Legislature(2007 - 2008)CAPITOL 106


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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
-- Recessed to 12:30 pm today --
Moved HCS CSSB 28(HES) Out of Committee
<Bill Hearing Rescheduled from 04/01/08>
Moved Out of Committee
+ Bills Previously Heard/Scheduled TELECONFERENCED
                    ALASKA STATE LEGISLATURE                                                                                  
 HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE                                                               
                         April 5, 2008                                                                                          
                           9:02 a.m.                                                                                            
MEMBERS PRESENT                                                                                                               
Representative Peggy Wilson, Chair                                                                                              
Representative Bob Roses, Vice Chair                                                                                            
Representative Anna Fairclough                                                                                                  
Representative Wes Keller                                                                                                       
Representative Paul Seaton                                                                                                      
Representative Sharon Cissna                                                                                                    
Representative Berta Gardner                                                                                                    
MEMBERS ABSENT                                                                                                                
All members present                                                                                                             
COMMITTEE CALENDAR                                                                                                            
SENATE BILL NO. 259                                                                                                             
"An  Act repealing  certain provisions  relating to  applications                                                               
for  medical assistance  coverage; making  certain provisions  of                                                               
ch. 96,  SLA 2006, retroactive;  providing for an  effective date                                                               
by  repealing an  effective date  section  in ch.  96, SLA  2006;                                                               
providing for an  effective date for certain sections  of ch. 96,                                                               
SLA 2006; and providing for an effective date."                                                                                 
     - MOVED SB 259 OUT OF COMMITTEE                                                                                            
CS FOR SENATE BILL NO. 28(FIN)                                                                                                  
"An  Act  relating  to  limitations  on  mandatory  overtime  for                                                               
registered nurses  and licensed  practical nurses in  health care                                                               
facilities; and providing for an effective date."                                                                               
     - MOVED HCS CSSB 28(HES) OUT OF COMMITTEE                                                                                  
PREVIOUS COMMITTEE ACTION                                                                                                     
BILL: SB 259                                                                                                                  
SHORT TITLE: EFFECTIVE DATE: MEDICAL ASSISTANCE LAWS                                                                            
SPONSOR(s): RULES BY REQUEST OF LEGISLATIVE COUNCIL                                                                             
02/04/08       (S)       READ THE FIRST TIME - REFERRALS                                                                        
02/04/08       (S)       STA, FIN                                                                                               
03/18/08       (S)       STA AT 9:00 AM BELTZ 211                                                                               
03/18/08       (S)       Scheduled But Not Heard                                                                                
03/19/08       (S)       STA RPT   1DP 3NR                                                                                      
03/19/08       (S)       DP: GREEN                                                                                              
03/19/08       (S)       NR: MCGUIRE, FRENCH, STEVENS                                                                           
03/19/08       (S)       STA AT 9:30 AM BELTZ 211                                                                               
03/19/08       (S)       -- Continued from 03/18/08 --                                                                          
03/24/08       (S)       FIN RPT  4DP                                                                                           
03/24/08       (S)       DP: STEDMAN, ELTON, THOMAS, DYSON                                                                      
03/24/08       (S)       FIN AT 9:00 AM SENATE FINANCE 532                                                                      
03/24/08       (S)       Moved SB 259 Out of Committee                                                                          
03/24/08       (S)       MINUTE(FIN)                                                                                            
03/26/08       (S)       TRANSMITTED TO (H)                                                                                     
03/26/08       (S)       VERSION: SB 259                                                                                        
03/27/08       (H)       READ THE FIRST TIME - REFERRALS                                                                        
03/27/08       (H)       HES, FIN                                                                                               
04/05/08       (H)       HES RPT 4DP 3NR                                                                                        
04/05/08       (H)       DP: CISSNA, SEATON, ROSES, WILSON                                                                      
04/05/08       (H)       NR: KELLER, FAIRCLOUGH, GARDNER                                                                        
04/05/08       (H)       HES AT 9:00 AM CAPITOL 106                                                                             
BILL: SB  28                                                                                                                  
SHORT TITLE: LIMIT OVERTIME FOR REGISTERED NURSES                                                                               
SPONSOR(s): SENATOR(s) DAVIS                                                                                                    
01/16/07       (S)       PREFILE RELEASED 1/5/07                                                                                
01/16/07       (S)       READ THE FIRST TIME - REFERRALS                                                                        
01/16/07       (S)       HES, L&C, FIN                                                                                          
04/04/07       (S)       HES AT 2:45 PM BUTROVICH 205                                                                           
04/04/07       (S)       Heard & Held                                                                                           
04/04/07       (S)       MINUTE(HES)                                                                                            
04/16/07       (S)       HES AT 1:30 PM BELTZ 211                                                                               
04/16/07       (S)       Moved CSSB 28(HES) Out of Committee                                                                    
04/16/07       (S)       MINUTE(HES)                                                                                            
04/18/07       (S)       HES RPT CS  2DP 1NR 2AM   SAME TITLE                                                                   
04/18/07       (S)       DP: DAVIS, ELTON                                                                                       
04/18/07       (S)       NR: THOMAS                                                                                             
04/18/07       (S)       AM: DYSON, COWDERY                                                                                     
04/24/07       (S)       L&C AT 1:30 PM BELTZ 211                                                                               
04/24/07       (S)       <Bill Hearing Postponed until Thursday>                                                                
04/26/07       (S)       L&C AT 1:30 PM BELTZ 211                                                                               
04/26/07       (S)       Heard & Held                                                                                           
04/26/07       (S)       MINUTE(L&C)                                                                                            
01/15/08       (S)       L&C AT 1:30 PM BELTZ 211                                                                               
01/15/08       (S)       -- MEETING CANCELED --                                                                                 
01/17/08       (S)       L&C AT 1:30 PM BELTZ 211                                                                               
01/17/08       (S)       -- MEETING CANCELED --                                                                                 
01/22/08       (S)       L&C AT 1:30 PM BELTZ 211                                                                               
01/22/08       (S)       Moved CSSB  28(L&C) Out of Committee                                                                   
01/22/08       (S)       MINUTE(L&C)                                                                                            
01/23/08       (S)       L&C RPT CS  2DP 3NR    SAME TITLE                                                                      
01/23/08       (S)       DP: ELLIS, DAVIS                                                                                       
01/23/08       (S)       NR: BUNDE, STEVENS, HOFFMAN                                                                            
03/04/08       (S)       FIN AT 9:00 AM SENATE FINANCE 532                                                                      
03/04/08       (S)       Heard & Held                                                                                           
03/04/08       (S)       MINUTE(FIN)                                                                                            
03/21/08       (S)       FIN AT 9:00 AM SENATE FINANCE 532                                                                      
03/21/08       (S)       Heard & Held                                                                                           
03/21/08       (S)       MINUTE(FIN)                                                                                            
03/25/08       (S)       FIN RPT CS  2DP 4NR   SAME TITLE                                                                       
03/25/08       (S)       DP: ELTON, THOMAS                                                                                      
03/25/08       (S)       NR: HOFFMAN, STEDMAN, DYSON, OLSON                                                                     
03/25/08       (S)       FIN AT 9:00 AM SENATE FINANCE 532                                                                      
03/25/08       (S)       Moved CSSB  28(FIN) Out of Committee                                                                   
03/25/08       (S)       MINUTE(FIN)                                                                                            
04/01/08       (S)       TRANSMITTED TO (H)                                                                                     
04/01/08       (S)       VERSION: CSSB 28(FIN)                                                                                  
04/01/08       (H)       HES AT 3:00 PM CAPITOL 106                                                                             
04/01/08       (H)       <Bill Hearing Rescheduled to 04/05/08>                                                                 
04/02/08       (H)       READ THE FIRST TIME - REFERRALS                                                                        
04/02/08       (H)       HES, FIN                                                                                               
04/05/08       (H)       HES AT 9:00 AM CAPITOL 106                                                                             
WITNESS REGISTER                                                                                                              
KATHRYN KURTZ, Assistant Revisor                                                                                                
Legislative Legal Counsel                                                                                                       
Legislative Legal and Research Services                                                                                         
Legislative Affairs Agency                                                                                                      
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Testified on SB 259.                                                                                     
JON SHERWOOD                                                                                                                    
Office of Program Review                                                                                                        
Department of Health and Social Services (DHSS)                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Answered a question during the hearing on                                                                
SB 259.                                                                                                                         
SENATOR BETTYE DAVIS                                                                                                            
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Spoke as the sponsor of SB 28.                                                                           
TOM OBERMEYER, Staff                                                                                                            
to Senator Bettye Davis                                                                                                         
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Presented SB 28, Version W, on behalf of                                                                 
Senator Davis, prime sponsor.                                                                                                   
ROD BETIT, President                                                                                                            
Alaska State Hospital and Nursing Home Association (ASHNHA)                                                                     
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Testified during the hearing on SB 28.                                                                   
TOM RENKES, RN; MS                                                                                                              
Executive Director                                                                                                              
Labor Program                                                                                                                   
Alaska Nurses Association                                                                                                       
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of SB 28.                                                                           
BARBARA HUFF, Director                                                                                                          
Governmental and Legislative Affairs                                                                                            
Teamsters Local 959                                                                                                             
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of SB 28.                                                                           
RYAN SMITH, Chief Executive Officer                                                                                             
Central Peninsula General Hospital                                                                                              
Soldotna, Alaska                                                                                                                
POSITION STATEMENT:  Testified during the hearing on SB 28.                                                                   
PATRICIA REYNAGA, Registered Nurse                                                                                              
Providence Hospital                                                                                                             
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Speaking as an individual, testified in                                                                  
opposition to SB 28.                                                                                                            
PATTY ARTHUR, Licensed Practical Nurse                                                                                          
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during the hearing on SB 28.                                                                   
PAM READ, Psychiatric Nurse                                                                                                     
North Star Hospital                                                                                                             
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during the hearing on SB 28.                                                                   
PAT HIGGINS, Human Resources Director                                                                                           
North Star Hospital                                                                                                             
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in opposition to SB 28.                                                                        
ELIZABETH CHENEY, Representative                                                                                                
Alaska Native Health Board; Alaska Native Tribal Health                                                                         
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in opposition to SB 28.                                                                        
TINA GONZALES, Registered Nurse                                                                                                 
Valdez, Alaska                                                                                                                  
POSITION STATEMENT:  Speaking as an individual, testified during                                                              
the hearing on SB 28.                                                                                                           
SHARA SUTHERLIN, Chief Nurse Executive                                                                                          
Providence Medical Center                                                                                                       
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during the hearing on SB 28.                                                                   
SCOTT JUNGWIRTH, Chief Human Resources Officer                                                                                  
Providence Health & Services, Alaska                                                                                            
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in opposition to SB 28.                                                                        
MARY STACKHOUSE, Neonatal Intensive Care Nurse                                                                                  
Providence Hospital                                                                                                             
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during the hearing on SB 28.                                                                   
NORMAN STEVENS, Chief Executive Officer                                                                                         
Mat-Su Regional Medical Center                                                                                                  
Palmer, Alaska                                                                                                                  
POSITION STATEMENT:  Testified in opposition to SB 28.                                                                        
PAUL MORDINI, Registered Nurse                                                                                                  
Nursing Supervisor                                                                                                              
Alaska Psychiatric Institute                                                                                                    
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of SB 28.                                                                           
JUDY EVANS, Registered and Certified Nurse                                                                                      
Alaska Regional Hospital                                                                                                        
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Speaking as an individual, testified in                                                                  
support of SB 28.                                                                                                               
DEB DRAKE, Recovery Room Nurse                                                                                                  
Alaska Regional Hospital                                                                                                        
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Speaking as an individual, testified in                                                                  
support for SB 28.                                                                                                              
STACY ALLEN, Registered Nurse; Business Agent                                                                                   
Laborers Local 341                                                                                                              
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support for SB 28.                                                                          
ELIZABETH WOODWARD, Chief Nursing Officer                                                                                       
Fairbanks Memorial Hospital                                                                                                     
Fairbanks, Alaska                                                                                                               
POSITION STATEMENT:  Testified in opposition to SB 28.                                                                        
MICHAEL ZIELASKIEWICZ, Chief Nursing Officer                                                                                    
Mat-Su Regional Medical Center                                                                                                  
