Legislature(2005 - 2006)Anch LIO Conf Rm
08/29/2005 01:30 PM House HEALTH, EDUCATION & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| Status of Personal Care Attendant Regulations | |
| HB303 | |
| HB271 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 271 | TELECONFERENCED | |
| += | TELECONFERENCED | ||
| *+ | HB 303 | TELECONFERENCED | |
| + | TELECONFERENCED |
ALASKA STATE LEGISLATURE
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE
Anchorage, Alaska
August 29, 2005
1:43 p.m.
MEMBERS PRESENT
Representative Peggy Wilson, Chair
Representative Paul Seaton, Vice Chair
Representative Tom Anderson
Representative Lesil McGuire
Representative Sharon Cissna (via teleconference)
Representative Berta Gardner
MEMBERS ABSENT
Representative Vic Kohring
COMMITTEE CALENDAR
STATUS OF PERSONAL CARE ATTENDANT REGULATIONS
- HEARD
HOUSE BILL NO. 303
"An Act expanding reimbursable waiver services under Medicaid
waivers for older Alaskans and adults with physical disabilities
to include adult companion services; and relating to legislative
intent concerning eligibility and coverage for personal care
attendant services."
- HEARD AND HELD
HOUSE BILL NO. 271
"An Act relating to limitations on overtime for registered
nurses in health care facilities; and providing for an effective
date."
- HEARD AND HELD
PREVIOUS COMMITTEE ACTION
BILL: HB 303
SHORT TITLE: ADULT COMPANION SERVICES WAIVER
SPONSOR(S): REPRESENTATIVE(S) WILSON
05/06/05 (H) READ THE FIRST TIME - REFERRALS
05/06/05 (H) HES, FIN
08/29/05 (H) HES AT 1:30 PM Anch LIO Conf Rm
BILL: HB 271
SHORT TITLE: LIMIT OVERTIME FOR REGISTERED NURSES
SPONSOR(S): REPRESENTATIVE(S) WILSON
04/15/05 (H) READ THE FIRST TIME - REFERRALS
04/15/05 (H) L&C, HES, FIN
04/30/05 (H) L&C AT 1:00 PM CAPITOL 17
04/30/05 (H) Moved Out of Committee
04/30/05 (H) MINUTE(L&C)
05/02/05 (H) L&C RPT 4DP 3NR
05/02/05 (H) DP: CRAWFORD, LYNN, GUTTENBERG,
ANDERSON;
05/02/05 (H) NR: LEDOUX, ROKEBERG, KOTT
05/03/05 (H) HES AT 3:00 PM CAPITOL 106
05/03/05 (H) Heard & Held
05/03/05 (H) MINUTE(HES)
08/29/05 (H) HES AT 1:30 PM Anch LIO Conf Rm
WITNESS REGISTER
JON SHERWOOD, Medical Assistant Administrator IV
Department of Health and Social Services (DHSS)
Juneau, Alaska
POSITION STATEMENT: Provided information regarding the status
of the personal care attendant regulations and waivers in
general.
JANET CLARKE, Assistant Commissioner
Finance and Management Services
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Reviewed HB 303, and related that the
department believes it's premature to pass this type of
legislation at this point; provided information on HB 271.
REBECCA BOLLING, President
Alaska Nurses Association
Anchorage, Alaska
POSITION STATEMENT: During hearing of HB 271, expressed
concerns with regard to mandatory overtime.
RUSSELL GRANGE, Chief Human Resources Officer
Providence Health System - Alaska
Anchorage, Alaska
POSITION STATEMENT: Expressed concerns with HB 271.
DIANE O'CONNELL, Labor Program Director
Alaska Nurses Association
Juneau, Alaska
POSITION STATEMENT: Testified on HB 271.
MARCIA COOPER, RN
Alaska Psychiatric Institute
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 271.
J.W. POUND, RN
Alaska Psychiatric Institute
Anchorage, Alaska
POSITION STATEMENT: During hearing of HB 271, related API's
wage information.
MIKE ALEXANDER, RN
Alaska Psychiatric Institute
Anchorage, Alaska
POSITION STATEMENT: During hearing of HB 271, expressed
concerns with mandatory overtime.
DOROTHY FULTON, Executive Administrator
Alaska Board of Nursing
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 271.
SHARA SUTHERLIN, Chief Nurse Executive
Providence Alaska Medical Center
Anchorage, Alaska
POSITION STATEMENT: During hearing of HB 271, related
Providence's work with regard to overtime.
PATRICIA CENTER (PH), Chair
of the Legislative Committee
Alaska Nurses Association
Anchorage, Alaska
POSITION STATEMENT: During hearing of HB 271, related
information regarding the nursing shortage.
STACEY ALLEN (ph), RN
Alaska Regional Hospital
Laborers' Local 341
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 271.
RON ADLER, CEO
Alaska Psychiatric Institute
Department of Health and Social Services
Anchorage, Alaska
POSITION STATEMENT: During hearing on HB 271, answered
questions.
MILA COSGROVE, Director
Division of Personnel
Department of Administration
Juneau, Alaska
POSITION STATEMENT: During hearing on HB 271, related ways in
which the division is addressing [the nurse shortage].
ROD BEANY (PH)
(No address provided)
POSITION STATEMENT: During hearing on HB 271, expressed the
need to find ways to address competitive salaries and have the
ability to make adjustments when necessary in order to have some
parity with the private sector.
ACTION NARRATIVE
CHAIR PEGGY WILSON called the House Health, Education and Social
Services Standing Committee meeting to order at 1:43:05 PM.
Representatives Wilson, Seaton, McGuire, and Gardner were
present at the call to order. Representative Anderson and
Cissna (via teleconference) arrived as the meeting was in
progress.
^Status of Personal Care Attendant Regulations
[Due to technical difficulties, the beginning of the meeting was
not recorded. The recording begins as the committee was hearing
the status of personal care attendant regulations.]
JON SHERWOOD, Medical Assistant Administrator IV, Department of
Health and Social Services (DHSS), informed the committee that
currently each agency uses its own assessment tool. The [new]
assessment would be administered by the state or state
contractor rather than by the PCA [personal care attendant]
agency itself. He related the need to implement clearer
standards for providers. As a result of some of the public
comments, some adjustments to the proposed regulations will have
to be made, he said. He indicated that those changes should be
available for the commissioner of DHSS to adopt some time in
September.
1:44:34 PM
CHAIR WILSON opined that it's good to know that the system works
and that public comments do make a difference. She commended
the department on that.
1:44:55 PM
REPRESENTATIVE SEATON asked if there was any particular area of
the 14 points that received the most comments and in most need
of revision.
MR. SHERWOOD noted that one area that received a lot of concern
was in regard to the standardized assessment and having it
performed by the state. Although he attributed some of that
concern to unfamiliarity with the new assessment tool, he also
attributed it to the state's ability to perform the assessments
in a timely manner. The regulations make some provisions for
short-term authorization when there is an urgent need for care.
There may be some further revisions to that, he noted.
Furthermore, the department is reviewing whether the regulations
can specify a guaranteed time [for some level of service].
MR. SHERWOOD identified the other area that received much
concern as the prior authorization for all personal care
services. Again, the concern was that this could complicate the
administration and billing process for providers. The
aforementioned requires a bit more paperwork and management. If
the state doesn't issue the prior authorization numbers in a
timely fashion, it can slow down the payments. Furthermore,
there are concerns with regard to the [department's] ability to
do that.
1:47:27 PM
CHAIR WILSON noted that due to some abuse of the program, these
[regulation changes] are occurring. Perhaps by the next session
it will be apparent whether the changes are helping. Still, she
noted, it will be difficult because people will continue to come
online.
REPRESENTATIVE SEATON informed the committee that the October
issue of Governing Magazine includes an interview with U.S.
Secretary of Health and Human Services, Michael Leavitt, in
which he says that states shouldn't need a waiver to use home
and community care with a long-term population. He asked if the
legislature has received any indications from the federal
government that it is implementing any changes that would impact
the regulations being modified.
