Legislature(2005 - 2006)CAPITOL 106
07/31/2006 10:30 AM House HEALTH, EDUCATION & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| State Staffing for Nurses | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE
July 31, 2006
10:35 a.m.
MEMBERS PRESENT
Representative Peggy Wilson, Chair
Representative Paul Seaton, Vice Chair
Representative Sharon Cissna
Representative Berta Gardner
MEMBERS ABSENT
Representative Tom Anderson
Representative Carl Gatto
Representative Vic Kohring
COMMITTEE CALENDAR
STATE STAFFING FOR NURSES
PREVIOUS COMMITTEE ACTION
No previous action to record
WITNESS REGISTER
CRISTY WILLER, Director
Division of Behavioral Health
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Discussed API.
RON ADLER, CEO
Alaska Psychiatric Institute
Division of Behavioral Health
Department of Health and Social Services
Anchorage, Alaska
POSITION STATEMENT: Related the successes, challenges, and
opportunities of API and answered questions.
ACTION NARRATIVE
CHAIR PEGGY WILSON called the House Health, Education and Social
Services Standing Committee meeting to order at 10:35:32 AM.
Representatives Wilson, Seaton, Cissna, and Gardner were present
at the call to order.
^State Staffing for Nurses
10:35:57 AM
CHAIR WILSON announced that the only order of business would be
to review the e-mail received by Representative Seaton and
discuss a course of action.
10:36:42 AM
REPRESENTATIVE SEATON explained that a personal friend of his
resigned from her nursing position at the Alaska Psychiatric
Institute (API). Upon her resignation, she shared her concerns
regarding the situation at API, which she did in the e-mail
dated June 1, 2006. The e-mail was provided to the committee.
The e-mail relates that this nurse left because she felt that
her license was at risk. He then recalled the discussions
during the last regular session regarding mandatory overtime
issues, which ultimately were found to be issues at only API.
10:41:24 AM
CHAIR WILSON requested that the department representative come
forward for response.
10:42:35 AM
CRISTY WILLER, Director, Division of Behavioral Health,
Department of Health and Social Services, said that her primary
purpose is to introduce the CEO of API to the committee and to
highlight that API falls within the Division of Behavioral
Health. She then related that the report entitled, "Grading the
States" from the National Alliance on Mental Illness identifies
API as an example of "stellar accomplishment ... transformation
in both facility and personnel development." She noted that
there has been other national recognition of the quality of API.
MS. WILLER then turned to API's responsiveness to issues from
the public, consumers, and patients. For example, more than 60
percent of the API governing body is comprised of consumers of
psychiatric services. This group meets quarterly to review the
status of the hospital and address issues that may require
attention. She noted that as the division director, she sits on
the governing board and thus she said she is well aware of the
issues that are discussed. Furthermore, the meetings always
include a lengthy portion for consumer input. In fact, not long
ago issues regarding API's grievance policy were brought forth
and resulted in the formation of a subcommittee on the matter.
Ms. Willer informed the committee that in September 2003, API
implemented a consumer & family specialist staff position to
initiate some fundamental changes in the way consumers and
family members provide input directly to the API CEO and the
senior management team. The API is transformative in ways
beyond the new building. Of more lasting importance is the
commitment to consumer planning and a changed attitude about
mental illness and those who are mentally ill. The
aforementioned is illustrated in the renaming of API from the
Alaska Psychiatric Institute to the Alaska Recovery Center,
which identifies recovery as a critical feature and expectation.
MS. WILLER related that the Division of Behavioral Health
endorses the concept of transformation and in fact, the current
administration has taken on the task of integrating substance
abuse and mental health services under the roof of one division.
She opined that API has consistently taken on the challenge to
be at the forefront of these developments, as shown by their
emphasis on recovery, consumer involvement, and other ideas that
are part of modern health care nationally. Change isn't easy in
any organization, particularly in the only state-funded
psychiatric hospital. Furthermore, this change involves a
change in attitude, which is often the most difficult change to
make. Still, API has consistently shown leadership in accepting
challenges, working with them, learning from them, and
incorporating them into the way they do business, which follows
the basic continuous quality improvement philosophy.