Palmer, Alaska                                                                                                                  
POSITION STATEMENT:  Testified in opposition to SB 28.                                                                        
REBECCA BOLLING, Registered Nurse                                                                                               
Ketchikan General Hospital                                                                                                      
Ketchikan, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support for SB 28.                                                                          
JACK DAVIS, Human Resources Director                                                                                            
Bristol Bay Area Health Corporation                                                                                             
Dillingham, Alaska                                                                                                              
POSITION STATEMENT:  Testified in opposition to SB 28.                                                                        
PAT SENNER                                                                                                                      
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of SB 28.                                                                           
NANCY DAVIS, Registered Nurse                                                                                                   
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Testified in support of SB 28.                                                                           
LAUREE MORTON                                                                                                                   
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Testified in support of SB 28.                                                                           
GREY MITCHELL, Director                                                                                                         
Central Office                                                                                                                  
Division of Labor Standards & Safety                                                                                            
Department of Labor & Workforce Development                                                                                     
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:   Answered a  question during the  hearing on                                                             
SB 28.                                                                                                                          
ACTION NARRATIVE                                                                                                              
CHAIR  WILSON  called  the House  Health,  Education  and  Social                                                             
Services  Standing  Committee meeting  to  order  at 9:02:51  AM.                                                             
Representatives Wilson, Fairclough,  Keller, Seaton, Gardner, and                                                               
Roses were present  at the call to order.   Representative Cissna                                                               
arrived as the meeting was in progress.                                                                                         
SB 259-EFFECTIVE DATE: MEDICAL ASSISTANCE LAWS                                                                                
9:03:46 AM                                                                                                                    
CHAIR WILSON announced that the  first order of business would be                                                               
SENATE  BILL  NO.  259,  "An  Act  repealing  certain  provisions                                                               
relating to applications for  medical assistance coverage; making                                                               
certain provisions  of ch. 96,  SLA 2006,  retroactive; providing                                                               
for an effective  date by repealing an effective  date section in                                                               
ch. 96,  SLA 2006;  providing for an  effective date  for certain                                                               
sections  of ch.  96, SLA  2006; and  providing for  an effective                                                               
9:04:35 AM                                                                                                                    
KATHRYN  KURTZ,  Assistant  Revisor, Legislative  Legal  Counsel,                                                               
Legislative  Legal  and  Research Services,  Legislative  Affairs                                                               
Agency, explained that  SB 259 was a special  revisor's bill that                                                               
was necessary to  change the wording of an  effective date clause                                                               
pertaining  to the  Medical Assistance  Act of  2006.   Ms. Kurtz                                                               
stated that  the revision provided  by the bill was  supported by                                                               
the  Department of  Law  (DOL)  and the  Department  of Health  &                                                               
Social Services (DHSS).                                                                                                         
9:05:43 AM                                                                                                                    
CHAIR WILSON opined  that the memorandum in  the committee packet                                                               
from Ms. Kurtz explained the situation well.                                                                                    
9:05:52 AM                                                                                                                    
REPRESENTATIVE  FAIRCLOUGH referred  to the  memorandum from  Ms.                                                               
Kurtz, dated March 27, 2008, and  asked for an explanation of the                                                               
amendments that were disapproved by the federal government.                                                                     
9:06:08 AM                                                                                                                    
MS.  KURTZ   explained  that  the  disapproved   provisions  were                                                               
repealed by the bill.                                                                                                           
9:06:34 AM                                                                                                                    
JON SHERWOOD, Office of Program  Review, Department of Health and                                                               
Social Services  (DHSS), further explained that  the disapprovals                                                               
were for Medicare  state plan amendments.   One amendment imposed                                                               
a $500,000 asset limit on  private residences and one changed the                                                               
authority of adults  to apply for Medicare on  behalf of children                                                               
under 18 years of age.                                                                                                          
9:07:35 AM                                                                                                                    
REPRESENTATIVE  GARDNER  noted  that  SB  259  repeals  statutory                                                               
language, in  AS 47.07.020  (J), dealing with  who can  apply for                                                               
Medicare for  a child  under the age  of 18.   She asked  how the                                                               
determination would be made after the repeal.                                                                                   
9:08:02 AM                                                                                                                    
MR.  SHERWOOD  answered  that  the  existing  policy  remains  in                                                               
effect, which  states that any  responsible person can  apply, on                                                               
behalf of a  child, if the child  is living at home.   The parent                                                               
would have  to cooperate in  the application, but currently  if a                                                               
child is  in a situation  where their  parent can not  apply, the                                                               
application will be accepted from another responsible party.                                                                    
9:08:57 AM                                                                                                                    
REPRESENTATIVE  GARDNER ascertained  that  "we're  not leaving  a                                                               
MR. SHERWOOD indicated not.                                                                                                     
9:09:09 AM                                                                                                                    
CHAIR  WILSON recalled  a previous  policy  change regarding  the                                                               
adoption of a person over the age  of 18.  She asked if this bill                                                               
affects that statute.                                                                                                           
MR.  SHERWOOD said  this bill  does  not affect  the adoption  of                                                               
adult children.                                                                                                                 
9:09:58 AM                                                                                                                    
REPRESENTATIVE  ROSES moved  to report  SB 259  out of  committee                                                               
with  individual  recommendations  and  the  accompanying  fiscal                                                               
notes.   There being no objection,  SB 259 was reported  from the                                                               
House Health, Education and Social Services Standing Committee.                                                                 
SB  28-LIMIT OVERTIME FOR REGISTERED NURSES                                                                                   
9:10:29 AM                                                                                                                    
CHAIR WILSON announced that the  final order of business would be                                                               
CS FOR SENATE  BILL NO. 28(FIN), "An Act  relating to limitations                                                               
on  mandatory   overtime  for  registered  nurses   and  licensed                                                               
practical nurses in health care  facilities; and providing for an                                                               
effective date."                                                                                                                
9:11:11 AM                                                                                                                    
SENATOR   BETTYE  DAVIS,   Alaska  State   Legislature,  sponsor,                                                               
deferred to  her staff member  for the introduction of  the bill,                                                               
and said that she would be available for questions.                                                                             
9:11:37 AM                                                                                                                    
TOM  OBERMEYER,  Staff  to Senator  Bettye  Davis,  Alaska  State                                                               
Legislature, introduced SB 28, Version  W,  paraphrasing from the                                                               
sponsor statement,  which read  as follows  [original punctuation                                                               
     SB  28, also  known  as "The  Alaska  Safe Nursing  and                                                                    
     Patient  Care Act,"  modeled somewhat  after H.R.  791,                                                                    
     109th Congress, assists  Alaska registered and licensed                                                                    
     practical nurses  from being  forced to  work mandatory                                                                    
     overtime,  i.e.,  compulsory  as opposed  to  voluntary                                                                    
     work  in   excess  of  an  agreed   to,  predetermined,                                                                    
     regularly  scheduled shift,  and  it protects  patients                                                                    
     from the dangers  caused by overworked nurses.   It was                                                                    
     reported   at    the   International    Conference   on                                                                    
     Occupational  Stress and  Health, March  2, 2006,  that                                                                    
     work shifts  longer than twelve hours  per day endanger                                                                    
     patient   safety  due   to  fatigue,   causing  reduced                                                                    
     capability of nurses to notice  and correct errors.  It                                                                    
     found  that 27%  of nurses  in full-time  hospitals and                                                                    
     nursing  homes worked  more than  13 consecutive  hours                                                                    
     one or more  times per week. The  January, 2008, report                                                                    
     by  the  Alaska  Nurses Association  titled  "Mandatory                                                                    
     Overtime Legislation:  A  positive approach to improved                                                                    
     patient care  for the  State of  Alaska," found  that a                                                                    
     majority  of the  staff nurses  present  at the  Alaska                                                                    
     Statewide Nurses Conference  held in Anchorage October,                                                                    
     2007, had  reported that  they had  been asked  to work                                                                    
     overtime  in  the  past  three  months.    Many  nurses                                                                    
     indicated that  they had  to take  mandatory call.   In                                                                    
     many cases  the call-back  occurred within a  few hours                                                                    
     of  completing a  regular 12-hour  shift, resulting  in                                                                    
     working  more than  14 hours  within a  24-hour period.                                                                    
     This bill directly addresses this problem.                                                                                 
     This bill has been a work  in process over the last two                                                                    
     years  with  a number  of  changes  to accommodate  the                                                                    
     unique  staffing   problems  at  various   health  care                                                                    
     facilities, while paying attention to patient care and                                                                     
     nursing work-hours.  While  most health care facilities                                                                    
     provide incentives for on-call  pay and on-call return-                                                                    
     to-work   status,  the   use   of  mandatory   overtime                                                                    
     continues to  remain a way  to staff  facilities across                                                                    
     the state without  hiring more RNs.   Faced with severe                                                                    
     nursing  shortages  in  Alaska and  nationwide,  Alaska                                                                    
     needs  to encourage  and support  nurses  to enter  and                                                                    
     stay in  the profession.  The  average age of an  RN in                                                                    
     the  US and  in  Alaska is  mid-forties. The  increased                                                                    
     numbers of  nurses trained at the  University of Alaska                                                                    
     still falls  short of the need,  especially in critical                                                                    
     care areas and highly-trained specialties.                                                                                 
     Nurses have  always been afraid  to object  to requests                                                                    
     by  employers  for  excessive  voluntary  or  mandatory                                                                    
     overtime or to testify on  behalf of this bill for fear                                                                    
     of direct or indirect  retaliation.  This bill protects                                                                    
     nurses   from   discrimination   and   retaliation   by                                                                    
     employers   and  requires   semi-annual  reporting   of                                                                    
     individual  nursing  hours to  the  state  in order  to                                                                    
     identify abuses.   It provides state  investigatory and                                                                    
     enforcement  mechanisms   to  encourage   employers  to                                                                    
     comply,   especially    in   situations    of   knowing                                                                    
     This bill attempts to balance  the often opposing views                                                                    
     and  objectives of  health care  facilities and  nurses                                                                    
     concerning  mandatory overtime,  but it  cannot resolve                                                                    
     all   nurse    staffing   and    scheduling   problems,                                                                    
     particularly with  shortages in critical areas.   Based                                                                    
     on  already  difficult  working  conditions  made  more                                                                    
     onerous  by  regular   mandatory  overtime,  this  bill                                                                    
     should provide  considerable relief to  Alaska's nurses                                                                    
     who often feel  overworked, underpaid, undervalued, and                                                                    
     with  little  control over  their  time  at home.    It                                                                    
     should improve  the lives of nurses  and their families                                                                    
     and enhance the quality  of patient care in communities                                                                    
     across  the state  and let  nurses decide  if they  can                                                                    
     provide   their  same   quality   care  while   working                                                                    
     overtime.   It provides a  number of exceptions  in the                                                                    
     use  of mandatory  overtime  for  nurses in  situations                                                                    
     such as  official state of emergency,  medical airlift,                                                                    
     and  other  listed  exceptions.    Finally,  this  bill                                                                    
     allows nurses  to work overtime voluntarily  so long as                                                                    
     the work is consistent  with professional standards and                                                                    
     safe patient  care and does  not exceed  14 consecutive                                                                    
9:15:42 AM                                                                                                                    
MR.  OBERMEYER  added  that there  is  Alaskan  legislation  that                                                               
limits the period  of employment in underground mines  to no more                                                               
than 10 hours  in a 24-hour day.   This problem is  not unique to                                                               
Alaska,  but  has  become  a pervasive  concern  in  the  nursing                                                               
profession.   Excessive overtime,  instead of hiring  more staff,                                                               
leads to burnout and can cause  a decline in the quality of care.                                                               
He  then pointed  out  that one  of the  provisions  in the  bill                                                               
requires  individuals  to  report  their work  schedules.    This                                                               
detailed  information  would allow  the  state  to review  actual                                                               
schedules  and should  aid hospitals  in their  staffing efforts.                                                               
Mr.  Obermeyer concluded  that mandatory  overtime  has become  a                                                               
common  practice as  a cost  saving measure  and has  resulted in                                                               
hiring traveling nurses, part-time  workers, or contract workers,                                                               
instead of training and hiring  full-time nurses at the necessary                                                               
staffing levels.                                                                                                                