1:48:50 PM
MR. SHERWOOD explained that states have the ability to provide
personal care as part of the regular state plan, and outside of
the waiver process. Currently, Alaska provides its personal
care services as a state plan service. Therefore, proposed
changes to eliminate the waiver requirement wouldn't impact
these regulations, although it would impact other services that
[the state] provides. Mr. Sherwood said he wasn't aware of
anything proposed for federal Medicaid reform that would
directly impact these regulations, although there have been some
discussions on generic items such as the total cap on Medicaid
administrative expenses allowed by the state.
HB 303-ADULT COMPANION SERVICES WAIVER
1:50:16 PM
CHAIR WILSON announced that the next order of business would be
HOUSE BILL NO. 303, "An Act expanding reimbursable waiver
services under Medicaid waivers for older Alaskans and adults
with physical disabilities to include adult companion services;
and relating to legislative intent concerning eligibility and
coverage for personal care attendant services."
1:51:12 PM
JON SHERWOOD, Medical Assistant Administrator IV, Department of
Health and Social Services (DHSS), per the chair's request,
explained that a Medicaid waiver is a device allowed by federal
law to bypass the normal limits that federal regulations would
impose on a state in operating a Medicaid program. Under normal
federal law certain services can and cannot be provided.
Therefore, a waiver allows those services not normally allowed
under federal law to be provided with some conditions. In
Alaska, waivers are usually home- and community-based service
waivers. Under the home- and community-based services waiver,
the state is allowed to provide certain services as an
alternative to nursing home care and institutions for the
mentally retarded and developmentally disabled. Mr. Sherwood
explained that under a waiver, the state has to define the
services it will offer, which have to be reasonably related to
meeting the needs of the target population.
MR. SHERWOOD, in response to Chair Wilson, specified that Alaska
has stayed with standard definitions, with some modifications.
It's simpler to use the federal government's definition because
there is less review of it, he noted. As part of the process of
submitting a waiver, the state has to specify the number of
people to be served. He highlighted that waivers are different
from the rest of Medicaid because under the rest of Medicaid if
a state meets the basic eligibility criteria, the service is
provided. However, under waivers, once the state specifies the
number of people it will serve, no more people can be served
even if the eligibility criteria is met because the state
wouldn't have the authority to add more people to the waiver.
1:55:11 PM
MR. SHERWOOD, in further response to Chair Wilson, said that
people [beyond the specified amount in the waiver] can be added
any time during the year as long as the department has received
authority from the federal government to serve additional
persons. He explained that part of what the department does to
get a waiver approved is to show that the waiver will be cost
neutral in that the department won't spend more on individuals
in a community setting than it would for those in an
institution. A complicated formula is offered as proof of the
aforementioned. Therefore, any time the number of people served
is changed, that formula has to be resubmitted.
MR. SHERWOOD specified that Alaska has four waivers. There is a
waiver that serves older Alaskans, those 65 years and older who
meet nursing home level care. Another waiver serves adults with
physical disabilities, those between the age of 21 and 64 who
meet nursing home level care. Yet another waiver serves
children with complex medical conditions, those children up
through the age of 21 who would be served by a nursing home or
long-term hospitalization. Finally, there is a waiver that
serves people of all ages with mental retardation or
developmental disabilities which meet the institutional standard
for the Intermediate Care Facility for the Mentally Retarded
(ICFMR). Mr. Sherwood informed the committee that at any given
time, about 2,800 people on waivers are served. He recalled
that in 2005, a little under 3,600 people on waivers were
served. These waivers have been available since late 1993, he
noted. Alaska obtained waivers to serve people of all ages for
both nursing home and ICFMR levels of care. Furthermore,
Alaska's breadth of services is fairly wide, he related. For
instance, Alaska's waivers offer care coordination, payment for
services in assisted living facilities, adult day care, private
duty nursing, respite, chores, meals, social transportation,
environmental modification, specialized equipment and supplies,
and a wide range of habilitative services for those with
developmental disabilities. Mr. Sherwood related that the
companion service is probably the only service not offered under
a waiver.
2:00:12 PM
MR. SHERWOOD informed the committee that each waiver requires
filling out a document that is 60-80 pages with backup
materials. The initial approval period is three years, and the
waivers are renewed every five years. In fact, this fiscal year
the department is preparing for renewal for all four of the
waivers. He explained that before the waivers are renewed, they
must undergo federal review, which occurred about a year ago.
Based on that review, Mr. Sherwood said he expected that the
department will have to provide additional documentation
regarding the department's quality assurance methods. He
related that over $100 million was spent on the waivers in
fiscal year (FY) 05. In conclusion, Mr. Sherwood opined that
Alaska has been very successful in using waivers to avoid
institutionalization.
2:02:04 PM
CHAIR WILSON requested a list detailing the services provided
under each waiver.
MR. SHERWOOD agreed to do so.
2:03:08 PM
JANET CLARKE, Assistant Commissioner, Finance and Management
Services, Department of Health and Social Services, began by
reviewing HB 303. Section 1 is legislative intent, which
basically addresses the personal care attendant program. She
then turned attention to subsection (b) on page 2, line 28,
which lays out the intent to restore the nonmedical care
supervision and socialization services through companion
services. Section 2 outlines the direction from the legislature
to seek assistance for an additional waiver, referred to as
companion care for services for older Alaskans and adults with
physical disabilities. She opined that the committee probably
saw this language in legislation such as HB 125 and HB 193.
2:04:55 PM
MS. CLARKE related that the department believes that it's
premature to pass this type of legislation at this point.
Currently, the department is performing a long-term care study,
which will help determine what services are necessary in the
continuum of care. To pass this legislation before the study is
complete is a bit premature, she reiterated. Ms. Clarke
explained that merely adding this additional service on top of
the existing service system without reviewing all of the other
components, some inefficiencies and costs will occur. The
department has been taking steps to look forward at the Medicaid
program, specifically a contractor has been acquired to help the
department develop a better long-term forecast for Medicaid. As
part of that, the contractor is reviewing the state's
demographics and outlining the services being used. Based on
those demographics, the contractor is relating what the service
array will look like in the future. Furthermore, the department
is embarking on the long-term care study. She opined that both
studies are trying to help the department get a handle on the
Medicaid budget as well as the program itself. The hope, she
further opined, is to obtain advice on how to best structure the
state's Medicaid program for the future.
2:08:48 PM
MS. CLARK turned attention to the draft fiscal note for HB 303.
2:09:34 PM
REPRESENTATIVE GARDNER inquired as to when the information from
the two contractors will be available.
MS. CLARKE answered that there should definitely be information
regarding the long-term forecast for Medicaid available by
January, but perhaps as early as November. In response to Chair
Wilson, Ms. Clarke agreed to provide the chair with a summary of
the information when available.
MR. SHERWOOD informed the committee that the notice of intent to
award the long-term care study has been issued. He estimated
that a contractor will probably be officially on board about
September 15th. According to the terms of the request for
proposals (RFP), the final report should be available by
February 10 although there may be some interim information prior
to that.
2:11:42 PM
MS. CLARKE referred to page 1 of the draft fiscal note. The
fiscal note projects that if HB 303 were to pass and the
department implemented regulations to add the service halfway
through the fiscal year, in FY 07 the cost would be $759,600.
In FY 08, there would be a full year of costs for the program
and the cost escalates forward such that in 2011 adding the
service would cost over $31 million. In response to Chair
Wilson, Ms. Clarke referred to page 2 of the fiscal note that
attempts to cost out companion services. Part of the cost model
was that companion services wouldn't replace any other services,
but would be in addition to existing services. Furthermore,
[the cost model] would allow the primary caregiver to sleep
during normal night-time hours when the care recipient may not
be left safely alone. The aforementioned is a significant part
of the cost. Page 2 of the fiscal note relates that currently
there are 1,915 older Alaskans and adults with disabilities
receiving waiver services, of those about 570 reside in an
assisted living home and thus wouldn't be eligible. Therefore,
the 1,345 is used and it's estimated that approximately 10
percent of those would have caregivers who would utilize
companion services for 10 hours a day to allow them to work
full-time. The median cost used for unskilled respite care
workers was $19.72 per hour. For overnight supervision, the
assumption was that 10 percent of the 1,345 recipients would be
in need of overnight companion services. If those were limited
to nine hours per evening and three nights per week, the cost is
$3,737.70 for 135 recipients per year. Of the approximately
1,200 recipients who don't qualify for work-related or overnight
companion services, the department estimates that 90 percent
would utilize basic companion services, limited to 10 hours per
week. Ms. Clarke acknowledged that the costs are startling, but
she opined that it does all add up.