10:51:06 AM
RON ADLER, CEO, Alaska Psychiatric Institute, Division of
Behavioral Health, Department of Health and Social Services,
paraphrased from the following written testimony [original
punctuation provided]:
Thank you for this opportunity to explain the
successes, challenges and opportunities in operating
Alaska's state psychiatric hospital. Since my start at
API in March 2003, not a month has gone by without
some reference (internal or external) to the issue of
nursing salaries, mandatory overtime, nursing
shortages and staff-patient safety. First and
foremost, these issues can only be understood within
the context of the following facts:
(1) API-Alaska Recovery Center is Alaska's only state
psychiatric hospital that exclusively treats patients
under Alaska Title 47 and Title 12 Statutes. The
hospital operates 24/7 and cannot refuse to accept the
patient who is committed to the hospital under Title
47 or Title 12.
10:52:27 AM
MR. ADLER, in response to Representative Gardner, specified that
99.9 percent of the patients admitted to API are admitted under
some type of legal status. Generally, API doesn't accept
voluntary admissions.
10:53:07 AM
MR. ADLER continued:
(2) Title 47 patients, by the very nature of their
serious mental illness, can be out of control, and
present a danger to self or others, or be gravely
disabled.
(3) There exists a national 'shortage' of qualified,
Registered Nurses. Alaska is also experiencing a
statewide shortage of RN's. This shortage is quite
evident in the Alaska Department of Health & Social
Services at API, Public Health, and Pioneer Homes. The
Department of Health & Social Services employs
approximately 3200 staff of which 700 are Registered
Nurses. API employs about 10% of the Department's
total workforce of RN's.
(4) Of all the nursing sub-specialties, psychiatric
nursing remains one of the less sought-after fields
for employment.
Yearly admissions to the hospital range from 1200-1452
patients per annum. For the employees at API,
regardless of job classification, the days are long
and the work is difficult.
10:55:00 AM
MR. ADLER, in response to Chair Wilson, explained that typically
the Monday through Friday shifts are 7.5 hours while the nursing
department runs 12-hour shifts on the weekends.
10:55:17 AM
MR. ADLER continued:
Although these challenges seem formidable, API has
developed a national reputation for innovation and
quality 'recovery-oriented' clinical services. This is
largely the result of dedicated employees!!
Let's review the number of nursing issues which have
surfaced through legislative testimony during the past
year:
Nursing salaries: it has been well established the API
nurses, as well as all nurses employed in state
government, are under paid. They are due a
comprehensive, market-based salary study and
commensurate wage adjustment.
Nursing recruitment and retention: it has been
recommended that the necessary state departments
become more pro-active in the recruitment and
retention of qualified nurses and that employment
within the DHSS presents a variety of work
opportunities in nursing.
Mandatory Overtime: regardless of the need, today's
workforce does not appreciate the constraints and
interference of mandatory overtime. The API Senior
Management Team has made a commitment to reduce this
burden on employees.
Bargaining Unit representation: it has been suggested
that state government establish a Healthcare
Bargaining Unit to represent Nurses and other licensed
professionals as has been done in other states
(testimony provided by ASHNHA and Alaska Nurses
Association).
Overhaul state compensation plan: regardless of any
monetary award that may be afforded to this job
classification, it is well established [that] state
employed nurses will again fall behind the competitive
salaries which exist in the private sector within two
years.
10:59:15 AM
MR. ADLER moved on to the details of mandatory overtime, as
follows:
Use of Mandatory Overtime
Mandatory overtime is used when no other staffing
options are available at the time. Mandatory overtime
is the last resort for staffing. If staff may be
needed for mandatory overtime, the Nursing Shift
Supervisor (NSS) will notify them as soon as the
possibility is apparent. The NSS will keep the staff
apprised of the status as the shift progresses. Staff
members may be directed to remain on duty for
mandatory overtime up until the end of their regular
shift.