9:18:54 AM                                                                                                                    
REPRESENTATIVE  ROSES  asked  how many  nurses  this  legislation                                                               
would affect.                                                                                                                   
MR.  OBERMEYER  answered that  about  4,500  licensed nurses  are                                                               
employed in the state, and one-half are under contract.                                                                         
9:19:36 AM                                                                                                                    
REPRESENTATIVE  ROSES noted  that there  has not  been an  outcry                                                               
from many  nurses about  this situation.   He  questioned whether                                                               
the [mandatory overtime] is a common practice.                                                                                  
9:20:13 AM                                                                                                                    
MR. OBERMEYER  observed that it  was not  in a nurse's  nature to                                                               
complain.  He  opined that nurses work for "take  it or leave it"                                                               
contracts,  and employers  have  the power  to enforce  mandatory                                                               
overtime  without adequate  rest between  shifts; in  fact, there                                                               
can be indirect  retaliation for complaints.    Hospitals want to                                                               
have  a good  "bottom line"  and the  nurses are  subject to  the                                                               
whims of the organization.                                                                                                      
9:22:28 AM                                                                                                                    
SENATOR DAVIS  informed the committee  that there have  been many                                                               
witnesses who  have testified in  support of this  bill; however,                                                               
many feel as  though they can not testify.   Further, the nurse's                                                               
associations are supportive of the bill.                                                                                        
9:23:04 AM                                                                                                                    
REPRESENTATIVE  ROSES  acknowledged  the  presentation  of  other                                                               
testimony during previous hearings.                                                                                             
9:23:14 AM                                                                                                                    
REPRESENTATIVE KELLER referred to page 2,  line 11 and 12, of the                                                               
bill  that  prohibits  "indirect  coercion."   He  asked  how  to                                                               
balance voluntary overtime against indirect coercion.                                                                           
9:23:52 AM                                                                                                                    
MR. OBERMEYER  explained that  indirect coercion  can be  the re-                                                               
assignment of  shifts or mandatory  on-call duty.  In  fact, many                                                               
nurses  will  feel compelled  to  volunteer  even when  they  are                                                               
exhausted.  He referred to  documentation in the committee packet                                                               
from the  American Medical  Association that  presents statistics                                                               
on the  increased risk to patients  after a nurse works  beyond a                                                               
12 hour shift.                                                                                                                  
9:25:41 AM                                                                                                                    
REPRESENTATIVE KELLER gave  an example of a nurse and  his or her                                                               
employer who disagree about whether overtime is voluntary.                                                                      
9:26:18 AM                                                                                                                    
MR.  OBERMEYER   opined  that   the  bill   includes  enforcement                                                               
mechanisms  to  handle   violations  through  the  commissioner's                                                               
office.  Furthermore,  the expectations of the  employer are well                                                               
documented and disputes should be kept to a minimum.                                                                            
9:27:20 AM                                                                                                                    
REPRESENTATIVE FAIRCLOUGH referred to page  2, line 15, and asked                                                               
whether a hospital  is limited to scheduling nurses to  work a 40                                                               
hour work week with zero overtime.                                                                                              
9:27:39 AM                                                                                                                    
MR.  OBERMEYER read:    "to  work beyond  80  hours  in a  14-day                                                               
period" and  explained that  this was a  standard work  week, and                                                               
the  language  following  allows   a  nurse  to  accept  overtime                                                               
voluntarily.   He stressed that  the bill was flexible  enough to                                                               
allow for exceptions, but would  still limit overtime in order to                                                               
provide 10 hours off between shifts.                                                                                            
9:28:46 AM                                                                                                                    
REPRESENTATIVE FAIRCLOUGH opined that,  according to the language                                                               
in the  bill, a nurse  does not have to  work over eight  hours a                                                               
day.  Furthermore,  page 3, lines 13 through 15,  are in conflict                                                               
with the  language on page 2.   She expressed her  support of the                                                               
ten hour break between shifts;  however, the bill appears to give                                                               
the nurse  the choice to  work an eight  hour day, which  may put                                                               
the employer at a disadvantage.                                                                                                 
9:30:09 AM                                                                                                                    
MR. OBERMEYER remarked:                                                                                                         
     I think you  can see, from what I've said  in the past,                                                                    
     that this  voluntary business tends  to largely  be, a,                                                                    
     encouraged,  to the  point of  being  mandatory on  the                                                                    
     part of the employers. ...  It does give a relief valve                                                                    
     to  the nurses  who can't  work that,  and to  say that                                                                    
     it's  impairing  the  ability   of  the  ...  employer,                                                                    
     because  we've asked  that these  people have  adequate                                                                    
     rest, I think it goes  in direct conflict with what the                                                                    
     intent of the bill is.                                                                                                     
9:31:11 AM                                                                                                                    
CHAIR WILSON  interjected her personal  nursing experience.   She                                                               
noted that many states are  implementing this type of legislation                                                               
to support the nursing profession.                                                                                              
9:33:52 AM                                                                                                                    
REPRESENTATIVE FAIRCLOUGH suggested that  a nurse could cite this                                                               
legislation and leave  an operating room after eight  hours.  She                                                               
questioned whether a shorter shift would always be possible.                                                                    
9:34:59 AM                                                                                                                    
CHAIR  WILSON observed  that in  certain situations,  such as  an                                                               
operation, there may be other options for the nursing staff.                                                                    
9:35:53 AM                                                                                                                    
REPRESENTATIVE FAIRCLOUGH re-stated the  language on page 2, line                                                               
15, of the bill.                                                                                                                
9:36:01 AM                                                                                                                    
REPRESENTATIVE SEATON  asked whether the  intent was to  say that                                                               
the nursing profession  was to have the same  anticipated 40 hour                                                               
work  week  as other  professions,  but  still allow  flexibility                                                               
within a certain time period.                                                                                                   
9:37:15 AM                                                                                                                    
MR. OBERMEYER  acknowledged that  the 80 hour  work week  was the                                                               
traditional work week;  however, nurses often work  three days of                                                               
twelve  hour shifts.   This  bill  would not  change shifts,  but                                                               
requires hospitals to  recognize that, after 14 hours  of work, a                                                               
nurse needs to  have 10 hours of rest.   Using mandatory overtime                                                               
as  a  staffing  tool  versus emergency  coverage  creates  undue                                                               
pressure on the nurses and contributes to the nursing shortage.                                                                 
9:39:06 AM                                                                                                                    
REPRESENTATIVE  CISSNA understood  that  this  bill provides  for                                                               
necessary  nursing  coverage  during  extreme  emergencies  while                                                               
providing protection for nurses working under normal conditions.                                                                
9:40:01 AM                                                                                                                    
MR. OBERMEYER indicated yes.                                                                                                    
9:40:05 AM                                                                                                                    
REPRESENTATIVE GARDNER pointed  out that the language  on page 3,                                                               
beginning on  line 1,  allows for overtime  status because  of an                                                               
unforeseen emergency  situation.  She supported  the bill's focus                                                               
against the  practice of using  mandatory overtime as  a staffing                                                               
9:41:00 AM                                                                                                                    
REPRESENTATIVE FAIRCLOUGH  asked whether  a hospital  schedule is                                                               
written on a weekly, bi-weekly or monthly basis.                                                                                
9:41:26 AM                                                                                                                    
CHAIR  WILSON   responded  that   there  are   primarily  monthly                                                               
schedules; however,  within the  monthly schedules there  will be                                                               
8, 10 and 12 hour shift schedules.                                                                                              
9:43:18 AM                                                                                                                    
REPRESENTATIVE FAIRCLOUGH  directed the committee's  attention to                                                               
page 4, and remarked:                                                                                                           
     ... they  can take  their schedule  and use  it against                                                                    
     their employer  every time the  emergency arises.   And                                                                    
     they're  going  to  respond to  the  emergency  because                                                                    
     that's   the  type   of   people   they  are,   they're                                                                    
     caregivers.  ... But  we're giving  them  a very  large                                                                    
     bat, is all I'm putting on the record.                                                                                     
REPRESENTATIVE FAIRCLOUGH  read the  violation provisions  of the                                                               
bill and expressed her concern.                                                                                                 
9:44:56 AM                                                                                                                    
SENATOR   DAVIS    suggested   that   a    hospital   association                                                               
representative or nurse should address this issue.                                                                              
9:45:19 AM                                                                                                                    
REPRESENTATIVE SEATON asked whether  the question would be solved                                                               
by  specifying one  hundred and  sixty  hours in  four weeks,  or                                                               
whether the limit on the hospitals was the problem.                                                                             
9:45:54 AM                                                                                                                    
REPRESENTATIVE  FAIRCLOUGH surmised  that  a  shorter week  gives                                                               
less  liability; in  fact, an  expansion to  the two  week period                                                               
invites  more  modification to  the  schedule  and thereby,  more                                                               
9:46:58 AM                                                                                                                    
REPRESENTATIVE  SEATON asked  whether, if  a nurse  volunteers to                                                               
work 60 hours in  one week and then works more  than 20 hours the                                                               
next  week, there  is a  violation.   Or,  whether the  violation                                                               
occurs when the nurse is scheduled to work those hours.                                                                         
9:47:51 AM                                                                                                                    
MR.  OBERMEYER  read from  page  3,  lines  13  through 15.    He                                                               
stressed  that the  bill  does not  say that  they  can not  work                                                               
longer hours,  but that they  would need to  have a 10  hour rest                                                               
after 14 hours.                                                                                                                 
9:49:39 AM                                                                                                                    
REPRESENTATIVE   CISSNA   requested   that   a   human   resource                                                               
administrator address the staffing questions.                                                                                   
9:50:07 AM                                                                                                                    
REPRESENTATIVE  FAIRCLOUGH  maintained  her concern,  and  stated                                                               
that she would not hold up the bill.                                                                                            
9:51:12 AM                                                                                                                    
CHAIR  WILSON agreed  that hospital  staffing  schedules are  not                                                               
REPRESENTATIVE FAIRCLOUGH suggested that  passage of the bill may                                                               
force the hiring of more nurses.                                                                                                
9:51:50 AM                                                                                                                    
REPRESENTATIVE  GARDNER opined  that the  hospital schedules  may                                                               
become more flexible based on this legislation.                                                                                 
9:53:05 AM                                                                                                                    
ROD  BETIT, President,  Alaska State  Hospital  and Nursing  Home                                                               
Association (ASHNHA),  directed the committee's attention  to the                                                               
voluntary  reports of  the  use of  mandatory  overtime at  state                                                               
facilities that were  provided to the committee.   He stated that                                                               
ASHNHA has  collected facts over  the last four years  to support                                                               
that mandatory  overtime is not  being used in a  significant way                                                               
in state  facilities, nor  is it  used as a  staffing tool.   The                                                               
exception  to  this would  be  the  Alaska Psychiatric  Institute                                                               
(API), that does continue to have  a staffing issue.  He referred                                                               
to  the  ASHNHA position  paper  and  surveys and  described  the                                                               
statistics  reported. Mr.  Betit  stated neither  ASHNHA nor  the                                                               
Department  of Labor  have received  grievances due  to mandatory                                                               
overtime and  that he is  at a loss  for why this  legislation is                                                               
offered.   He opined that a  greater problem pertains to   nurses                                                               
who must  remain on-call  and this  bill, on page  3, line  8 and                                                               
line 9,  exempts on-call  time from the  provisions of  the bill.                                                               
He  then reminded  the committee  that hospitals  are working  to                                                               
lessen the nursing shortage by  contributing to nursing education                                                               
programs through  the University of  Alaska; in fact,  200 nurses                                                               
are graduated  each year,  and 93 percent  are placed  in Alaska.                                                               
He  turned to  the reporting  requirement in  the bill  and noted                                                               
that no other  state has such a  burdensome reporting requirement                                                               
of  nurses. Furthermore,  he pointed  out that  ASHNHA facilities                                                               
are  monitored by  independent, state,  and federal  reviewers of                                                               
patient safety, and there is  nothing to substantiate that nurses                                                               
working  overtime cause  injuries to  patients.   He stated  that                                                               
bargaining units and unions are  very effective in bringing forth                                                               
work  scheduling  issues that  are  presented  by employees.  Mr.                                                               
Betit  concluded that  the  bill would  affect  the balance  that                                                               
exists  between  employers  and employees,  that  only  13  other                                                               