2:16:25 PM
REPRESENTATIVE McGUIRE expressed interest in the study reviewing
whether there is a population currently living in an
institution-like setting who could live in a home environment
with the assistance of a personal care attendant and the adult
companion services. She questioned whether any of the
aforementioned population would save the state money or create a
neutral fiscal impact.
2:17:55 PM
MS. CLARKE clarified that the department didn't calculate any
offsetting costs. To qualify to be in a nursing home one has to
meet the nursing home level of care. She highlighted that the
growth of nursing homes in Alaska has really been constrained
for the last 10-15 years. Prior to the availability of home-
and community-based services, the state's only source of
services for seniors were nursing homes. Ms. Clarke related
the department's belief that there will always be those who have
the need for the high level of nursing home care. She
reiterated that the state has been lucky in maintaining a fairly
static number of nursing home beds, which the department
believes will continue in the future.
2:19:42 PM
MR. SHERWOOD addressed the question regarding keeping people out
of an assisted living home, which companion services would
probably allow. However, when the individual needs extensive
overnight or daytime supervision while someone is out of the
house working, the wages for the companion would probably be
comparable to personal care/respite care provider, which is
around $20.00 per hour. When providing companion services on a
large scale, there isn't as much of an economy of scale as would
be achieved in an assisted living home. Therefore, the
department doesn't expect to save money by keeping those with
more intensive needs out of assisted living homes and placing
them in companion services. Although there might be individual
cases in which money would be saved, there will also be cases in
which more money would be spent. Under the waiver, there would
be an overall cost neutrality because once a service is offered
there isn't a lot of ability to restrict the service as long as
it's cheaper than an institution.
2:22:13 PM
REPRESENTATIVE CISSNA informed the committee that companion
services are listed in the regulations, although such services
haven't been implemented. The aforementioned would make a
difference in terms of the timing, she opined. She related that
she has recently been involved in workshops regarding senior
services from which she has surmised that Alaska is going
through some of the same things other states have experienced in
the past. Other states and the Legislative Legal and Research
Services 2004 study have found that the average for [companion
care services] is $50 or so a day, which is significantly less
than nursing home care. She inquired as to the department's
comments on that.
2:24:43 PM
MR. SHERWOOD opined that the department would agree that home-
and community-based services are significantly less expensive
than institutional care. However, the department doesn't
believe companion services would significantly reduce the amount
of institutional care for which the [department] pays. Already,
the [department] does an impressive job with regard to serving
people through the home and the community and have a relatively
small percentage of folks served in institutional care. At any
given time, of the 3,300 people [being served], only about 500
are in nursing homes. Mr. Sherwood related that the home- and
community-based system, including companion services, would
increase overall expenditures on waivers that wouldn't be offset
by a decline in nursing home units.
2:26:34 PM
REPRESENTATIVE CISSNA related that she has received the
sentiment of confusion with regard to the changes being put in
place. Therefore, she was pleased to hear Ms. Clarke's desire
not to include more changes before a study has been done.
Representative Cissna then expressed interest in how the state
will increase its efforts to make decisions regarding Medicaid.
She opined that the changes [from last summer and these proposed
today] are "incredibly brutal."
2:28:55 PM
MR. SHERWOOD, in response to Representative Seaton, said that
the large effect of companion services is that it would allow
people to remain in their own home versus an assisted living
facility [or] a nursing home.
2:30:04 PM
CHAIR WILSON surmised that there are many questions, and
therefore it would serve the committee to wait until it receives
the reports before deciding what to do next.
[HB 303 was held over.]
HB 271-LIMIT OVERTIME FOR REGISTERED NURSES
2:30:44 PM
CHAIR WILSON announced that the last order of business would be
HOUSE BILL NO. 271, "An Act relating to limitations on overtime
for registered nurses in health care facilities; and providing
for an effective date."
2:34:16 PM
CHAIR WILSON reminded the committee that she introduced HB 271
after hearing concern about mandatory overtime from nurses from
the Alaska Psychiatric Institute (API), the Department of
Corrections, and the Pioneers' Homes. As the chair of the
committee, she opined that she was concerned with regard to
public safety when a nurse is forced to work overtime.
2:37:07 PM
REPRESENTATIVE GARDNER inquired as to whether mandatory overtime
for nurses is customary in private facilities.
CHAIR WILSON said she didn't know.
The committee took an at-ease from 2:38 p.m. to 2:44 p.m.
2:44:45 PM
REBECCA BOLLING, President, Alaska Nurses Association (AaNA),
explained that AaNA is concerned about mandatory overtime and
has requested that the legislature review this issue. Mandatory
overtime is a nationwide issue, she noted. Therefore, AaNA has
urged all states to review this issue and if necessary pass
legislation such as HB 271. Although HB 271 focuses on the
nurse, this legislation is first and foremost based on a concern
for patient safety.
2:46:11 PM
MS. BOLLING highlighted that mandatory overtime is one of the
notable factors contributing to medical mistakes and poor
quality patient care. In fact, the Institute of Medicine (IOM)
estimates that 44,000-96,000 hospital deaths can be attributed
to medical errors each year. Therefore, the IOM has recommended
that all overtime, voluntary or mandatory, for nurses be
curtailed. Ms. Bolling reminded the committee that nationwide,
and especially in Alaska, data shows a growing shortage of
health care workers, particularly registered nurses. "As the
nursing shortage increases, so does the use of mandatory
overtime," she noted. Since as many as 20 percent of the
nursing workforce is planning to leave the profession in the
next five years, it's important to review prohibiting mandatory
overtime as an aspect of recruiting and retaining nurses in
Alaska. Although there are a number of ways to address the
issue, HB 271 specifies that a patient's safety shouldn't be put
at risk in order to achieve a short-term solution for a larger
problem. Furthermore, the legislation specifies that the health
and safety of nurses shouldn't be at risk either. She
acknowledged that there will be questions raised regarding the
potential costs for health care facilities. However, Ms.
Bolling urged the committee to review the costs resulting from
medical errors and nurse absenteeism.
2:47:57 PM
MS. BOLLING related the working conditions that run nurses away
from the bedside, the hospital, and in some cases the profession
itself. Therefore, it's not surprising there is an exodus of
nurses in many health care settings, particularly settings that
use mandatory overtime as a means to deal with inadequate
staffing and shortages. Ms. Bolling reiterated that HB 271
recognizes that errors do occur during medical treatment,
particularly when nurses work very long hours and doing so
consecutively. In conclusion, Ms. Bolling thanked the committee
and Chair Wilson for making the effort to learn about this
important issue within the nursing profession and the health
care community at large. She offered that AaNA is willing to
work with the legislature and the administration to resolve this
issue.
2:49:44 PM
MS. BOLLING, in response to Representative Gardner, reiterated
that the Institute of Medicine has made the suggestion that all
overtime, voluntary and mandatory, for nurses be curtailed.
REPRESENTATIVE GARDNER asked if mandatory overtime is a problem
for nurses in both the state and private sectors.
MS. BOLLING replied yes.
2:50:39 PM
CHAIR WILSON inquired as to how many states have prohibited
mandatory overtime.
MS. BOLLING said she didn't know, but deferred to a future
witness.
2:50:53 PM
REPRESENTATIVE SEATON returned to the latest issue of Governing,
which relates on page 24 that 90,000 patients in the U.S. die
per year due to errors. He asked if there is any data that
details the number of deaths attributable to the condition of
mandatory overtime.
MS. BOLLING said that she didn't have such data, but offered to
obtain that data for the committee.
2:52:08 PM
RUSSELL GRANGE, Chief Human Resources Officer, Providence Health
System - Alaska, informed the committee that over the past three
years the costs of overtime have increased. In response to
Chair Wilson, Mr. Grange explained that Providence has a
practice of "mandatory on-call" in some areas of the hospital.