Staff doing mandatory overtime have the choice of
remaining on their home unit or to another unit where
staff is needed. An employee who has worked voluntary
overtime of at least four hours in duration within the
past 30 calendar days shall have the right to one pass
per month on a mandatory overtime requirement. In the
event that all employees on the mandatory overtime
list decline, the Employer has the right to refuse to
accept the declination by the employee.
11:01:20 AM
CHAIR WILSON surmised then that the nurses are very careful
about when to pass since it's only allowed once a month.
MR. ADLER agreed, adding that the nurses are thinking about this
all the time.
11:01:53 AM
REPRESENTATIVE SEATON related his understanding that API nurses
work an eight-hour shift. He then inquired as to how the breaks
are determined.
MR. ADLER specified that according to the bargaining unit
agreements there is a morning, afternoon, and lunch break.
REPRESENTATIVE SEATON asked if an additional break is scheduled
between shifts when one is forced to work mandatory overtime.
MR. ADLER said there are rules for that in the bargaining unit
agreement for overtime and mandatory overtime, which he offered
to provide to the committee later.
11:03:44 AM
CHAIR WILSON related that in a hospital situation one of the
nurses from the outgoing shift informs the incoming shift of
[the status of] each patient. She asked if something similar
occurs at API.
MR. ADLER related that when he arrived at API, there was no
change of shift report in the nursing department. However,
there has been discussion about doing so. He reminded the
committee of the situation with regard to the elimination of
standby pay during the prior administration of API. After the
aforementioned situation subsided, a change of shift nursing
report was implemented such that every day 30 minutes of
overtime was built-in for the reporting nurse to provide the
detailed nursing report to the incoming nurses. He clarified
that each treatment unit does such a report. In further
response to Chair Wilson, Mr. Adler explained that the
physician's assistants really need to remain on the floor
because the change of shift is a critical time.
11:06:59 AM
REPRESENTATIVE CISSNA recalled hearing strong positives [from
the] staff of API, save those in the nursing section.
Therefore, she surmised that "it sounds like it's different for
the nurses than it is for the rest of the staff." If that's the
case, she inquired as to why. She inquired as to how API
determines the number of nurses needed at any given time. She
then questioned whether there is a need for more staff at API.
MR. ADLER said that he will address these points in his
testimony.
11:10:00 AM
MR. ADLER continued with his testimony:
If a mandatory overtime person finds someone else to
work for them this is acceptable. The name of the
mandatory staff remains at the top of the Mandatory
Overtime List. The volunteer cannot be someone who is
also required to stay mandatory that day.
All prospective employees to the Nursing Department
are advised of the necessity of mandatory overtime,
the reasons for this policy, and efforts to reduce
this burden on employees.
Let's be clear about this: mandatory and voluntary
overtime correlates directly to the API census, acuity
level and nursing staff shortage. For example, this
past Fiscal Year, API recorded 1,452 admissions to the
hospital, the highest admission rate since FY 2002.
Utilization was exceptionally high in March 06 (155),
April 06 (124), May 06 (136), June 06 (139). Although
we made some progress in managing Mandatory Overtime
during FY 05, usage will certainly exceed all previous
years with the kind of admission rates experienced in
FY 06.
Another example: on Saturday, July 22 and Sunday July
23, just two weeks ago, API admitted 16 acute care
patients. In fact, the hospital was full and no other
beds were available. It was almost certain we had
several patients under close observation status. Under
these circumstances, API has no other alternative than
to exercise the use of Mandatory Overtime.
When an employee is required to work mandatory
overtime, the Nursing Shift Supervisor provides a meal
ticket - and by the way, we serve restaurant quality
food at API. All employees are encouraged to make use
of the employee lounge which has a 32" color TV, a
number of desk top terminals with internet access and
a full kitchen. Some employees make use of the
meditation room located in the front lobby for quiet
time during breaks.
MR. ADLER informed the committee that recently API submitted a
draft letter of agreement requesting another way to manage some
of the mandatory overtime through standby and premium policy.
The draft letter conforms to state personnel regulations and
policies relative to standby pay. Furthermore, it looks very
much like the methodology utilized in private hospitals.