states  have legislation  governing  mandatory  overtime, and  he                                                               
expressed his concern  for the implications of  the precedent set                                                               
by the bill                                                                                                                     
10:05:28 AM                                                                                                                   
CHAIR WILSON asked, "If none of  this is happening, ... then what                                                               
is the fear? ... Why does this bother you so much?"                                                                             
10:05:49 AM                                                                                                                   
MR.  BETIT  explained that  the  bill  moves  into an  area  that                                                               
prescribes the  relationship between  management and  health care                                                               
employees.  Until  there is evidence that  facilities are abusing                                                               
employees or  patients, the legislature should  not be installing                                                               
10:07:08 AM                                                                                                                   
REPRESENTATIVE  CISSNA suggested  that many  times people  do not                                                               
disclose information, nor may it show  up in a survey.  Responses                                                               
to an employer  survey are often skewed by  participants, and she                                                               
suggested  that other  issues, such  as retention,  turnover, and                                                               
the  health  of  employees,  are  better  indicators  of  working                                                               
conditions.     Her  experience reveals  that hospital  employees                                                               
would not bring these issues to the employer.                                                                                   
10:09:54 AM                                                                                                                   
REPRESENTATIVE  KELLER  asked   whether  health  care  facilities                                                               
complete exit surveys when nurses resign.                                                                                       
10:10:27 AM                                                                                                                   
MR. BETIT responded that some do.                                                                                               
10:11:04 AM                                                                                                                   
CHAIR  WILSON asked  whether staff  nurses were  involved in  the                                                               
facility surveys.                                                                                                               
10:11:17 AM                                                                                                                   
MR.  BETIT answered  that his  office submitted  the request  for                                                               
information  through   the  Chief   Executive  Officer   of  each                                                               
10:11:36 AM                                                                                                                   
REPRESENTATIVE FAIRCLOUGH  stated that  what was  being presented                                                               
was inconsistent  with information  from hospitals that  has been                                                               
solicited directly by  her office.  She asked if  Mr. Betit would                                                               
agree  with a  Health Affairs  study that  there are  three times                                                             
more errors by nurses working over 12.5 hours.                                                                                  
10:12:25 AM                                                                                                                   
MR.  BETIT  said that  he  would  accept  the finding  by  Health                                                             
10:12:53 AM                                                                                                                   
REPRESENTATIVE  FAIRCLOUGH  offered  to  sign  a  confidentiality                                                               
agreement  in order  to view  hospital internal  incident reports                                                               
and determine whether or not  incidents increase during a nurse's                                                               
overtime  shift.   She relayed  the questions  and responses  her                                                               
office  solicited:    To  the question  of  whether  nurses  work                                                               
overtime immediately after a 12  hour shift, hospitals responded,                                                               
"rarely" and  "on a  volunteer basis."  Representative Fairclough                                                               
than  requested additional  details on  the percentage  of nurses                                                               
who work  eight, ten,  and twelve hour  shifts at  each facility.                                                               
Returning to the questions she asked of hospitals, she remarked:                                                                
     I asked  for, "how frequent  people work, ...  over the                                                                    
     14 hour  shifts" and  I'd like  to understand  how each                                                                    
     hospital   interprets  a   mandatory  overtime   versus                                                                    
     mandatory  on-call  because  I  think  it  affects  the                                                                    
     quality of  care and, truthfully,  for me,  the benefit                                                                    
     is, if  a nurse  is willing to  take the  mandatory on-                                                                    
     call ...  there is  a balance  there in  revenue that's                                                                    
     coming  to  the  nurse  that she's  trying  to  protect                                                                    
     versus  also protecting  her schedule.  ...  So I  just                                                                    
     want to see the balance  there. ... I've been told that                                                                    
     your nurse  vacancy rate is  not what you  provided the                                                                    
     union.  ...  The rates,  again  on  the chart  provided                                                                    
     here, were  different than the  rates that you  gave to                                                                    
     the bargaining  unit that  is representing  the nursing                                                                    
     association. ...  I'd like to understand,  from some of                                                                    
     the  hospitals,  why  they continue  to  use  temporary                                                                    
     nurses and traveling nurses, and  I understand if we're                                                                    
     reaching out to rural  Alaska or other communities, why                                                                    
     you  might  want to  use  that,  but understanding  the                                                                    
     difference  and  how   the  hospitals  interpret  those                                                                    
     definitions would be helpful to me.                                                                                        
10:16:36 AM                                                                                                                   
MR. BETIT responded that the  information on how many nurses work                                                               
eight-,  ten-,  or twelve-hour  shifts  would  be provided.    In                                                               
response to the  question of inconsistencies, he  stated that the                                                               
survey information was returned directly from each hospital.                                                                    
10:17:12 AM                                                                                                                   
REPRESENTATIVE  FAIRCLOUGH clarified  that  her  question to  the                                                               
hospitals  regarding mandatory  overtime  included mandatory  on-                                                               
call time  and the  ASHNHA survey was  unclear on  this question,                                                               
thus hospitals responded differently.                                                                                           
10:17:56 AM                                                                                                                   
MR.  BETIT confirmed  that the  ASHNHA survey  did not  intend to                                                               
include mandatory on-call time.                                                                                                 
10:18:03 AM                                                                                                                   
REPRESENTATIVE GARDNER  asked Mr. Betit to  clarify his statement                                                               
that  the sponsors  of  the bill  have  presented   "allegations,                                                               
assumptions,  and suppositions."    Further, she  asked for  hard                                                               
data  supporting his  statement that  93 percent  of the  nursing                                                               
graduates are  being hired in  the state.  She  reviewed ASHNHA's                                                               
concerns about the reporting requirement  and penalties and asked                                                               
whether  the removal  of  these two  provisions  would allay  its                                                               
10:20:15 AM                                                                                                                   
MR. BETIT affirmed that the allegations  he referred to  are that                                                               
hospitals  are  intimidating  nurses,  that  patients  are  being                                                               
seriously harmed by tired nurses,  and that there is damage being                                                               
done to health care in the state.                                                                                               
10:20:51 AM                                                                                                                   
REPRESENTATIVE  GARDNER  pointed  out that  the  statements  were                                                               
drawn  from national  studies  that reported  a  higher level  of                                                               
mistakes made by exhausted nurses.                                                                                              
MR. BETIT apologized.                                                                                                           
10:21:39 AM                                                                                                                   
REPRESENTATIVE  GARDNER  stated her  concern  that  if there  are                                                               
nurses who are unable to  maintain competency due to overwork, it                                                               
would be  derelict of the  committee's duties to not  address the                                                               
situation.   She stressed her support  for the core of  the bill,                                                               
which is  to limit overtime,  in order  to help in  the retention                                                               
and job satisfaction of nurses, and in patient safety.                                                                          
10:22:44 AM                                                                                                                   
REPRESENTATIVE SEATON  recalled testimony  two years ago  about a                                                               
suicide at  API and a situation  where a nurse left  her position                                                               
because  of  concern  for  her  license.   He  pointed  out  that                                                               
attempts to  address problems at  API by increasing the  level of                                                               
compensation  have  not  made  a difference.    He  directed  the                                                               
committee's attention to the ASHNHA survey and remarked:                                                                        
     That  facility that  uses the  most mandatory  overtime                                                                    
     doesn't require  any on-call.   Any yet, I look  at the                                                                    
     other ones, that have zero  mandatory overtime and have                                                                    
     required  on-call, and  I guess,  I'm trying  to figure                                                                    
     out if  in a contract,  or in an agreement,  the nurses                                                                    
     are required  to have  on-call, and  we don't  have the                                                                    
     information of how many of  those on-calls are required                                                                    
     to take place  right after previous shift[s],   and how                                                                    
     that differentiates from mandatory  overtime.  ...  If,                                                                    
     in  fact, ...  in some  facilities is  having mandatory                                                                    
     on-call and using  that as a scheduling tool,  ...  I'm                                                                    
     wondering  whether we  really have  the same  situation                                                                    
     taking place in two different labels.                                                                                      
10:26:15 AM                                                                                                                   
REPRESENTATIVE   SEATON  further   noted  that   South  Peninsula                                                               
Hospital was not  a Critical Access Hospital as  indicated on the                                                               
ASHNHA survey and  asked for clarification of  the on-call policy                                                               
10:27:16 AM                                                                                                                   
MR.  BETIT responded  that South  Peninsula Hospital  was in  the                                                               
process of  being certified  as a Critical  Access Hospital.   He                                                               
further explained that his intent  was to determine the number of                                                               
times  each nurse  was on-call  per month.  He acknowledged  that                                                               
more detailed information could be requested.                                                                                   
10:29:42 AM                                                                                                                   
REPRESENTATIVE SEATON stated that  the majority of hospitals have                                                               
a concern  with the reporting  requirement proposed by  the bill.                                                               
He opined that the hospital's   existing personnel offices should                                                               
have  information on  overtime and  asked why  this report  was a                                                               
10:31:12 AM                                                                                                                   
MR.  BETIT  said  that  the estimated  cost  of  producing  these                                                               
reports was unknown to him.                                                                                                     
10:31:52 AM                                                                                                                   
REPRESENTATIVE ROSES asked whether  the use of mandatory overtime                                                               
is a standard practice at any of the facilities.                                                                                
10:32:29 AM                                                                                                                   
MR.  BETIT affirmed  its  use  at API  and  at Bartlett  Regional                                                               
10:32:42 AM                                                                                                                   
REPRESENTATIVE  ROSES further  asked about  the existence  of "an                                                               
adhesion contract."                                                                                                             
MR. BETIT said that he was not familiar with that term.                                                                         
10:33:03 AM                                                                                                                   
REPRESENTATIVE ROSES referred  to page 2, line  11, and expressed                                                               
concern for how  coercion could be clearly defined.   He provided                                                               
a  personal example  of possible  coercion  that illustrated  the                                                               
difficulty  of  the definition.    He  then  asked Mr.  Betit  to                                                               
estimate  the  cost  of malpractice  or  liability  insurance  to                                                               
10:35:19 AM                                                                                                                   
MR. BETIT estimated that insurance  is a significant growing cost                                                               
to hospitals.                                                                                                                   
10:35:31 AM                                                                                                                   
REPRESENTATIVE  ROSES recalled  that  insurance renewals  require                                                               
the filing  of incident reports.                                                                                                
10:36:05 AM                                                                                                                   
MR. BETIT  agreed that adverse  patient incidents  are cataloged.                                                               
In further  response, he  said that  details of  incident reports                                                               
are not released  by insurance companies in order  to comply with                                                               
the Health  Insurance Portability and Accountability  Act of 1996                                                               
10:36:17 AM                                                                                                                   
REPRESENTATIVE ROSES  assumed that liability  insurance companies                                                               
have data on  adverse incidents in order to determine  rates.  It                                                               
would be  in everyone's  best interest to  respond to  the safety                                                               
data on overtime hours and lower the cost of insurance.                                                                         
10:37:51 AM                                                                                                                   
MR. BETIT  relayed that  ASHNHA members have  stated that  the 14                                                               
hour limit  is reasonable,  12 hour shifts  are basic,  and other                                                               
shifts can be  considered.  Furthermore, there  is a professional                                                               
camaraderie in health  care facilities that enables  the staff to                                                               
work  as a  team.    He provided  scenarios  of voluntary  versus                                                               
mandatory overtime and concluded that  the bill leaves this point                                                               
open to conjecture.                                                                                                             
REPRESENTATIVE   ROSES  stated   the   difficulty  in   balancing                                                               
bargaining  unit  rights  with  intervention  by  legislation  to                                                               
protect patient's safety.                                                                                                       
10:40:56 AM                                                                                                                   
CHAIR  WILSON  announced her  intent  to  hear from  the  nurse's                                                               
association, a union  representative, and from the  API, prior to                                                               
a two-hour recess.                                                                                                              
10:41:49 AM                                                                                                                   
REPRESENTATIVE GARDNER  stated her questions, to  be addressed in                                                               
her  absence:   How  often   nurses  work   overtime  immediately                                                               
