nurse practitioner role was very new and in a more conservative state than Washington. I was (I think) eventually cleared of any wrongdoing, but the stress of that time cascaded into my divorce, loss of my job, episodes of homelessness, and a bitter vow to leave nursing. The overwhelming feelings of shame, isolation, betrayal/loss of trust in the health regulatory system, led me to contemplate suicide. I did not have the media hounding me. It has taken me 25 years to be able to process those events and be able to talk about it with other nurses. Silence can be deadly.