Therefore, a RN on standby pay would have a telephone number or
pager for contact. At this point, API knows when such is
necessary. Mr. Adler highlighted that the nurse on standby
receives a monetary increment.
11:15:53 AM
MR. ADLER then continued by addressing recruitment efforts. He
highlighted that API is utilizing informal networking in order
to capture those nurses who are interested in pulling shifts in
other hospitals.
MR. ADLER, in response to Representative Seaton, clarified that
API nurses are burdened with mandatory overtime and thus aren't
likely to be working in other nursing jobs. However, in other
facilities nurses typically work another shift at another
facility. The API would like to be positioned such that it
could take advantage of those interested in shift work.
REPRESENTATIVE GARDNER inquired as to whether the API nursing
staff require special training.
MR. ADLER answered that API orients [new staff].
11:18:11 AM
MR. ADLER then informed the committee that API has become a
major internship site for the University of Alaska - Anchorage
nursing program. He specified that every student nurse comes
through API for an internship. The aforementioned is viewed as
a marketing opportunity. Mr. Adler reminded the committee that
about a year ago Assistant Deputy Commissioner Janet Clarke
began a series of informal meetings with the director of the
Division of Personnel, a new professional recruiter, Mr. Adler,
and other DHSS division directors who employed nurses. The
general topic was in regard to how DHSS could position itself to
become more proactive and competitive in the marketplace.
Although that series of informal meetings has temporarily
stopped, API has moved ahead. Mr. Adler specified:
The API-Alaska Recovery Center Nursing Department,
under the leadership of newly appointed Director of
Nursing Sharon Bergstedt, held a special 'Open House'
for registered nurses in the greater Anchorage area on
June 29, 2006, from 4:00 - 9:00 PM.
The event, which was advertised in the Anchorage Daily
News as well as via a direct mail brochure, targeted
RNs, LPNs, and ANPs. The result: over 49 licensed
professionals came into the hospital for a tour and
inquired about employment opportunities. This event is
scheduled to be repeated in October, 2006. As of this
moment, the Director of Nursing continues to receive
phone calls regarding job openings.
MR. ADLER informed the committee that API has a new assistant
director of nursing with over 20 years experience in psychiatric
nursing. He opined that the new assistant director will add
additional energy to the nurse recruitment process. He then
turned to the current nursing vacancy report and related that
the nursing administration has had a difficult time over the
past nine months as it has experienced significant retirement,
including the previous director of nursing, two nursing unit
managers, one nursing shift supervisor, and a nursing health
educator. He highlighted that it's difficult for nurses to
consider employment at a hospital when the nursing management
team isn't present to support the nurses. However, as of this
week, API only has one vacancy left in nursing administration
and interviews for that position are occurring this week. Mr.
Adler specified that on January 24, 2006, when he provided
testimony before this committee, API had 20 vacancies out of 58
direct-line nursing positions. As of this date, there are only
10 vacancies. If the increment in the governor's budget is
maintained by the legislature, there will be interest [in the
vacant positions at API].
11:23:33 AM
MR. ADLER paraphrased from the following written comments: "In
summary, API can report substantial progress in filling numerous
vacancies in Nursing Administration. With a fresh approach to
recruitment, and the widely anticipated wage increment, it is
expected that filling RN staff vacancies will be as successful."
11:23:55 AM
REPRESENTATIVE SEATON asked if the 10 vacancies are filled with
RNs.
MR. ADLER replied no, and specified that 20 of 58 are staff RN
positions, which is the RN I/II flex position. Those 20
positions include the on-call, full-time, and permanent part-
time positions.
11:24:42 AM
MR. ADLER, in response to Chair Wilson, related that API is very
competitive with its salaries for psychiatric nursing assistants
(PNAs). Furthermore, API seems to have an adequate supply of
PNAs. He then informed the committee that when the census
increases, the PNA position requires an extraordinary amount of
additional help in API. If the API units aren't larger than 25
patients, then two RNs or the combination of an RN and LPN can
adequately handle the duties.