following a  12-hour shift;  how often nurses  work more  than 14                                                               
consecutive hours; how  often nurses are called  back following a                                                               
12-hour  shift;  and whether  nurses  work  more than  4  12-hour                                                               
shifts on consecutive days.                                                                                                     
10:42:46 AM                                                                                                                   
CHAIR  WILSON  corrected  her statement  about  the  transfer  of                                                               
patient information to an incoming nurse.                                                                                       
10:43:18 AM                                                                                                                   
TOM  RENKES, RN;  MS, Executive  Director, Labor  Program, Alaska                                                               
Nurses Association, informed  the committee of his  many years of                                                               
professional  experience as  a registered  nurse,  a health  care                                                               
educator, a health care Chief  Executive Office, a staff nurse, a                                                               
hospital  manager and  administrator, and  a consultant  to state                                                               
government and  health care  institutions.  He  said that  he has                                                               
personally spoken  with nurses  in Fairbanks,  Valdez, Anchorage,                                                               
Wrangell,  Ketchikan, Juneau,  Soldotna, and  Wasilla and  all of                                                               
those  he  interviewed  confirmed   that  on-call  and  mandatory                                                               
overtime was  a problem for them.   He addressed the  question of                                                               
the  percentage of  graduating  nurses that  stay  in Alaska  and                                                               
clarified that 93  percent stay for two years as  required to get                                                               
a  sign-on bonus,  after that  the percentage  drops.   He opined                                                               
that SB  28 was about patient  safety and the nurse's  ability to                                                               
not  work  excessive  hours.     The  Alaska  Nurses  Association                                                               
supports  trying to  retain nurses  in Alaska,  and in  the other                                                               
states  that  have passed  similar  legislation,  there has  been                                                               
nursing job growth.  He related  that nurses leave the work force                                                               
due to  retirement and  the work environment;  in fact,  of 9,000                                                               
licensed registered  nurses in  Alaska, less  than 4,000  work in                                                               
acute care settings.  Furthermore,  this issue can not be handled                                                               
by  union labor  contracts  because  all nurses  do  not work  in                                                               
unionized facilities.      Mr. Renkes  then pointed out  that the                                                               
regulatory  reporting  required by  SB  28  carries no  financial                                                               
burden.   In  response  to  an earlier  comment,  he stated  that                                                               
similar  legislation in  other states  does include  requirements                                                               
for regulatory reporting.                                                                                                       
10:47:52 AM                                                                                                                   
MR.  RENKES  continued to  explain  that  documentation has  been                                                               
provided  that  health  care institutions  and  governments  save                                                               
money  on better  community health  care with  a well  rested and                                                               
well staffed  workforce.  He  provided statistics  supporting the                                                               
reduction  of illnesses.   Mr.  Renkes  concluded that  SB 28  is                                                               
about  retaining nurses  in the  workforce, spending  less health                                                               
care  dollars on  preventable illnesses,  spending less  money on                                                               
traveling and temporary nurses,  and making the state competitive                                                               
for nursing jobs and career pathways.                                                                                           
REPRESENTATIVE  ROSES  asked  for  details of  the  reasons  that                                                               
nurses leave due to the working environment.                                                                                    
MR. RENKES answered that the  information comes from the Board of                                                               
Nursing and is not broken down into specific problems.                                                                          
REPRESENTATIVE  ROSES  stressed  the  importance  of  doing  exit                                                               
surveys that provide greater details.                                                                                           
10:50:47 AM                                                                                                                   
MR.  RENKES  pointed   out  that  there  have   been  300  nurses                                                               
questioned  throughout  the  state  and  100  percent  documented                                                               
mandatory overtime as a part of  their complaint.  He assured the                                                               
committee that mandatory overtime was the "number one issue."                                                                   
10:51:13 AM                                                                                                                   
REPRESENTATIVE  FAIRCLOUGH asked  how  many nurses  there are  in                                                               
MR.  RENKES answered  that  there are  9,000  licensed and  6,000                                                               
reside in Alaska.                                                                                                               
REPRESENTATIVE FAIRCLOUGH further asked  how many are represented                                                               
by union.                                                                                                                       
MR. RENKES said about 50 percent.                                                                                               
10:51:51 AM                                                                                                                   
REPRESENTATIVE FAIRCLOUGH  then asked how was  it consistent that                                                               
mandatory overtime was an issue, but mandatory on-call was not.                                                                 
MR. RENKES observed that both are issues.                                                                                       
10:52:07 AM                                                                                                                   
REPRESENTATIVE  GARDNER said,  "Every  nurse you  talked to  said                                                               
mandatory overtime was a problem?"                                                                                              
MR.  RENKES indicated  yes; in  fact, the  nurses would  not give                                                               
their last names.  He then described several situations.                                                                        
10:53:22 AM                                                                                                                   
BARBARA  HUFF, Director,  Governmental  and Legislative  Affairs,                                                               
Teamsters  Local  959,  informed  the committee  that  Local  959                                                               
represents all  of the health  care employees at  South Peninsula                                                               
Hospital, as  well as  those at  Kodiak Island.   She  stated her                                                               
support for  SB 28,  for the  benefit of  nurses and  health care                                                               
workers in general. She acknowledged  that mandatory overtime and                                                               
on-call  are major  contract negotiation  issues with  nurses and                                                               
nursing assistants  in acute  care and on  the floor  in general.                                                               
Through collective  bargaining, provisions have  been instituted,                                                               
even for  employees that work  12 hour shifts, to  allow flexible                                                               
work  hours within  an 80  hour work  period.   In addition,  the                                                               
collective  bargaining agreement  allows those  who prefer  to be                                                               
assigned alternative  shifts.  She  opined that any   health care                                                               
facility,  large or  small,  needs to  have  this flexibility  in                                                               
scheduling.    The  camaraderie   of  the  staff,  as  previously                                                               
discussed,  does  minimize  overtime situations.    However,  she                                                               
pointed out that  being on-call is restrictive  for the employee,                                                               
and needs to be considered as  such.  It requires the employee to                                                               
be within a twenty five minute  response time of the facility and                                                               
severely  limits   family  activities.     Contract  negotiations                                                               
appropriately  deal with  these issues  by gathering  information                                                               
and data  to properly  address the situation.   Ms.  Huff assured                                                               
the committee  that reports of  overtime and on-call  hours, that                                                               
the committee is requesting, are  available through the union, as                                                               
this information is  necessary for the bargaining unit.   For the                                                               
facilities  that  are not  organized,  this  information may  not                                                               
exist,  she  pointed  out.    Contract  language  is  crafted  by                                                               
addressing  the  issues directly,  she  said,  and explained  the                                                               
process of "interest based" bargaining.   She continued, relating                                                               
an  anecdotal  situation  that occurred  recently  at  the  Homer                                                               
facility,  during  her visit.    A  clear  contract, at  a  union                                                               
represented  facility, is  a  distinct  advantage over  employees                                                               
without representation.   Ms. Huff concluded that SB  28 would be                                                               
of  assistance   to  those  employees   who  are   not  similarly                                                               
10:59:34 AM                                                                                                                   
REPRESENTATIVE FAIRCLOUGH asked:                                                                                                
     Inside of the contracts that you negotiate, if you're                                                                      
      negotiating flexible schedules where the nurses are                                                                       
       wanting to do 3 12's ... they do that on a case-by-                                                                      
     case basis,  with the supervisor inside  of a facility.                                                                    
     I want to  know, on a flexible schedule, is  it after 8                                                                    
     hours  overtime,  or  is that  the  trade-off  for  the                                                                    
     flexible schedule.                                                                                                         
11:00:10 AM                                                                                                                   
MS. HUFF  responded that if they  are working a five  [day] eight                                                               
[hour]  schedule,  then  anything   over  eight  hours  would  be                                                               
11:00:29 AM                                                                                                                   
CHAIR WILSON  announced that  the meeting  was recessed  at 11:00                                                               
a.m. to a call of the chair.                                                                                                    
CHAIR  WILSON called  the meeting  back  to order  at 12:40  p.m.                                                               
Present  at   the  call  back   to  order   were  Representatives                                                               
Fairclough, Keller, Gardner, Roses,  and Wilson.  Representatives                                                               
Seaton and Cissna arrived as the meeting was in progress.                                                                       
12:41:47 PM                                                                                                                   
RYAN SMITH,  Chief Executive  Officer, Central  Peninsula General                                                               
Hospital, agreed with  the legislature that  it  is essential for                                                               
nurses  and  licensed  practical   nurses  to  be  available  for                                                               
patients; however, quality patient  care is jeopardized by nurses                                                               
who  work unnecessarily  long hours.   In  addition, nurses  need                                                               
improved work  environments to  stay on the  job.   He questioned                                                               
the fact  that the  bill was written  for registered  nurses only                                                               
and does  not cover physicians  and other health  care providers,                                                               
for  example,   Certified  Registered  Nurse   Anesthesia  (CRNA)                                                               
nurses.   He cautioned that there  are holes in the  bill and did                                                               
not  see that  it would  be possible  to allow  10 hours  of rest                                                               
between shifts for nurses working in specialty areas.                                                                           
12:45:16 PM                                                                                                                   
REPRESENTATIVE GARDNER asked, "... at  what point do you think an                                                               
individual should not be required to work additional hours?"                                                                    
12:45:28 PM                                                                                                                   
MR. SMITH gave an example of  two surgeons who provided care to a                                                               
community for  forty-eight hours straight.   He said that  he did                                                               
not have an answer to her question.                                                                                             
12:46:10 PM                                                                                                                   
REPRESENTATIVE GARDNER asked  whether Mr. Smith was  aware of the                                                               
studies that indicate  a decrease in competence  after many hours                                                               
of working time.                                                                                                                
MR. SMITH  said yes.   He  cited studies that  have been  done at                                                               
Central Peninsula General Hospital.                                                                                             
12:46:55 PM                                                                                                                   
REPRESENTATIVE   GARDNER  recalled   testimony  that   there  are                                                               
licensed nurses who are not  working in the profession because of                                                               
working  conditions.    She  asked   Mr.  Smith  whether  working                                                               
conditions contribute to the shortage of competent nurses.                                                                      
MR. SMITH  advised that  hiring competent nurses  has not  been a                                                               
problem at Central Peninsula General Hospital.                                                                                  
12:47:47 PM                                                                                                                   
REPRESENTATIVE GARDNER further asked, "...  if you can get plenty                                                               
of competent  nurses why would  you find yourself in  a situation                                                               
where nurses might need to work more than 14 hours ...."                                                                        
12:48:04 PM                                                                                                                   
MR. SMITH gave the example of  operating room nurses who may wish                                                               
to remain on-call  after their shift. In this case,  there is the                                                               
potential for the nurse to work  more than 14 hours; in fact, the                                                               
nurse may  prefer to work under  that scenario rather than  to be                                                               
on-call  the next  day.   He explained  that these  variables are                                                               
allowed  by the  negotiated collective  bargaining agreement  and                                                               
save the hospital the cost of hiring more nurses.                                                                               
12:49:06 PM                                                                                                                   
REPRESENTATIVE  GARDNER  observed  that,  although  the  hospital                                                               
administration may  believe it  would not  make sense  to relieve                                                               
the nurse, a patient may have  the perspective that the nurse has                                                               
worked 14 hours and is ready to go home.                                                                                        
12:49:35 PM                                                                                                                   
MR. SMITH stated  that he did not know what  a nurse would prefer                                                               
to do in that situation.                                                                                                        
12:49:54 PM                                                                                                                   
PATRICIA   REYNAGA,   Registered  Nurse,   Providence   Hospital,                                                               
informed the  committee that she  was speaking as  an individual.                                                               
She  said  that  during    her  29-year  career  in  nursing  and                                                               
management  she has  not been  asked,  or asked  anyone, to  work                                                               
overtime.   During  her  experience as  a  nursing supervisor  at                                                               
Elmendorf Air  Force Base and  at Providence Hospital  she stated                                                               
that  she would  not have  wanted  anyone working  who was  sleep                                                               
deprived  or  unable  to  work  for  any  reason.    Ms.  Reynaga                                                               
expressed  her opposition  to the  bill and  opined that  nursing                                                               
shortages  and retention  are not  a problem  in her  area.   She                                                               
acknowledged  that problems  persist  at the  API  and that  more                                                               
valid  data is  needed to  make  decisions; in  fact, the  Alaska                                                               
Board of Nursing is conducting a survey.                                                                                        
12:52:51 PM                                                                                                                   
REPRESENTATIVE ROSES asked Ms. Reynaga  to explain her opposition                                                               
to the bill.                                                                                                                    