However, he said that it's infrequent that employees are
expected to work overtime on a mandatory basis. In regard to
the specifics of the aforementioned practice, Mr. Grange
deferred to the nurse executive who will be speaking later.
2:54:15 PM
MR. GRANGE informed the committee that the average overtime
expenditure for Providence Health Care System in Alaska for
registered nurses (RNs) over the past three years is $4.8
million. Therefore, for RNs to increase that to triple time for
overtime would increase the cost to $9.6 million. Within the
Providence Health System, there is a practice of trying to be
comparable or equitable with pay, he noted. Therefore, if the
triple time pay practice for overtime was expanded to all
clinical employees, the cost would rise to $7.8 million or with
triple time it would be $15.6 million. Therefore, triple time
for all health care workers for the Providence Health Care
System would increase from $9.6 million to $19.2 million
annually.
2:56:15 PM
MR. GRANGE, in response to Representative Gardner, said that if
HB 271 passed and there was mandatory overtime pay at triple
time, there would be a disincentive for employees who currently
volunteer to work overtime to continue to volunteer. He
explained that Providence Health Care System's overtime
calculations have been based on total overtime hours at time and
a half versus triple time. Mr. Grange highlighted what he
called the national challenge of the rising cost of health care.
The customers, in this case the patients, would have to pay for
the increased costs. Therefore, instituting triple time for
overtime would exacerbate the cost of health care.
2:58:09 PM
REPRESENTATIVE SEATON directed attention to page 3 of HB 271
where it refers to triple time. He related his understanding
that triple time and a fine are the penalties for violation of
the chapter. However, Mr. Grange's testimony suggests that HB
271 would mandate triple time for any overtime.
MR. GRANGE related his understanding that facilities have one
hour to find volunteers for overtime. The concern, he
reiterated, is that there would be a disincentive for employees
to volunteer to work for time and a half when they could receive
triple time if they merely waited an hour. Therefore, the
facility would automatically be placed in the [triple-time]
situation.
3:00:22 PM
REPRESENTATIVE SEATON asked if Mr. Grange would be more
comfortable if a nurse was paid time and a half for overtime and
another time and a half was added to the fines. Therefore, it
wouldn't be compensation to the nurse, but rather would just be
part of the fines. For example, currently a second violation
[of mandatory overtime] would result in a $500 fine with triple
time. However, Representative Seaton suggested that in the
aforementioned situation the nurse would receive time and a half
and an additional equal amount per the [overtime] hours would be
added to the fine.
MR. GRANGE surmised then that the employer would pay the same
amount of money, although it would be in the form of a fine
rather than compensation for staff members.
3:02:48 PM
MR. GRANGE related that [the human resource managers] have a
philosophical preference to not work people overtime if
possible. In fact, at Providence it's very infrequent that
employees are required to work overtime because of the
associated problems and the downside to employee relations.
However, there are occasions in the health care business when
circumstances arise such that there's no choice but to have
people work overtime. Therefore, to have a fine of the nature
described when the situation is unavoidable would be
problematic.
3:04:35 PM
CHAIR WILSON inquired as to the per hour wage of an entry level
RN.
MR. GRANGE specified that an entry level RN effective 5/1/05
receives $21.20/hour base rate, without benefits. A nurse at
Step 31, the highest, is paid $38.42/hour.
3:06:07 PM
MR. GRANGE acknowledged the possible alternative of placing
nurses on-call and then calling them in instead of triple time.
The aforementioned would increase Providence's on-call expense
from $1.4 million to almost $3 million and place people on-call
who don't need to be today. When an employee is on-call, he/she
has a to be on site within 60 minutes from the time called. The
aforementioned really restricts people's lives. Therefore, the
on-call option is a poor alternative to triple time.
3:07:35 PM
REPRESENTATIVE SEATON asked if Mr. Grange is referring to page
2, line 16 of HB 271 and suggesting that the provision may
provide a situation in which many people are scheduled for lots
of on-call time in order to avoid the triple time consequence,
although it isn't necessary.
MR. GRANGE replied yes.
3:08:26 PM
REPRESENTATIVE GARDNER asked if Mr. Grange has a sense of how
the shortage Providence experiences compares to the chronic
shortage for state institutions.
MR. GRANGE answered that the vacancy rate for RNs within the
Providence Health System in Alaska is approximately 6 percent,
which is well below the national average for vacancy rate. He
said he didn't know how it compares with the state.
3:09:20 PM
CHAIR WILSON inquired as to how much more traveling nurses,
"travelers," are paid per hour.
MR. GRANGE said he would provide that to the committee.
CHAIR WILSON recalled that four years ago [Wrangell's] hospital
was paying $45/hour for travelers.
MR. GRANGE related that [Providence Health Care System] tries to
minimize its use of travelers in order to have the continuity of
its own employees.
MR. GRANGE, in response to Representative Seaton, confirmed that
the 6 percent vacancy rate is filled by voluntary overtime and
travelers.
3:11:19 PM
DIANE O'CONNELL, Labor Program Director, Alaska Nurses
Association, informed the committee that the Alaska Nurses
Association does represent the nurses of the Providence Alaska
Medical Center. Ms. O'Connell opined that HB 271 isn't designed
or intended to discourage volunteerism. The legislation
provides for voluntary overtime as well as prescheduled on-call
time. She characterized the prescheduled on-call as a key part
of the legislation. Only a couple of units in Providence have a
mandatory overtime question because there has been work to
resolve the issues. However, when there is a mandatory call,
there is mandatory overtime eventually. She pointed out that
there is a shortage of operating nurses, and as the shortage
becomes more severe the nurses on staff are more frequently
called upon to be on-call. Ms. O'Connell said that although
it's being handled fairly well currently, she expressed concern
that as the nursing shortage continues it will worsen.
Therefore, she expressed the desire to discourage mandatory
overtime while encouraging other ways to address this problem.
Ms. O'Connell said that the nurses with which she has spoken
aren't interested in overtime, whether it's triple time or time
and a half. The triple time was used in order to grab attention
and deter the use of overtime.
3:15:48 PM
MS. O'CONNELL said that she didn't fully understand Mr. Grange's
position on the on-call status. In Providence, one unit already
has people on-call. She didn't believe many places in the
hospital have a set on-call schedule, although the Alaska
Psychiatric Institute is a different matter to which they can
speak. She then informed the committee that 10 states have
[passed] legislation limiting the use of mandatory overtime and
similar legislation has been introduced in 15 other states,
including Alaska.
3:17:02 PM
REPRESENTATIVE GARDNER asked if the new nursing program at the
University of Alaska - Anchorage is working toward alleviating
the shortage or will many of those graduates seek employment in
other [states].
MS. O'CONNELL said the program can't help but help the
situation.
3:18:03 PM
REPRESENTATIVE SEATON returned to his earlier suggestion
regarding triple time and asked whether it would be a concern
for Ms. O'Connell.
MS. O'CONNELL reiterated that her main concern is to discourage
mandatory overtime, the means by which it's accomplished may
continue to be the subject of conversation. Triple time isn't
necessary for the nurse, she opined. Although it seems that the
individual that's the "victim" in this case should receive
additional compensation, limiting overtime results in the
individual not receiving compensation anyway. In further
response to Representative Seaton, Ms. O'Connell acknowledged
the association's concern with regard to prescheduled on-call
time, but noted that it understands the need for people to be
on-call and come in during emergencies. The desire, she opined,
is to limit [prescheduled on-call] to emergencies because
there's a difference between being on-call for emergencies and
mandatory overtime.
3:21:07 PM
REPRESENTATIVE SEATON expressed the need for the Alaska Nurses
Association to review this and provide suggestions as to how the
distinction between on-call for emergencies and mandatory
overtime can be made in the law.