11:25:40 AM
MR. ADLER continued to address nursing salaries and paraphrased
from the following written testimony:
Nursing Salaries
API Nurses, as well as all RNs in the DHSS were
awarded a 7.5 % increment effective July 1, 2006,
which they have yet to see materialize.
Dept. of Administration conducted the market based
study on the nurses salary and expects to have the
findings finalized at the end of July (which is
today!), with the recommendations for the official
range.
If they recommend a 1 range increase we have funding
for the year; if it is 2 ranges we'll have to request
additional funding.
In any event, any monetary award will be retroactive to
July 1, 2006.
MR. ADLER then suggested that committee members put themselves
in the shoes of the nurse who wrote the e-mail in regard to the
lack of the salary increase materializing. The aforementioned
is becoming a morale issue at API.
11:27:27 AM
MR. ADLER moved on to discuss LPNs and advanced nurse
practitioners (ANPs). He paraphrased from the following written
testimony:
LPNs and ANPs
These abbreviations stand for Licensed Practical Nurse
and Advanced Nurse Practitioner. The accreditation
standard relative to the deployment of RNs in a
psychiatric hospital requires API to staff each shift
and Treatment Unit with a Registered Nurse. On the
larger Units, API attempts to have 2 RNs on each
shift, however, with staffing shortages, this is
difficult to maintain.
It has become standard practice in the industry to
pair an LPN with an RN to accommodate the clinical
needs of psychiatric patients on larger units. API
has moved in this direction as one possible solution
to ease the burden of mandatory overtime.
MR. ADLER explained that LPNs can't perform all of the functions
that RNs can. He related that LPNs can pass medication, provide
nursing care relative to the scope of their practice. However,
LPNs can't perform a comprehensive nursing assessment.
Furthermore, LPNs don't have access to the medication carts.
Still, LPNs are being used in both private and state facilities.
Similarly, the industry has effectively utilized an advanced
nurse practitioner to enhance the medical staff of an inpatient
unit. He explained that ANPs have prescriptive authority and
are used in two areas of API. The medical officer has two mid-
level practitioners working for her because each admitted
patient must have a history and physical performed within 24
hours. Therefore, API plans special weekend coverage in order
to cover those times when there are 16 admissions. He informed
the committee that API medical staff decided to create a
psychiatric advanced nurse practitioner who reports to and is
supervised by the medical director of the hospital. Mr. Adler
said he was reasonably pleased with the outcome and is likely to
recruit for such a position again. These, he opined, are viable
alternatives. In fact, he further opined that ANPs bring
something to the table that biologically trained psychologist
don't, which he specified is the holistic approach to treatment.
11:32:37 AM
MR. ADLER, in response to Representative Cissna, confirmed that
LPNs are the lowest level of licensed individual. In further
response to Representative Cissna, Mr. Adler confirmed that
PNAs, who aren't licensed, can help with lifting and such.
11:33:31 AM
MR. ADLER continued by paraphrasing from the following written
testimony:
Communication between API Nurses and Nursing
Administration
In September 2004, Nursing Administration implemented
a plan to communicate directly with staff RNs. Since
this date, the hospital has consistently held a
monthly meeting for registered nurses. API nurses
construct the agenda and the meetings have been
regarded as successful and beneficial to both nurses
and Nursing Administration. New initiatives, changes
in policy and procedures are discussed in detail.
API will also present a regularly scheduled CEO update
which is recorded and employees may watch the meeting
on desk top computers in the hospital.
11:35:31 AM
MR. ADLER moved on to the realignment of patient treatment units
and paraphrased from the following written testimony:
Realignment of Patient Treatment Units
For a number of years, API operated an admitting unit
and one adult acute unit. The admitting unit was the
point of entry for patients coming into the Hospital.
On this unit the patients were seen by a psychiatrist
and multi-disciplinary treatment team for an
evaluation and treatment planning. If the patient
responded quickly to treatment he or she might have
been discharged in 2 or 3 days. If, however, the
individual required longer and more intensive
treatment, as the majority of patients do, that
individual would then have been transferred to the
acute adult unit. Here the patient would be required
to meet a new clinician and treatment team, become
acquainted with a whole new unit and staff, and repeat
their history again. This process required at least a
day for the individual to settle in and begin
treatment on the new unit.