MS. REYNAGA  explained that scheduling becomes  more difficult if                                                               
nurses can  not make  changes to their  schedule that  they want.                                                               
The  present system  allows for  more flexibility.   Furthermore,                                                               
she pointed  out that there  are not many  complaints considering                                                               
the number of nurses working in the state.                                                                                      
12:55:29 PM                                                                                                                   
PATTY ARTHUR,  Licensed Practical  Nurse, informed  the committee                                                               
that she  was speaking on behalf  of the Baylor program  at North                                                               
Star Hospital.   Her  16-hour, weekend  work schedule  allows her                                                               
and her  fellow employees to  continue  their educations  or care                                                               
for children  during the  week.   She expressed  her appreciation                                                               
for the  added language  on page  3, line 16  through 17,  of the                                                               
12:57:42 PM                                                                                                                   
PAM  READ, Psychiatric  Nurse, North  Star Hospital,  stated that                                                               
she is a single mom who  also attends school and works long hours                                                               
by  choice, not  because she  is forced  to.   She expressed  her                                                               
support for "the amendment."                                                                                                    
12:58:58 PM                                                                                                                   
REPRESENTATIVE ROSES asked whether  other nurses are pressured to                                                               
work long hours, not by choice.                                                                                                 
MS. READ said no.  During her  shift if someone needs to go home,                                                               
they are replaced.                                                                                                              
1:00:01 PM                                                                                                                    
REPRESENTATIVE GARDNER  asked whether  Ms. Read feels  as capable                                                               
in her fifteenth hour of work as in the seventh hour of work.                                                                   
MS.  READ   opined  that  she   can  provide  the   care  needed.                                                               
Furthermore, she  is able to  report to doctors on  her patient's                                                               
behavior through the entire course of the day.                                                                                  
1:01:10 PM                                                                                                                    
REPRESENTATIVE  GARDNER  asked  whether  Ms. Read  has  read  the                                                               
studies that  report that acuity and  effectiveness diminish with                                                               
MS. READ stated that she  was familiar with the studies; however,                                                               
working long  hours is a personal  decision and is not  a problem                                                               
for some people.                                                                                                                
1:01:58 PM                                                                                                                    
REPRESENTATIVE GARDNER asked for Ms.  Read's opinion on state and                                                               
federal regulations that limit the  hours airline pilots or truck                                                               
drivers can work without resting.                                                                                               
MS. READ opined that "blanket  laws" should allow for exceptions.                                                               
She could not speak for pilots or truck drivers.                                                                                
1:02:41 PM                                                                                                                    
REPRESENTATIVE  FAIRCLOUGH asked  whether Ms.  Read could  relate                                                               
how many  "incidents" on  her record occurred  after 12  hours of                                                               
MS. READ said no.                                                                                                               
1:03:21 PM                                                                                                                    
PAT  HIGGINS, Director,  Human  Resources,  North Star  Hospital,                                                               
spoke in  opposition to SB 28,  and pointed out the  disparity of                                                               
its effect  on facilities of  various sizes and specialties.   He                                                               
described  North Star  Hospital's use  of the  Baylor program  of                                                               
weekend scheduling  that does not  rely on mandatory  overtime or                                                               
on-call time.  He noted that  the inflexibility of the bill would                                                               
prevent smaller  hospitals from placing specially  trained nurses                                                               
on call to cover their departments.                                                                                             
1:05:22 PM                                                                                                                    
ELIZABETH  CHENEY, Representative,  Alaska Native  Health Board;,                                                               
Alaska Native  Tribal Health  Consortium, informed  the committee                                                               
that  the  Alaska  Native  Health Board  (ANHB)  is  a  statewide                                                               
advocate for Native health  that encourages self-determination in                                                               
health care  services and wellness in  Native communities through                                                               
policy  change.   She  was also  representing  the Alaska  Native                                                               
Tribal Health Consortium (ANTHC),  that is a tribally controlled,                                                               
non-profit, statewide  tribal organization  providing a  range of                                                               
medical  and community  health services  for  Alaska Natives  and                                                               
that is  a part of  the Alaska Tribal  Health System.   She noted                                                               
that these  two organizations have  three primary  concerns about                                                               
the legislation.   The  first was  that the  bill is  in conflict                                                               
with  Alaska's   policy  of   allowing  health   care  facilities                                                               
flexibility   in  scheduling   direct   health  care   providers.                                                               
Secondly,  the bill  creates the  impression that  it applies  to                                                               
federal  and tribal  facilities.   Lastly, as  currently drafted,                                                               
the bill  would have a  disproportionately detrimental  impact on                                                               
citizens  in rural  Alaska.   Ms. Cheney  pointed out  that nurse                                                               
vacancy  rates,   staff  turnover,  and  recruitment   costs  for                                                               
Northwest  and Southwest  Alaska are  much higher  than they  are                                                               
statewide and  the shortage  of nurses  with special  training is                                                               
critical.  Limiting  the availability of these  nurses would mean                                                               
some patients would not be cared  for by the most experienced and                                                               
highly trained nurse.  She concluded  by asking how to explain to                                                               
a patient that the most  qualified nurse is not available because                                                               
she has already worked one shift.                                                                                               
1:08:57 PM                                                                                                                    
REPRESENTATIVE GARDNER pointed out the  exemption on page 3, line                                                               
1,  of  the  bill  that   allows  for  "an  unforeseen  emergency                                                               
situation"  and  opined  that  the exemption  would  apply  to  a                                                               
situation  that could  jeopardize  patient safety.   Further,  in                                                               
response  to  a  question  from Ms.  Cheney  about  an  emergency                                                               
exacerbated  by   transportation  delays  due  to   weather,  she                                                               
informed  Ms.  Cheney  of  a  forthcoming  amendment  that  would                                                               
include weather as a condition to exempt mandatory overtime.                                                                    
MS. CHENEY  asked for a  response to the proposed  amendment that                                                               
she submitted with her written testimony.                                                                                       
1:10:21 PM                                                                                                                    
REPRESENTATIVE GARDNER  replied that  she had read  the amendment                                                               
but disagreed  with the  exemption of  federal facilities  due to                                                               
safety concerns.                                                                                                                
1:11:09 PM                                                                                                                    
TINA  GONZALES,  Registered  Nurse,  stated  that  she  has  been                                                               
required to  work mandatory overtime.  Her job began  in October,                                                               
and she was  told that she would have to  work on-call once-in-a-                                                               
while.   In  fact, the  on-call  requirement is  one night  every                                                               
week, and can equal one whole extra week of work.                                                                               
1:12:19 PM                                                                                                                    
CHAIR  WILSON  asked whether  Ms.  Gonzales  worked work  12-hour                                                               
MS.  GONZALES said  yes, and  added that  her graveyard  shift is                                                               
three on,  two off,  three on.  Under some  circumstances, nurses                                                               
work eight  nights in  a row  and safety  becomes involved.   She                                                               
concluded that mandatory overtime is a reality.                                                                                 
1:13:12 PM                                                                                                                    
REPRESENTATIVE  FAIRCLOUGH asked  for clarification  between what                                                               
was required  from the  hospitals; mandatory  overtime, mandatory                                                               
on-call, or both.                                                                                                               
1:13:46 PM                                                                                                                    
MS. GONZALES said she was told  that she would have mandatory on-                                                               
call;  however,   when  called  in  that   equates  to  mandatory                                                               
overtime.   Further, nurses are  required to sign up  for on-call                                                               
time, and additional time is assigned, when necessary.                                                                          
1:14:40 PM                                                                                                                    
REPRESENTATIVE GARDNER pointed  out that the use  of overtime and                                                               
the on-call  policy at Providence  Valdez Medical Center  was not                                                               
reported on the chart provided by ASHNHA.                                                                                       
1:15:14 PM                                                                                                                    
SHARA  SUTHERLIN,  Chief   Nurse  Executive,  Providence  Medical                                                               
Center,  stated that  she  has been  a nurse  for  31 years  with                                                               
experience in  medical-surgical, cardiovascular, float  pool, and                                                               
leadership positions in  nursing.  She expressed  her support for                                                               
the previous  testimony by Rob  Betit of ASHNHA and  informed the                                                               
committee  that  patient  safety  and  concern  for  the  healthy                                                               
working  environment  of  nurses  are a  priority  at  Providence                                                               
Medical Center.    In fact, the  hospital conducts collaborative,                                                               
unit-based  councils   and  key  committees  with   clinical  and                                                               
management  nursing teams  to  develop  nurse staffing  schedules                                                               
that  meet  nurse and  patient  needs.   Furthermore,  Providence                                                               
Medical  Center maintains  appropriate nurse  and patient  ratios                                                               
and  hires  new  nursing  graduates   and  students  through  its                                                               
fellowship  program.    Collective   bargaining  with  staff  has                                                               
resulted  in   the  following  improvements:     an  increase  in                                                               
specially  certified nurses;  the  deployment  of rapid  response                                                               
teams  to  support  nurses; implementation  of  a  transport  and                                                               
lifting center; and improvements  in the function and convenience                                                               
of  rooms.  Ms. Sutherlin  concluded  by  saying that  Providence                                                               
Medical  Center has  increased the  conversion rate  of traveling                                                               
nurses to permanent hire.                                                                                                       
1:18:17 PM                                                                                                                    
REPRESENTATIVE  ROSES  asked  whether Ms.  Sutherlin  tracks  the                                                               
incidents of possible compromise of patient care.                                                                               
MS.  SUTHERLIN said  yes.   She  added that  the risk  management                                                               
department  looks at  incidents  such as  "never events,"  falls,                                                               
infections, and  injuries, and balances  those events  with "work                                                               
hours  per  patient  day."   The  results  are  communicated  and                                                               
interventions are made when necessary.                                                                                          
REPRESENTATIVE  ROSES asked  whether the  incidents are  reported                                                               
internally or externally.                                                                                                       
MS. SUTHERLIN explained  that incidents are reported  back to the                                                               
clinical and  managerial staff and  improvements are  reported on                                                               
an  annual   basis.    In   addition,  there  is   a  performance                                                               
improvement team  and administrative review of  cumulative issues                                                               
and trends.                                                                                                                     
1:20:18 PM                                                                                                                    
REPRESENTATIVE   ROSES  further   asked  whether   there  is   an                                                               
opportunity  in the  incident report  to indicate  the amount  of                                                               
time that the person involved has been working.                                                                                 
1:20:40 PM                                                                                                                    
MS.  SUTHERLIN  stated  that  every   incident  report  has  many                                                               
variables and  factors that are  considered.  A  team scrutinizes                                                               
root cause analyses to understand the work environment involved.                                                                
REPRESENTATIVE ROSES then  asked whether there has  there been an                                                               
increase  or decrease  in incidents  that  were a  result of  the                                                               
amount of time an employee has been working.                                                                                    
MS. SUTHERLIN stated that when there  is an increase in volume in                                                               
a unit,  such as  the neonatal  unit, additional  bedside support                                                               
and specialists are brought in.                                                                                                 
1:22:03 PM                                                                                                                    
REPRESENTATIVE  ROSES   restated  her  answer  for   clarity  and                                                               
repeated his question.                                                                                                          
1:22:33 PM                                                                                                                    
MS.  SUTHERLIN  opined  that there  have  been  seasonal  issues,                                                               
particularly   in   the   children's  hospital   and   additional                                                               
physicians  have been  added and,  when necessary,  patients have                                                               
been diverted  to other  facilities.   In response  to additional                                                               
questioning by  Chair Wilson,  she concluded  that the  number of                                                               
incidents is staying the same.                                                                                                  
1:24:02 PM                                                                                                                    
REPRESENTATIVE  GARDNER asked  Ms. Sutherlin  whether her  nurses                                                               
work overtime immediately following a 12-hour shift.                                                                            
1:24:22 PM                                                                                                                    
MS. SUTHERLIN, said nurses work  beyond a 12-hour shift less than                                                               
10 percent of the time.                                                                                                         
1:25:07 PM                                                                                                                    
REPRESENTATIVE GARDNER  then asked  how often nurses  work longer                                                               
than 14 consecutive hours.                                                                                                      
MS.  SUTHERLIN stated  that  she  was unsure  of  how often  that                                                               
1:25:19 PM                                                                                                                    
REPRESENTATIVE  GARDNER asked  whether  nurses  were called  back                                                               
following a 12-hour shift.                                                                                                      
MS. SUTHERLIN explained that the  focus of the on-call program is                                                               