3:21:48 PM
CHAIR WILSON reviewed HB 271, which limits the overtime in
nursing such that a nurse may not be required or coerced into
accepting an assignment of overtime if the nurse believes the
overtime would jeopardize the patient's or the employee's
safety. Chair Wilson specified that HB 271 doesn't apply to the
following: a nurse on duty in overtime status because of an
unforeseen emergency situation; prescheduled on-call time; a
nurse voluntarily working overtime; the first hour of overtime
status; and a critical access hospital. However, the
legislation does require that the nurse should have at least 8
consecutive hours time off after working 12 or more consecutive
hours. Furthermore, the health care facility should provide for
an anonymous process for patients and nurses to make complaints
related to staffing levels and patient safety. The legislation
has protections for complainants and specifies the enforcement,
offenses, and penalties.
3:26:38 PM
MARCIA COOPER, RN, Alaska Psychiatric Institute (API), informed
the committee that nurses at API are required to work overtime
shifts and usually have to work overtime shifts every week.
However, during peak times, such as summer vacation and
holidays, the overtime shifts are more frequent than once a
week. Ms. Cooper related that she works the 11:00 p.m. to 7:00
a.m. shift, and therefore a mandatory overtime shift would begin
at 7:00 a.m. During that time, Ms. Cooper related that she is
required to give the morning medications. After already working
eight hours, she said she suffers from fatigue, which isn't
conducive to the proper and accurate administration of
medication to the patients. From July 1 to August 26 of this
year, API employees, including the psychiatric nursing
assistances as well as the RNs, have worked a total 437 overtime
shifts. She noted that many nurses volunteer for overtime in
order to remove their names from the mandatory overtime list to
ensure they won't be required to come in on a day they are
scheduled to be off. Ms. Cooper informed the committee that in
July 2005, API nurses worked 54 overtime shifts. She echoed
earlier comments regarding that overtime results in nurses being
more prone to mistakes, fatigue, and burnout. She specified
that burnout results in higher levels of turnover and a lack of
experienced personnel, which is supported by many reputable
journals.
MS. COOPER related that a 1992 American Journal of Public Health
study found that nurses working variable schedules, such as
mandatory overtime, were twice as likely to report an accident
or error and two-and-a-half times more likely to report near
miss accidents. The study concluded that these conditions
related to increased error rates on the performance of tasks. A
2000 IOM report on safer health systems relates that designing
safe medication administration systems for hospitals requires
that nurses work with appropriate staff levels. "The report
states that designing jobs with attention to human factors means
attending to the effective work hours, work loads, staff ratios,
sources of distraction, and inversion in assigned shifts which
affects the workers' circadian rhythms and the relationship to
fatigue, alertness, and sleep deprivation," she related. Ms.
Cooper concluded:
In short, the practice of requiring nurses at API to
work overtime shifts not only increases the fatigue
and likelihood of burnout among the nurses, it also
increases the chances of errors in patient care;
compromising the responsibility of the staff and the
hospital to provide reliable, accurate, and proper
medical care for its patients. As such, it is
imperative that HB 271 is passed, not just for the
nurses but for the patients that we treat every day.
3:30:52 PM
MS. COOPER, in response to Representative Seaton, specified that
the work schedule [for nurses] is usually 7.5-8 hours a day with
12 hour shifts on the weekend. In further response to
Representative Seaton, Ms. Cooper said that the mandatory
overtime is usually an 8 hour shift. She added that it has
become more difficult to find someone who will split a shift.
3:32:27 PM
CHAIR WILSON asked if the mandatory overtime is such that the
nurse doesn't work two shifts back-to-back but rather the nurse
comes in on his/her day off.
MS. COOPER replied yes, adding that on Saturday, her usual day
off, she worked from 3:00 a.m. to 7:00 a.m. The aforementioned
allowed her to get off the mandatory overtime list so that she
would hopefully not have to stay this weekend.
3:33:04 PM
REPRESENTATIVE GARDNER posed a scenario in which HB 271 were law
along with a continuing shortage of nurses, and inquired as to
what would happen to the patients.
MS. COOPER said she couldn't answer that.
3:33:47 PM
REPRESENTATIVE CISSNA requested that someone comment on the
turnover rate and number of employee sick days. She also
requested that someone comment on the general retention rate of
nurses.
3:35:36 PM
CHAIR WILSON inquired as to the entrance level and higher level
salaries of a nurse at API.
MS. COOPER deferred to an upcoming speaker from API.
3:36:06 PM
J.W. POUND, RN, Alaska Psychiatric Institute, informed the
committee that he has worked for API for 14 years. He related
when he started with API he began as step A, RN2. Five years
ago comparative studies were performed for Alaska's state nurses
salaries because of problems with recruiting and retention.
That study found that psychiatric nurse salaries at API were far
below the national average. Therefore, a 10 percent increase in
pay was given and kept for two-and-a-half years and then it was
taken away by labor relations because of the semantics. The
aforementioned left many RNs in financial hardship and again the
union and the state are attempting to perform comparative
studies, which reveal even lower salaries than that of the
national average salaries [of nurses]. Mr. Pound informed the
committee of the starting wages for nurses in various states,
which highlighted API's low wages. Furthermore, API offers less
evening and night differentials than most facilities and it
doesn't offer a weekend differential at all. He offered
examples of differentials in other states as well as other
facilities in Alaska.
3:40:15 PM
MR. POUND pointed out that most facilities will have a bonus for
every certification earned, such as for advanced life support,
CPR, and board certification. Furthermore, facilities often pay
a bonus for education and years of experience. However, API
does not. Mr. Pound explained that the annual merit step
increases amount to about $.88 each year for the first eight
years and then there are two longevity periods with an increase
of $1.09 for both. Toward the end of the [merit step increases]
there are two five-year longevity periods with an average
increase of about $1.13 for both of the five-year periods. He
noted that Providence, Alaska Regional, and Central Peninsula
all have a 30-31 step program in which an increase is awarded
annually with no empty longevity years. Mr. Pound then turned
attention to the Cost of Living Allowance (COLA) for which the
federal [employees] have a 25 percent COLA while [employees at
API] have 1.5-2 percent COLA. In conclusion, Mr. Pound said:
When one adds up all the extras that the state does
not allow to the basic RN's salary, one can see that
the nurses at API fare far lower than any of the
hospitals in our nearby surroundings or the national
average.
3:42:54 PM
MIKE ALEXANDER, RN, Alaska Psychiatric Institute, began by
informing the committee that he is one of the 12-hour nurses on
the weekends. Mr. Alexander opined that his biggest concern
with mandatory overtime is patient and employee safety. He
related the scenarios in which mandatory overtime and low pay
has caused nurses to leave API. He specified that the pay is
important with regard to recruiting and retaining nurses.
According to API's assistant director of nursing, if a nurse can
be kept for two years, the nurse will stay. However, the
mandatory overtime is brutal. Mr. Alexander emphasized his
observation that the entire API staff is tired and nurses don't
give patients their best when they are tired.
MR. ALEXANDER related how the nurses at API have tried to
address the errors that occur with mandatory overtime by trying
not to have the nurses working mandatory overtime deal with the
medication cart. Furthermore, nurses volunteer for mandatory
overtime when possible. In response to the earlier question
regarding the top wage at API, he estimated that it is
approximately $33.00 [an hour].
3:49:28 PM
REPRESENTATIVE CISSNA inquired as to whether incidents of
injuries in correctional and psychiatric facilities with violent
patients is ever an issue [in conjunction with mandatory
overtime].
3:50:26 PM
MR. ALEXANDER opined that the aforementioned is a factor because
if a nurse is tired, the nurse may or may not pickup on the
signs [of an impending violent incident]. He informed the
committee that 90-96 percent of suicides in correctional
facilities are hangings, which he estimated to be roughly the
same percentage in psychiatric facilities. If staff isn't
alert, warning signs might not be caught. Therefore, the desire
is to have adequate staff. Prohibiting the use of mandatory
overtime as a staffing tool is a major step forward.
3:53:01 PM
CHAIR WILSON, in response to Representative Cissna's earlier
question, related that an IOM study regarding nurse work hours
and health care errors estimates that annually 44,000-98,000
hospital deaths can be attributed to medical errors to which
mandatory overtime is a serious contributing factor. Therefore,
the IOM recommends that all overtime by nurses, whether
voluntary or mandatory, should be curtailed.