After API occupied its new building last July, it
became apparent for a number of reasons that the
admitting unit was not an effective or efficient part
of patient flow. Feedback from API professional staff
indicated that having patients transfer from one unit
to another to complete treatment was the cause of
redundant and time-consuming evaluations. It was felt
that it not only slowed down the treatment process,
but it did not allow for continuity of care to be
delivered by one provider during a hospitalization.
Additionally, it was observed that the process of
transferring a patient from one unit to another
increased the opportunity for communication errors and
this was seen as a potential safety hazard.
MR. ADLER mentioned that over the last three-and-a-half years
the implementation of the single point of entry with the
Providence psych emergency room has helped API's ability to
decrease reliance on an admissions and screening unit. The
belief is that those patients entering API with the screening
can proceed to a treatment unit and have one doctor and
treatment team for the duration of that patient's treatment. He
then continued paraphrasing from the following written
testimony:
Based upon these observations and concerns expressed
by staff and consumer advocacy groups, the decision
was made to re-organize and have two acute adult
admitting units. Patients would be admitted to the
care of a clinician and treatment team and remain
there for their entire hospitalization. Additionally,
API policies and procedures were changed to allow for
patients that required re-hospitalization within a 6
month period following discharge to do so with the
treatment team and clinician that treated them last.
This was seen as yet another move to improve
continuity of care, efficiency, and safety for API
patients.
MR. ADLER, referring to Representative Cissna's earlier
questions, pointed out that API's well-documented database
illustrates that one-third of its discharged patients return to
the hospital within six months. The aforementioned is also
relevant to the continuity of care concept and notion of
patients returning to the doctor and team that treated them
during their last episode of care.
11:40:00 AM
MR. ADLER then recalled last legislative session when HB 343 was
passed. He pointed out that many API employees are subject to
verbal abuse, spitting, stalking, and assaultive behavior. The
aforementioned can occur with patients who are gravely disabled
and don't realize what they are doing. However, such abusive
and assaultive behavior is from patients with very severe
characterological disorders. The staff has never had recourse.
In fact, when the Anchorage Police Department (APD) has been
called, APD would come and take a report. The ultimate result
was APD saying that the abusive patient is in the right place.
However, in many other states licensed health care professionals
are generally protected by some law. Therefore, HB 343 is
viewed as protection for API employees and is welcomed by API
staff. Currently, API is writing a policy and procedure to
address this.
11:41:46 AM
REPRESENTATIVE SEATON surmised then that the e-mail is correct
in that the patient isn't held accountable for his/her behavior
when law enforcement are called. Therefore, there isn't any
basic assault protection for the nurses.
MR. ADLER replied yes.
11:42:28 AM
MR. ADLER continued with his testimony, and informed the
committee that API has a well-documented quality improvement
program. Furthermore, API tracks various things occurring in
the hospital such as medication errors, slips and falls,
assaults, patient injuries, and staff injuries. All of the
aforementioned is documented on the unusual occurrence report
(UOR). He related that generally when a UOR is submitted, the
immediate supervisor has to investigate the situation and the
information is entered into a database. The UOR is used as a
source of feedback and the database in which the information is
entered is used to track how the hospital is managing. He noted
that some staff view the UOR as an adversarial report placing
management against line staff. However, the UOR provides
critical information and is exactly what the joint commission
wants to see during the accreditation process because it wants
to be sure that data-driven management decisions are being made
for the hospital and its patients.
11:45:40 AM
REPRESENTATIVE CISSNA recalled her college years in the early
1960s when there was much discussion regarding closing
institutions and moving toward outpatient community care for the
long-term mentally ill patients. Some of the things brought up
today are reminiscent of the behaviors and feelings individuals
experience when they are institutionalized. However, currently
there are homeless camps filled with mentally ill individuals
who don't come to API for help. She questioned how much of this
[problem] is a nursing problem and how much of this is the lack
of ability to address mental health care. She questioned
whether there is the need to get more out of institutional care
while having a network that is fully capable and without a lot
of holes. "Our system has enormous holes ... and I think we're
paying a price for that." she opined.