on those who have had time off.                                                                                                 
REPRESENTATIVE GARDNER re-stated her question.                                                                                  
MS. SUTHERLIN said, "That is very minimal."                                                                                     
REPRESENTATIVE GARDNER  asked whether  there are nurses  who work                                                               
more than four 12-hour shifts over consecutive days.                                                                            
MS. SUTHERLIN explained that most  people prefer to work three or                                                               
less  twelve-hour shifts;  in  fact, working  over  four or  five                                                               
twelve-hour shifts is  not favored and those who  do are followed                                                               
closely for negative impacts.                                                                                                   
1:26:40 PM                                                                                                                    
REPRESENTATIVE GARDNER remarked:                                                                                                
       When you have an incident and you do your balance                                                                        
     score card, what percentage of the time would you say                                                                      
     that the nurse has worked more than 12 hours?                                                                              
MS.  SUTHERLIN  responded  that  the working  hours  may  not  be                                                               
cumulatively  added.    The  unit's hours  per  patient  day  are                                                               
considered along with the type of care model.                                                                                   
1:27:14 PM                                                                                                                    
SCOTT JUNGWIRTH, Chief Human  Resources Officer Providence Health                                                               
&  Services, Alaska,  stated that  he is  representing Providence                                                               
Health &  Services, Alaska and  is in opposition  to SB 28.   His                                                               
experience  is that  Providence has  never mandated  a registered                                                               
nurse  to  work  overtime.   The  primary  solution  to  staffing                                                               
shortages is the  use of traveling nurses and  agency nurses, and                                                               
some  voluntary   overtime.  Mr.   Jungwirth  pointed   out  that                                                               
Providence  commits thousands  of  dollars  to address  shortages                                                               
every year,  while nurse and  patient safety is at  the forefront                                                               
of every  staffing decision.   He assured the committee  that the                                                               
request of  any nurse to  rest would  be granted by   management.                                                               
Furthermore,    Providence   strives    to   maintain    employee                                                               
satisfaction;     in   fact,  long-term   employees  cite   their                                                               
satisfaction with  managers, flexibility  of schedules,  and work                                                               
options.    He  cautioned that  mandating legislation  around the                                                               
use of  overtime would  limit Providence's  ability to  work with                                                               
nurses and generate ways to  address patient needs, and requested                                                               
that SB 28 not be moved forward.                                                                                                
1:29:37 PM                                                                                                                    
CHAIR  WILSON  stated  that  she  has  received  complaints  from                                                               
Providence nurses regarding patient care and work obligations.                                                                  
1:30:18 PM                                                                                                                    
REPRESENTATIVE  FAIRCLOUGH  asked  whether  Mr.  Jungwirth  would                                                               
consider someone  who is called  in during on-call to  be working                                                               
voluntary overtime.                                                                                                             
MR. JUNGWIRTH  acknowledged that there is  mandatory on-call and,                                                               
when an  individual is  called in,  overtime would  be associated                                                               
with that.                                                                                                                      
REPRESENTATIVE  FAIRCLOUGH further  asked whether  that situation                                                               
would be counted as mandatory or voluntary.                                                                                     
MR. JUNGWIRTH said that would be a mandatory situation.                                                                         
1:30:51 PM                                                                                                                    
REPRESENTATIVE  FAIRCLOUGH  referred  to the  survey  information                                                               
received from ASHNHA  and asked whether Mr.  Jungwirth would like                                                               
to re-state his answer.                                                                                                         
MR. JUNGWIRTH  opined that mandatory  on-call was  different than                                                               
mandatory overtime.                                                                                                             
REPRESENTATIVE FAIRCLOUGH disagreed.  She asked:                                                                                
     If you  have somebody on  a mandatory on-call  and they                                                                    
     come in, I  want to know, on this  report that's before                                                                    
     us,  when  you  answer   the  question  from  your  own                                                                    
     hospital's  association,  are   you  counting  that  as                                                                    
1:31:26 PM                                                                                                                    
MR. JUNGWIRTH  stated that  he did  not fill  out the  report and                                                               
would have to look at the response to that question.                                                                            
REPRESENTATIVE   FAIRCLOUGH    pointed   out    the   conflicting                                                               
information from different hospitals  revolving  around mandatory                                                               
overtime  and mandatory  on-call. Hospitals  report that  they do                                                               
use  mandatory  on-call  and not  mandatory  overtime,  but  then                                                               
incorrectly  state  that  mandatory  on-call  does  not  generate                                                               
mandatory overtime.                                                                                                             
MR.  JUNGWIRTH  opined  that  there   is  a  distinction  between                                                               
mandatory on-call  and mandatory  overtime and  mandatory on-call                                                               
was used as a last resort.                                                                                                      
1:33:00 PM                                                                                                                    
REPRESENTATIVE   FAIRCLOUGH  asked   whether  assigning   on-call                                                               
scheduling  by  an administrator  on  a  non-voluntary basis  was                                                               
MR.  JUNGWIRTH stated  that the  question was  unclear.   He then                                                               
stressed that mandatory  on-call was still a last  resort but was                                                               
necessary  to care  for  patients  when time  was  not filled  by                                                               
agency or traveling nurses.                                                                                                     
1:34:06 PM                                                                                                                    
REPRESENTATIVE  FAIRCLOUGH cited  her  personal understanding  of                                                               
the high frequency that on-call  was assigned at his facility and                                                               
invited  him  to  contact  her   directly  if  he  has  different                                                               
1:34:49 PM                                                                                                                    
MARY  STACKHOUSE,  Neonatal   Intensive  Care  Nurse,  Providence                                                               
Hospital,  stated that  she has  been a  registered nurse  for 35                                                               
years, with  21 years  working in  Alaska.   She stated  that the                                                               
intent of nurses  is to disallow employers  from mandating nurses                                                               
to work longer than the  regularly scheduled time.  She cautioned                                                               
that  the mandate  must not  be used  as a  staffing tool  and to                                                               
prevent  the  need  for  mandating   overtime  is  preferable  to                                                               
searching for a remedy later.                                                                                                   
1:37:35 PM                                                                                                                    
NORMAN STEVENS, Chief Executive  Officer, Mat-Su Regional Medical                                                               
Center,  stated that  the legal  and  union representatives  have                                                               
presented  a  predictable  mantra   that  working  conditions  in                                                               
hospitals are very  poor.  He voiced his highest  concern for the                                                               
welfare  of  the staff  and  nurses  at Mat-Su  Regional  Medical                                                               
Center.    Mr.  Stevens  pointed   out  that  the  House  Health,                                                               
Education and Social Services Standing  Committee was going to be                                                               
challenged not only  with nurse overtime issues,  but with health                                                               
care reform.  He opined  that mandatory on-call was necessary for                                                               
units such  as surgery, because they  are a low volume  unit that                                                               
is not staffed 24-hours a day,  but must be open for emergencies.                                                               
He responded to a question  by Representative Roses and explained                                                               
that the price of malpractice  insurance is minimal when compared                                                               
to staff costs.  Mr.  Stevens concluded that hospital staffing is                                                               
a complicated and difficult problem to regulate.                                                                                
1:41:18 PM                                                                                                                    
REPRESENTATIVE  GARDNER  asked Mr.  Stevens  to  respond to  Mary                                                               
Stackhouse's  testimony  that  nurses  who asked  for  rest  were                                                               
required to work anyway.                                                                                                        
MR. STEVENS  acknowledged that that  situation is a  tragedy, and                                                               
represents a staffing  breakdown due to emergencies  that can not                                                               
be planned  for.   Further, he  said shame  on any  hospital that                                                               
tries to make  extra profit off the backs of  their nursing staff                                                               
by  not providing  an adequate  staffing level.   He  opined that                                                               
working a  12-hour day is  arduous and  working a 14-hour  day is                                                               
unbearable.   Because there is  no nursing shortage in  his area,                                                               
this has not been an issue at the hospital he oversees.                                                                         
1:44:14 PM                                                                                                                    
REPRESENTATIVE  GARDNER   asked  whether  nurses   work  overtime                                                               
immediately following a 12 hour shift.                                                                                          
MR. STEVENS said frequently.                                                                                                    
REPRESENTATIVE GARDNER  further asked  whether nurses  are called                                                               
back after a 12-hour shift.                                                                                                     
MR. STEVENS  said that is almost  unheard of due to  the presence                                                               
of working managers.                                                                                                            
1:45:01 PM                                                                                                                    
REPRESENTATIVE GARDNER  then asked  how often nurses  work longer                                                               
than 14 consecutive hours.                                                                                                      
MR. STEVENS said almost never.                                                                                                  
1:45:34 PM                                                                                                                    
PAUL  MORDINI,  Registered   Nurse,  Nursing  Supervisor,  Alaska                                                               
Psychiatric Institute,  stated his  support for  SB 28  and cited                                                               
his   experience  in   the  military   where,  during   emergency                                                               
operations,  he worked  12  hours  on, 12  hours  off, to  ensure                                                               
adequate  rest and  safe practices.   When  he took  his civilian                                                               
position  he  was required  to  work  mandatory overtime  and  he                                                               
sometime  works  double shifts  on  a  voluntary basis  to  avoid                                                               
mandatory  overtime that  interferes with  his family  time.   He                                                               
questioned the  safety of  having an aging  nurse work  a 15-hour                                                               
day and  then dispense complicated medication,  assist with life-                                                               
saving surgery, or complete assessments.                                                                                        
1:48:48 PM                                                                                                                    
REPRESENTATIVE FAIRCLOUGH  requested an  opportunity to  speak to                                                               
the forthcoming amendments.                                                                                                     
The committee took an at-ease from 1:49:20 PM to 1:50:38 PM.                                                                
1:50:44 PM                                                                                                                    
CHAIR WILSON  announced her  intent to move  the bill  today, and                                                               
encouraged the witnesses to speak briefly.                                                                                      
1:51:35 PM                                                                                                                    
JUDY  EVANS,  Registered  and Certified  Nurse,  Alaska  Regional                                                               
Hospital, stated that  she has been a nurse for  34 years in many                                                               
fields.  She said that she is  a recovery room nurse and has been                                                               
on  call since  last  Saturday;  in fact,  she  relayed her  work                                                               
schedule for  the last week.   Ms. Evans told the  committee of a                                                               
recent  experience with  a  co-worker who  fell  asleep during  a                                                               
1:53:30 PM                                                                                                                    
DEB  DRAKE,  Recovery  Room   Nurse,  Alaska  Regional  Hospital,                                                               
agreed that  mandatory on-call equates to  mandatory overtime and                                                               
results in  personal difficulties for the  nurses and compromised                                                               
care for the patients.                                                                                                          
1:54:17 PM                                                                                                                    
STACY  ALLEN, Registered  Nurse; Business  Agent, Laborers  Local                                                               
341,  Alaska Regional  Hospital, stated  that Laborers  Local 341                                                               
represents 225  nurses at Alaska  Regional Hospital.  She pointed                                                               
out that  numerous industries regulate  hours worked as  a matter                                                               
of public safety;   this regulation was not  self-imposed but was                                                               
legislated by  the government.    On behalf of the  2,500 members                                                               
of Laborers Local  341, she expressed her strong  support for the                                                               
1:55:35 PM                                                                                                                    
ELIZABETH  WOODWARD, Chief  Nursing  Officer, Fairbanks  Memorial                                                               
Hospital,  informed  the committee  that  she  is an  experienced                                                               
nurse.  She stated that, although  nurses should not have to work                                                               
when unsafe, she  opposed the bill due to her  belief that nurses                                                               
and management  can work  together.   There is  successful shared                                                               
decision making at  her hospital and schedules should  be made at                                                               
the local level.                                                                                                                
1:56:48 PM                                                                                                                    
REPRESENTATIVE  GARDNER asked  whether legislation  to solve  the                                                               
problem is  appropriate if management  at the local level  is not                                                               
working  well, and  nurses  are being  forced  to take  mandatory                                                               
MS. WOODWARD opined that that situation would be tragic.                                                                        
1:57:08 PM                                                                                                                    
MICHAEL  ZIELASKIEWICZ, Chief  Nursing  Officer, Mat-Su  Regional                                                               
Medical Center,  stated his personal objection  to nurses working                                                               
in  a mandatory  overtime  situation; however,  he  said that  he                                                               
opposed  the  bill  because it  is  unnecessary  and  unwarranted                                                               
legislation.    Further,  he  opined  that  this  is  a  hospital                                                               
specific issue  and should be  addressed on an  individual basis.                                                               
His  experience  is in  keeping  overtime  to  a minimum  and  he                                                               
challenged the  methodology of the Alaska  Nurses Association and                                                               
its conclusions.   He  warned that  the legislation  would create                                                               
more dangerous situations for patients  when they are turned away                                                               
due to  the lack  of staff  at the  hospital.   Mr. Zielaskiewicz                                                               