3:54:00 PM
REPRESENTATIVE SEATON asked if there are people on the nursing
staff who count on overtime for additional income, and therefore
would leave if overtime was eliminated.
MR. ALEXANDER replied yes, at times. However, most of the
nurses at API know when they've [worked] enough. He related
that the overtime at API amounts to about $4,800 per
person/year. He opined that the overtime creates a perpetual
cycle of needing someone to cover because staff become exhausted
and call in because they aren't fit to work.
3:57:36 PM
DOROTHY FULTON, Executive Administrator, Alaska Board of
Nursing, testified on behalf of the board in support of HB 271.
The Alaska Board of Nursing, she related, feels that a nurse is
a professional level person and should know when he/she is not
safe to be practicing. After a 12 hour shift, [a nurse]
certainly isn't safe to practice, she opined.
3:59:36 PM
SHARA SUTHERLIN, Chief Nurse Executive, Providence Alaska
Medical Center (Providence), related she has been a nurse since
1976. Ms. Sutherlin informed the committee that Providence has
an agreement with AaNA, which codifies the essential elements of
nurse staffing in the hospital. The purpose of this agreement,
she related, is to promote the mutual objective of providing
quality patient care through stable employee relationships and
to set forth the agreement reached with regard to wages, hours
of work, and other terms and conditions of employment. Ms.
Sutherlin related that Providence has utilized creative ideas
and resources to address the issues that impact nursing care.
For instance, a float pool is utilized. She explained that the
float pool is a separate department within Providence that
employs nurses who like combination care sets or have skill sets
beyond care sets. The nurses in the float pool are placed where
they are needed. Also, Providence has a registry or per diem
staff to help supplement where needed as well as cover
vacations. Traveler nurses, who tend to be seasonal, cover
vacations as well as when there are core physician staffing
issues.
MS. SUTHERLIN specified that Providence basically utilizes 12-
hour shifts throughout the medical center, which is a
combination of preference, as well as continuity of care.
Providence also has rotational shifts as well as nurse educator
positions. As pointed out by Dr. Linda Aiken (ph) and Dr.
Porter O'Grady (ph), it's not always the number of nurses.
Although the number of nurses at the bedside correlates to
patient safety and outcomes, critical thinking and educational
pursuits of professional staff make the difference, she opined.
The goal of Providence is not to use mandatory overtime as a
priority staffing tool, and therefore other avenues are
reviewed. For example, in the OR there are nurse fellowships in
order to allow nurses interested in doing something different to
do so. Ms. Sutherlin informed the committee that Providence
utilizes mandatory on-call in the CATH (ph) lab due to the
emergency situations that can arise in an interventional
cardiovascular patient.
MS. SUTHERLIN further informed the committee that Providence is
focused on increasing patient access while simultaneously
providing nurses the ability to rest between shifts. Last year,
Providence, in attempting to decrease its need for travelers,
expanded its ability to hire adult critical care nurses. In
doing so, Providence faced spending more money to fill some of
the core positions as well as to allow the nurses time off
during the summer. She characterized the aforementioned as a
retention issue yet to be solved.
4:06:40 PM
MS. SUTHERLIN, in response to Representative Seaton, confirmed
that a full-time nurse at Providence would work three shifts per
week.
4:07:29 PM
REPRESENTATIVE SEATON asked if Providence provides longer breaks
during its 12-hour shift as compared to the 8-hour shift plus
overtime at API.
MS. SUTHERLIN specified that at Providence there are 15 minute
breaks every four hours. Furthermore, 30 minutes is given for
meal breaks. In fact, Providence is using a log to ensure
nurses receive their breaks in the adult critical care
[division]. However, that's quite a challenge in critical care
settings because critical care patients don't always comply with
meal or break times.
4:08:39 PM
CHAIR WILSON recalled that when she was a nurse she scarcely
remembers taking a 15-minute break, which she emphasized would
be most important when one works a 12-hour shift on a regular
basis.
4:08:59 PM
MS. SUTHERLIN related her personal belief that UAA has done much
to address the nursing shortage. With Providence's vacancy rate
of 4-6 percent, it hasn't had as many vacancies as [necessary]
for the graduate nurses. Furthermore, the Providence Alaska
Learning Institute is focused on intensifying its efforts for
internships and fellowships as well as the resources with the
advanced practice nursing team. She related that on average
Providence hires between 25-40 new graduates a year. Moreover,
the hospital is connected with Spokane Community College for
difficult to fill positions. She indicated the need to utilize
creative ways to supplement staffing, such as rapid response
teams, as recommended in the "The Wall of Silence."
4:11:38 PM
MS. SUTHERLIN, in response to Representative Seaton, confirmed
that the 12-hour shifts are scheduled three days in a row or
with breaks. Although there is a continuity issue, there is
also a workplace balance issue. Ms. Sutherlin noted that
Providence recently won an award in reviewing workplace balances
and providing resources, such as child care centers in order to
create a schedule that works for nurses and their families.
However, she acknowledged that it's a challenge.
4:13:05 PM
PATRICIA CENTER (PH), Chair of the Legislative Committee, Alaska
Nurses Association (AaNA), submitted the written testimony of
Kathleen Gettys (ph), chair of the Providence Collective
Bargaining Unit. Ms. Center then turned attention to the issue
of RNs who work for the state. The discussion today has been in
regard to the API nurse shortage due to lack of pay and lack of
competitive pay with the private sector. In the past, higher
benefits made up for the aforementioned. However, that's not
the case now [with Tier III and IV]. She alluded to the fact
that API is not the only state facility having trouble with
retention, it's also a problem with the corrections facility in
Anchorage as well as the pioneers' homes. Furthermore, there
are recruitment and retention problems for the Division of
Public Health nurses. She recalled that there was a request for
the Department of Administration to review the pay of nurses.
MS. CENTER then turned to mandatory overtime, which has resulted
in a "death spiral" in other states. Since there's a shortage,
employers have used "mandation" to make existing nurses work
more and address the shortage. However, that increases injury
and burnout rates amongst nurses. California, which was one of
the first states to prohibit mandatory overtime, found in the
three years after passage of the prohibition a 60 percent
increase in nurses applying for RN licenses. Therefore, it's
great that Alaska is being proactive in this matter. She then
related that one of the reasons most of the hospitals within the
state haven't had a problem [with mandatory overtime and low
pay] is because they are covered by union contracts. Although
the unions [for nurses in private facilities] have been working
on the issue, the state employees' union, under which the nurses
in state facilities fall, isn't on top of nursing profession
issues as much as the [private] hospital and nursing unions.
MS. CENTER related that the average age of nurses is
approximately 48. Furthermore, the physical demands of hospital
nurses are tremendous, especially as society becomes heavier.
She highlighted that [UAA's] School of Nursing is trying to
double its output, which Ms. Center hoped would coincide with
the number of nurses who will retire in the next couple of
years. She offered that most of the nurses who graduate from
UAA do remain in Alaska, and therefore she expressed her belief
that it's worthwhile to continue to support that effort.
4:18:05 PM
REPRESENTATIVE GARDNER asked if other states have tried to poach
Alaska's nursing graduates.
CHAIR WILSON related that an unidentified speaker said he saw an
advertisement on the Internet to which nine out-of-state
agencies responded in three days.
4:19:25 PM
CHAIR WILSON commented that within public health various
diseases that once were believed to be overcome are returning.
Therefore, public health nurses are critical.
4:20:37 PM
REPRESENTATIVE CISSNA emphasized the need to ensure that all
nurse positions are covered, especially in view of the public
health concerns the state may face, such as the bird flu that is
working its way across Siberia.
4:21:54 PM
CHAIR WILSON talked about a conference she attended in which the
discussion was about when the pandemic will hit. Therefore, she
was pleased that the state is talking about it and providing
training on it.
MS. CENTER interjected that Alaska is fortunate in that it has a
strong public health infrastructure.
4:23:25 PM
REPRESENTATIVE SEATON inquired as to how HB 271 compares with
the legislation proposed or adopted in other states.