concluded  that the  real  problem is  the  nursing shortage  and                                                               
advocated support for nursing schools.                                                                                          
1:59:39 PM                                                                                                                    
REBECCA  BOLLING, Registered  Nurse, Ketchikan  General Hospital,                                                               
confirmed  that mandatory  on-call generally  leads to  mandatory                                                               
overtime and is used on a  regular basis in the operating room at                                                               
Ketchikan General Hospital.  The  bargaining unit has been unable                                                               
to  address the  situation and  stronger action  is needed.   She                                                               
stressed  the  importance of  a  mandatory  rest period  for  the                                                               
health of the nurses and the safety of the patients.                                                                            
2:01:03 PM                                                                                                                    
JACK DAVIS,  Director, Human Resources,  Bristol Bay  Area Health                                                               
Corporation, spoke  in opposition to SB  28.  He agreed  with the                                                               
purpose to  protect nurses;  however, as  written, the  bill does                                                               
not support  the availability of nursing  staff.  In fact,  for a                                                               
small, rural, critical  access hospital, staffing has  to be used                                                               
to meet patient care needs and  can not be done without traveling                                                               
and  agency nurses.    He  urged the  committee  to consider  the                                                               
effect of the legislation on  small facilities in rural settings.                                                               
Mr. Davis observed that his  hospital uses mandatory shifts about                                                               
once per month, per nurse.                                                                                                      
2:03:20 PM                                                                                                                    
PAT SENNER,  Anchorage, Alaska, addressed the  proposed amendment                                                               
that exempts federal and Native  health facilities from the bill.                                                               
She described the present staffing  difficulties at a health care                                                               
facility  in the  state.   Ms.  Senner  opined that  SB  28 is  a                                                               
"prevention  bill"   that  will  prevent  other   hospitals  from                                                               
situations similar to that of API.                                                                                              
2:05:03 PM                                                                                                                    
NANCY DAVIS,  Registered Nurse, relayed her  varied experience in                                                               
nursing  for 39  years.   She stated  her support  for SB  28 and                                                               
cited recent evidence  that indicate that fatigue  and long hours                                                               
can equal response times and  judgment similar to that of driving                                                               
under the  influence.  She  opined that nurses continue  to work,                                                               
powered by  adrenaline and obligation.   Ms. Davis  expressed her                                                               
support for the protective aspect of SB 28.                                                                                     
2:06:46 PM                                                                                                                    
LAUREE MORTON,  as an  observer not employed  in the  health care                                                               
industry, stated  her support  for SB 28.   She  acknowledged the                                                               
different perspectives  of administrators, nurses,  and patients.                                                               
Ms. Morton  recalled her  personal experience  observing hospital                                                               
care for long periods of time  and reported that care was abraded                                                               
at the  end of  long shifts;  in fact, mistakes  were made.   She                                                               
reminded  the committee  of its  responsibility  to keep  patient                                                               
safety  in mind.    She  opined that  the  reporting and  penalty                                                               
requirements of the  bill should be retained.   Furthermore, this                                                               
is a public  policy issue and the legislature  should be involved                                                               
in mismanagement and worker's concerns.                                                                                         
2:10:14 PM                                                                                                                    
CHAIR WILSON closed public testimony.                                                                                           
2:10:27 PM                                                                                                                    
REPRESENTATIVE  GARDNER   offered  Conceptual  Amendment   1,  as                                                               
     Page 3, line 4, following "disaster,";                                                                                     
          Insert "weather,"                                                                                                     
REPRESENTATIVE  GARDNER  explained  that  this  amendment  is  in                                                               
response to  Ms. Cheney's  concern that  delays due  to inclement                                                               
weather need to be exempted from the limitations of overtime.                                                                   
There being no objection, Conceptual Amendment 1 was adopted.                                                                   
2:11:18 PM                                                                                                                    
REPRESENTATIVE ROSES offered Amendment 2, as follows:                                                                           
     Page 2, lines 11 and 12;                                                                                                   
          Delete "or coerced, directly or indirectly,"                                                                          
CHAIR WILSON objected.                                                                                                          
REPRESENTATIVE  GARDNER  said  that  the  amendment  removes  the                                                               
controversy over the definition of  "what is mandatory and who is                                                               
using it and who is not."                                                                                                       
2:12:23 PM                                                                                                                    
GREY  MITCHELL,  Director,  Central  Office,  Division  of  Labor                                                               
Standards & Safety, Department of  Labor & Workforce Development,                                                               
advised  that the  amendment would  make things  simpler from  an                                                               
enforcement  perspective.    He   explained  that  the  issue  of                                                               
coercion opens "a  can of worms" that would need  to be addressed                                                               
by regulations.                                                                                                                 
2:13:29 PM                                                                                                                    
CHAIR WILSON removed her objection.                                                                                             
There being no further objection, Amendment 2 was adopted.                                                                      
2:13:41 PM]                                                                                                                   
REPRESENTATIVE GARDNER offered Amendment  3, as follows [original                                                               
punctuation provided]:                                                                                                          
     Page 3, lines 8 and 9;                                                                                                     
        Delete (4) "a nurse fulfilling on-call time that                                                                        
     is agreed upon by the nurse and a health care facility                                                                     
     before it is scheduled."                                                                                                   
REPRESENTATIVE GARDNER stated that  agreement with the underlying                                                               
bill that  working beyond 14 hours  per day, or beyond  a certain                                                               
number of  shifts, is dangerous,  then voluntary  on-call retains                                                               
that same level  of danger.  The amendment  directs that extended                                                               
on-call would be disallowed whether it is mandated or voluntary.                                                                
REPRESENTATIVE ROSES objected.                                                                                                  
2:14:14 PM                                                                                                                    
REPRESENTATIVE SEATON asked for clarification of the phrase                                                                     
"fulfilling on-call time."                                                                                                      
2:14:43 PM                                                                                                                    
CHAIR WILSON explained that "these situations don't count."                                                                     
2:15:12 PM                                                                                                                    
REPRESENTATIVE SEATON said:                                                                                                     
     We're removing  an exception  but I'm  not sure  if the                                                                    
     exception is  working time,  or if  it's on-call.   And                                                                    
     whether, if  someone is  on-call, they  can be  at home                                                                    
     and does that, they could be on call for 12 hours.                                                                         
CHAIR WILSON stated that a nurse could be at home and not get                                                                   
called, or could be called in and have to work for 12 hours.                                                                    
2:15:50 PM                                                                                                                    
REPRESENTATIVE SEATON further asked if someone is on-call for 12                                                                
hours ...                                                                                                                       
2:16:01 PM                                                                                                                    
REPRESENTATIVE ROSES spoke to his objection.  He remarked:                                                                      
     If  you  read  it  in  its  entirety,  it  says,    ...                                                                    
     subsection  (a) of  this section  does not  apply to  a                                                                    
     nurse fulfilling  on-call time  that is agreed  upon by                                                                    
     the  nurse.   We're talking  about mandatory  overtime,                                                                    
     mandatory on-call,  this is one where  they have agreed                                                                    
     to be on-call.                                                                                                             
2:16:35 PM                                                                                                                    
REPRESENTATIVE GARDNER paraphrased:                                                                                             
     The  way  it would  read,  ...  except as  provided  in                                                                    
     section  (c),  a nurse  may  not  be required  to  work                                                                    
     beyond a predetermined regularly  scheduled shift.  And                                                                    
     then  some sections  that do  not apply  are:   a nurse                                                                    
     fulfilling an on-call  time that is agreed  upon by the                                                                    
     nurse before it's scheduled.   What we're trying to get                                                                    
     at ... is a nurse  working on-call, who's not just come                                                                    
     off of  a 14 hour shift,  who's had 10 hours  rest, on-                                                                    
     call is  fine.   But, if the  nurse works  that 12-hour                                                                    
     on-call   shift,  then   he   or  she   can  not   work                                                                    
     subsequently  a  scheduled  shift that  is  immediately                                                                    
     following.  The provisions  limiting the amount of time                                                                    
     working  still are  in effect,  even if  the nurse  has                                                                    
     agreed to on-call time.                                                                                                    
2:17:53 PM                                                                                                                    
CHAIR WILSON asked, "Then you don't want that to be an                                                                          
REPRESENTATIVE GARDNER said, "Exactly."                                                                                         
REPRESENTATIVE ROSES maintained his objection.                                                                                  
2:18:16 PM                                                                                                                    
REPRESENTATIVE CISSNA asked whether, in a situation where the                                                                   
nurse may want to work extra hours, limiting hours would protect                                                                
the patient.                                                                                                                    
2:20:00 PM                                                                                                                    
REPRESENTATIVE GARDNER agreed that the intent of the amendment                                                                  
was to ensure that the maximum safe overtime can not be exceeded                                                                
even by agreement with the nurse.                                                                                               
2:20:21 PM                                                                                                                    
CHAIR WILSON asked about paragraph 5, and read:                                                                                 
     ...   so  long   as   the  work   is  consistent   with                                                                    
     professional standards  and safe patient care  and does                                                                    
     not exceed 14 consecutive hours.                                                                                           
CHAIR WILSON suggested that this caveat could be applied to                                                                     
section (4).                                                                                                                    
2:20:41 PM                                                                                                                    
REPRESENTATIVE ROSES  disagreed.   He opined  that each  of these                                                               
provisions apply to the entire bill.   It is not necessary to add                                                               
2:21:00 PM                                                                                                                    
REPRESENTATIVE GARDNER agreed and withdrew Amendment 3.                                                                         
2:22:04 PM                                                                                                                    
REPRESENTATIVE SEATON moved Conceptual Amendment 4, as follows:                                                                 
     Page 3, line 16, following "contract";                                                                                     
         Insert "at a residential psychiatric treatment                                                                         
REPRESENTATIVE ROSES objected.                                                                                                  
REPRESENTATIVE SEATON explained that  the amendment addresses the                                                               
Baylor  plan  [of  weekend  scheduling] that  is  specific  to  a                                                               
residential  psychiatric treatment  center (RPTC).   It  has been                                                               
determined that at  a RPTC, nursing is a different  job than in a                                                               
hospital.  Thus, limiting the  maximum hours to 14 was applicable                                                               
to  other cases,  except 16-hour  shifts would  be allowed  at an                                                               
2:23:33 PM                                                                                                                    
REPRESENTATIVE  ROSES  maintained  his objection.    He  recalled                                                               
testimony  that supported  this  type of  weekend scheduling  for                                                               
facilities other than RPTCs.                                                                                                    
2:24:08 PM                                                                                                                    
CHAIR WILSON agreed.                                                                                                            
2:24:21 PM                                                                                                                    
REPRESENTATIVE GARDNER  stated her support for  the amendment and                                                               
pointed out the  difference between a hospital  and a residential                                                               
treatment center.                                                                                                               
2:25:22 PM                                                                                                                    
REPRESENTATIVE  SEATON  stressed  that  the  amendment  addresses                                                               
health and safety.   He opined that data  indicates that allowing                                                               
16  hours  in  any  regular  nursing  situation  was  asking  for                                                               
2:26:09 PM                                                                                                                    
REPRESENTATIVE  ROSES  noted that  the  amendment  takes out  the                                                               
flexibility of the bill.  He maintained his objection.                                                                          
2:26:45 PM                                                                                                                    
A  roll call  vote was  taken.   Representatives Seaton,  Cissna,                                                               
Gardner, voted  in favor of  Amendment 4.   Representatives Roses                                                               
and Wilson voted against it.   Therefore, Amendment 4 was adopted                                                               
by a vote of 3-2.                                                                                                               
2:27:42 PM                                                                                                                    
REPRESENTATIVE GARDNER moved to  report CSSB 28(FIN), as amended,                                                               
out  of   committee  with  individual  recommendations   and  the                                                               
accompanying fiscal  notes.  There  being no objection,  HCS CSSB                                                               
28(HES)  was reported  out  of the  House  Health, Education  and                                                               
Social Services Standing Committee.                                                                                             
There being no  further business before the  committee, the House                                                               
Health, Education and Social  Services Standing Committee meeting                                                               
was adjourned at 2:28:14 PM.                                                                                                  

Document Name Date/Time Subjects