MS. CENTER related that HB 271 was drafted after legislation in
other states. However, she deferred to others regarding the
specifics. She related that studies have shown that as soon as
a nurse goes into overtime, the chance of an error increases.
Therefore, some states have specified a cap with regard to the
amount of hours a nurse can work in a week. In further response
to Representative Seaton, she said that at the moment [AaNA] is
looking at the mandatory component of overtime.
4:26:08 PM
MS. O'CONNELL specified that AaNA isn't looking at an all-out
ban of overtime but rather limits on mandatory overtime. She
acknowledged that there are variations on the legislation, but
she focused on the shortest and simplest version with a limit on
overtime rather than a complete ban.
4:27:17 PM
REPRESENTATIVE SEATON commented on the difficulty in getting
legislation through, and therefore expressed the hope that it
isn't necessary to follow up with another piece of legislation
later.
MS. O'CONNELL said that certainly isn't her goal, although she
noted that there may need to be changes to HB 271 in order to
address the concerns that have been specified.
4:28:25 PM
STACEY ALLEN (ph), RN, Alaska Regional Hospital, Laborers' Local
341, related that the Laborers' Local 341 supports HB 271. She
said that there is precedent in other industries for limiting
the time period an individual works due to public safety
concerns. However, HB 271 is a bit different than how the issue
has been addressed in other industries because it allows the
nurse to say he/she is not safe.
4:30:08 PM
JANET CLARKE, Assistant Commissioner, Finance and Management
Services, Department of Health and Social Services, related that
DHSS doesn't like using overtime. Furthermore, the department
attempts to limit the amount of mandatory overtime it uses and
utilize voluntary overtime when possible. As today's testimony
has related, the managers, supervisors, and nurses work hard not
to compromise care. In the specialized facilities, API and the
pioneers' homes, the state is responsible for providing care for
a very vulnerable population. Therefore, [DHSS] is in a Catch
22.
MS. CLARKE characterized mandatory overtime as a symptom of the
circumstances. Overtime is a primary issue in API, the
pioneers' homes, and the juvenile facilities, although the
juvenile justice employees aren't nurses. Public health nurses
don't have overtime issues, but there are recruitment and
retention issues in that area. Ms. Clarke attributed the major
cause of overtime to the fact that DHSS can't fill all of its
nursing positions in a timely fashion. If the current budgeted
authorized positions were filled, the problem with overtime
would be negligible. She highlighted the vacancy problem by
reminding the committee of Providence's vacancy rate of 4-6
percent as compared to [the state facilities] 15-20 percent
vacancy rate for nurses. The turnover rate [for the state's
nurses] is about 17 percent on average. She informed the
committee that she recently was informed of a 23 percent vacancy
rate for nurses at API.
MS. CLARKE, in addressing why overtime is used, turned to the
national nurse shortage and said employers need to be proactive,
flexible, and competitive. However, that's not the case for the
state. Furthermore, nurses are represented by the general
bargaining unit, which doesn't specialize in the nursing field.
4:34:27 PM
MS. CLARKE, in response to Chair Wilson, related that DHSS
utilizes contract nurses, which are similar to travelers.
RON ADLER, CEO, Alaska Psychiatric Institute, Department of
Health and Social Services, specified that of the three
temporary relief agencies in Anchorage only two psychiatric
nurses can be obtained to come to API. Such nurses would be
paid between $45-$60, just as they would for a general medical
facility like Providence. He noted that psychiatric nursing
isn't the most desirable field.
4:34:57 PM
MS. CLARKE informed the committee that state facilities also
utilize on-call nurses. However, it's very difficult to fill
the high number of vacancies. Furthermore, the state doesn't
offer some of the benefits that are attractive to nurse
candidates, such as signing bonuses, on-site daycare, premium
relocation programs, and a central recruiting effort in the
state. Moreover, the state's hiring system doesn't provide
flexibility for quick job offers. In fact, there have been a
couple of instances in which a nurse, while waiting to complete
the hiring process, has taken a position elsewhere. She pointed
out that other employers offer yearly merit steps as nurses
achieve certification levels, while the state's nurses top out
at longevity steps as described earlier. Finally, Ms. Clarke
highlighted that the state's salary schedule is below the market
and thus is a barrier to recruitment and retention.
4:37:26 PM
MS. CLARKE returned to the earlier mentioned pay raise that was
taken from state nurses after being in effect for two years.
She explained that the former CEO of API saw that there were
going to be issues in retention and recruitment of nurses as
well as the market going in a different direction than the
state's salary schedule. She pointed out that there is a
provision in state pay for standby pay, which means that an
individual is on call. Therefore, the former CEO decided to
offer standby pay to all nurses. However, the union filed a
grievance that the standby pay option should also be available
to nursing assistants as well as nurses. During the arbitration
phase, the state labor relations mandated that API stop paying
standby pay to all nurses.
4:38:55 PM
CHAIR WILSON asked if it's equally as difficult to obtain nurse
assistants as it is RNs.
MS. CLARKE replied no.
MR. ADLER interjected that it's more difficult to obtain RNs,
who are licensed and without whom a hospital can't function.
MS. CLARKE, in response to Chair Wilson, related that most of
the state employees are covered by the general government unit,
which is the case with the RNs and the nurse assistants.
4:40:29 PM
MS. CLARKE opined:
We either have to have some special dispensation for
some ability to be more proactive, flexible, and
competitive or we're kind of in a Catch 22 because if
we can't solve those causes of not being able to fill
our authorized positions and this bill were to pass,
you've really put us in a barrel. We really need to
deal with those other issues as well, and that's ...
what I would urge the committee to consider.
4:41:05 PM
CHAIR WILSON requested that Ms. Clarke think about what could be
done legislatively to allow special dispensation for these
facilities to [go outside of the state employee construct].
4:41:31 PM
MR. ADLER said that the three employees from API who testified
today were remarkably accurate. He surmised that the three are
relating that API isn't attractively priced in terms of the
hourly wage.
4:43:20 PM
CHAIR WILSON pointed out that there is a teacher placement
agency, which might be something that could be helpful for the
recruitment of RNs.
4:44:46 PM
MR. ADLER noted that Providence does a nice job with regard to
recruitment and retention. He suggested that at some point, the
state is going to have to think outside of the box such that
API, the pioneers' homes, and public health are viewed together
and working under the umbrella of DHSS in order to create a
lifetime of vocational experiences for licensed professionals
[at all levels]. Perhaps such a think-tank within DHSS would be
appropriate, he opined.
4:45:47 PM
CHAIR WILSON commented that such should be reviewed before the
crisis gets worse because if the state doesn't gain control,
institutions may close.
4:46:05 PM
REPRESENTATIVE GARDNER asked if this crisis is partly to blame
for the empty beds at the pioneers' homes.
CHAIR WILSON said that it's one of the reasons.
4:46:19 PM
MR. ADLER informed the committee that API has an incredible
workforce and one of the lowest restraint seclusion rates in the
U.S. for a state psychiatric hospital. The ability to keep
employees and patients safe is remarkable, he emphasized.
However, the staff is suggesting that it's not going to be this
way forever.
4:46:54 PM
MILA COSGROVE, Director, Division of Personnel, Department of
Administration, informed the committee that the division
oversees the state's recruitment services, employee relations,
et cetera. In response to an earlier request for overtime
figures, Ms. Cosgrove directed attention to a document entitled,
"Overtime Paid in Fiscal Year 2005 to Nurses by Facility". She
clarified that the aforementioned document only refers to
nursing positions. The second and third columns relates that
there are more employees who worked overtime than positions,
which she attributed to the fact that the number of positions is
the number of budgeted positions. A position may become vacant
and be replaced during the course of the year, and therefore
it's possible to have more employees over the course of a fiscal
year than there are positions.
4:48:56 PM
CHAIR WILSON surmised then that if more people were recruited,
the amount of overtime would decrease.
MS. COSGROVE replied yes, adding that the straight wages would
increase because of the increase in employees. However, since
these are employees of facilities that are open 24 hours a day,
there will always be overtime issues. In further response to
Chair Wilson, Ms. Cosgrove specified that the [overtime] figures
refer to primarily time-and-a-half and don't include overtime
for holiday purposes. She noted that there are special letters
of agreement for employees of 24-hour facilities to "swap
holidays." The number 4 handout breaks down the specific job
class titles, she pointed out.
MS. COSGROVE then returned to her testimony. She related that
the U.S. is experiencing a general reduction in applicant pools,
not just in nursing. The aforementioned is related to the aging
of the Baby Boomers and the fact that there are less people to
take their place. However, nursing is critical because the
services can't merely be stopped when there isn't enough staff.
Ms. Cosgrove turned to the national shortage of nurses that is
caused by the same factors as well as the fact that there is an
overall increase in the demand for nurses, in part attributable
to the aging of Baby Boomers who require more health care as
well as the way the U.S. administers its health care. She
indicated that the duties and responsibilities assigned to
nurses have changed over the years, which has also increased the
demand for nurses.
4:51:54 PM
MS. COSGROVE turned attention to the "State Public Health
Employee Worker Shortage Report", which speaks mostly to public
health. The report relates that 85 percent of the state
agencies responding to the survey indicated that severe
personnel shortages were seen with health care personnel.
Furthermore, the Department of Labor & Workforce Development has
projected that between 2002 and 2012 there will be a 33.3
percent increase in registered nurse positions. She clarified
that the aforementioned percentage is in addition to the
positions that are already present and doesn't replace the
outgoing employees. As an employer, the State of Alaska feels
that pressure, she opined.
4:52:55 PM
REPRESENTATIVE SEATON returned attention to the overtime table
and the last column referring to the average hours per position.
MS. COSGROVE specified that the column reflects the average
hours worked per employee in these job classifications.
However, because voluntary overtime is used first a list of
employees with overtime hours worked would relate a huge
[discrepancy]. Therefore, she requested the average hour per
employee per the fiscal year.
4:54:22 PM
MS. COSGROVE continued with her testimony and related that the
primary employers of nurses for the state are DHSS and the
Department of Corrections. At the end of calendar year 2004,
there were about 279 positions allocated to nursing
classifications. The Division of Personnel tries to track
turnover and retirement eligibility data, although the division
is having difficult with its aging system. Therefore, the data
isn't 100 percent [accurate]. The handout in number 4 specifies
that the [state] has about a 17 percent turnover rate [for
nurses employed by the state], which looks quite different in
the job class level. For instance, at the Nurse 1 level, there
is a 50 percent turnover rate and at the Journey/Nurse 2 level
the turnover rate is about 22 percent.
4:55:40 PM
CHAIR WILSON asked if exit interviews are performed in order to
determine why the nurses employed by the state are leaving.
MS. COSGROVE replied yes, but it isn't highly used. She agreed
with Chair Wilson that an exit interview would probably be
helpful. Ms. Cosgrove then turned to the other factor that the
division is reviewing, which is the aging of the workforce.
Last year a fairly comprehensive retirement analysis was
published. That analysis relates that at the end of fiscal year
2004, 13.9 percent of employees in nursing positions were
eligible to retire in one year. That percentage increases to
35.2 percent when viewed in a five-year window. Therefore, this
confluence of events needs to be watched, she opined.
4:56:47 PM
CHAIR WILSON turned attention to the document that specifies
that by 2012, [the state] will need another 1,666 nurses, which
doesn't include the one-third that will be lost to that point.
MS. COSGROVE replied yes, and specified that the document from
the Department of Labor & Workforce Development refers to
positions while she is now discussing people available to fill
those positions. In further response to Chair Wilson, Ms.
Cosgrove, said that one-third of the current 280 positions would
be approximately 95 positions. She confirmed that the
[document] is referring to the public and private sector in
Alaska. Ms. Cosgrove explained that she isn't saying that the
state will necessarily increase its need for nurses by 33
percent, but 35 percent of the state's nurses can retire in five
years. Therefore, even if the state doesn't increase the number
of nursing positions, finding people for the vacancies will be
more difficult because the competition will be more intense.
She characterized it as basic supply and demand.
4:58:35 PM
REPRESENTATIVE SEATON asked if nurses who are able to retire do
so when they are eligible, or do nurses tend to stay past
retirement.
MS. COSGROVE informed the committee that the division is hoping
to, this year, be able to accurately review projected
retirements versus actual retirements. She related her "gut-
level guess" that most [nurses] retire because they can retire
with the full state employment and work elsewhere for a higher
hourly wage. She mentioned HB 161, and informed the committee
that the state has no retired nurses who have returned. The
aforementioned she attributed to the fact that nurses can work
anywhere, whereas the expertise of many other public employees
is in the public sector. In the way of background data, Ms.
Cosgrove informed the committee that the average years of state
service for a Nurse 2 are 6.67 years and 1.29 years for entry
level nurses.
MS. COSGROVE then turned to the fact that state wages are
trailing private sector wages. In fact, the state's entry level
[nursing] wages are approximately 7.3 percent below Providence's
wage. Furthermore, private sector companies enjoy more
flexibility than the state, in terms of offering various bonuses
and more steps. Additionally, the state's classification and
pay plan isn't established to address fluctuations in the
market, rather the state's plan is established to ensure that
all state's employees receive like pay for like work. To
address the aforementioned, the division has a number of short-
term and long-term strategies. In fact, the division is
reviewing a policy that would change the way nurses are hired
and at what level they would enter the pay scale. The same
policy change would allow a hiring manager the ability to offer
something to the nurse more quickly than is currently allowed.
5:02:08 PM
MS. COSGROVE explained that the aforementioned policy change
would allow hiring managers to advertise and start nurses at a
wage as high as $27.46 an hour, which she characterized as a
competitive entry level wage. The division is also creating a
proactive recruitment function in order to work with the
operating agencies and nurses will be the first to be reviewed.
The aforementioned will allow the division to review recruitment
efforts, job fairs, partnering with the university, marketing
state employment, and other outreach efforts designed to make
the state, as an employer, more visible. Furthermore, the
division is designing and implementing both entrance and exit
surveys. The division also plans to work with hiring managers
to market the state's nondirect salary compensation, such as
leave, holiday, and retirement benefits that may be better than
the state's primary competitors. The division is looking to
partner with representatives from the operating agencies to
strategize efforts to rearrange the work. With regard to long-
term goals, the division is reviewing the state's current
classification and compensation structure in order to determine
the legal options that exist to allow market data to influence
wage assignments.
5:05:14 PM
REPRESENTATIVE SEATON asked if any of the aforementioned
[strategies/goals] require legislative fixes.
MS. COSGROVE answered that at this point most of what was
mentioned is what can be done administratively. However, the
larger issue of the classification and compensation structure
may require legislative action. She assured the committee that
if that's the case, the division will approach the legislature.
CHAIR WILSON opined that [the nurse shortage] is a challenge
that requires thinking outside of the box. Therefore, she said
she was open to any suggestions.
5:07:29 PM
REPRESENTATIVE SEATON asked if the fact that Tier IV will cover
occupational disability has been identified as an area of
concern within the nursing profession. He also asked if that is
being reviewed as one of the recruitment tools under the new
legislation.
MS. COSGROVE said she couldn't specify whether that's something
that could be highlighted as a marketing tool since the division
is still in the process of putting together a recruitment
strategy.
5:10:00 PM
ROD BEANY (PH) mentioned that he had spoken with the chair and
said that he would talk with the administration regarding an
administrative way to address the salary and recruiting problems
and to survey the membership regarding their view of HB 271.
The committee has already heard a lot of the membership's
concern in that the passage of HB 271 would increase overtime
costs. With regard to the issue of mandatory overtime, Mr.
Beany recalled his time as the director in Utah and related that
he had flexibility with the state institutions to keep current
with the market. He offered that since his membership doesn't
use mandatory overtime very much, he expressed the need to find
ways to address competitive salaries and have the ability to
make adjustments when necessary in order to have some parity
with the private sector. He offered to work with the department
on achieving management flexibility.
[HB 271 was held over.]
5:13:48 PM
ADJOURNMENT
There being no further business before the committee, the House
Health, Education and Social Services Standing Committee meeting
was adjourned at 5:17 p.m.
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