11:48:27 AM
CHAIR WILSON commented that there are certain individuals who,
no matter what's available, make the rounds. She attributed the
aforementioned to why the number of beds was ratcheted down in
API.
11:48:51 AM
MR. ADLER related that the commissioner's office is doing much
in analyzing needs. He then recalled back when outreach teams
were funded.
MS. WILLER agreed with Representative Cissna. She then
specified that the objective of downsizing the beds at API was
to include and compliment the community mental health network to
allow receipt of services closer to home in order to eliminate
negative responses to institutionalization. She commented that
much of the pressures on API are occurring because of [Alaska's]
system of care needing more work in the outlying areas.
11:51:03 AM
REPRESENTATIVE SEATON highlighted the e-mail reference to most
staff working at least one mandatory overtime per week. He
asked if there is any data with regard to how much overtime a
week is worked. He then inquired as to the incidence of
mandatory overtime during the higher vacancy rate at API as
compared to the current lower vacancy rate.
MR. ADLER offered to provide the committee with the raw data and
an analysis. From anecdotal observations, Mr. Adler opined that
the mandatory overtime rates remain high, which he attributed to
the unlimited vacation time. He identified one solution as
capping vacation leave for each individual to two week annual
leaves. However, he recognized that state employees generally
accumulate more than 10-14 days of annual leave. Mr. Adler then
related his belief that the nursing department works hard and if
a nurse has the ability to take three weeks annual because of a
special event, then that should be accommodated. Therefore,
there needs to be a system such that not all of the most
qualified [nurses] are on leave at the same time.
11:53:32 AM
REPRESENTATIVE SEATON related his belief that four of the five
issues discussed by Mr. Adler appear to deal with wages. He
noted that the other issues are mandatory overtime and
retention. However, the e-mail doesn't seem to relate concerns
with regard to wages and thus Representative Seaton expressed
the need to focus on other aspects of a nursing job at API that
caused a very qualified nurse to leave the system. He asked if
Mr. Adler would believe that API will be fully staffed with RNs
in the next months.
MR. ADLER replied yes, API will continue to make progress in
that area. He related that RNs view themselves as professionals
and they like training. However, the health educator position
in charge of hospital training has been vacant for some time and
is an issue. Many licensed professionals, he opined, feel that
the hospital has let them down with regard to ongoing continuing
education.
11:57:36 AM
MR. ADLER, in response to Representative Seaton, specified that
continuing education for nurses is paid time. In further
response to Representative Seaton, Mr. Adler explained that
continuing education is scheduled such that the nurses come to
the classroom in the hospital while another RN would be
scheduled to cover that time as part of his/her normal work
week. He remarked that [continuing education] is an area that
needs work at API. In response to Chair Wilson, Mr. Adler
confirmed that although the health educator position has been
vacant, nurses have received training from nursing
administrators with competency in a certain area.
11:59:40 AM
REPRESENTATIVE CISSNA asked if API performs exit reviews when
employees give notice.
MR. ADLER replied yes, and noted that it's documented through
the Director of Nurses Office. He related that the e-mail reads
almost verbatim to that nurse's exit interview. The information
from exit interviews are reviewed for possible improvements, he
mentioned.
12:00:18 PM
REPRESENTATIVE CISSNA returned to the notion of utilizing
community-based treatment options. She asked if there has been
any cost-benefit analysis to determine the cost of treatment in
a hospital versus in a community-based treatment option.
12:02:37 PM
REPRESENTATIVE SEATON referred to the portion of the e-mail
regarding the nurse's inability to note on a patient's chart
that a patient is on suicide watch because there isn't adequate
staff to supervise such a patient. He inquired as to how such a
circumstance has been addressed.
MR. ADLER noted that the aforementioned portion of the e-mail
wasn't included in the exit review. He explained that the
normal protocol for an RN is to notify the nursing shift
supervisor, who is the de facto executive of the hospital after
5:00 p.m. and is responsible for staffing and other leadership
responsibilities. Under no circumstances would the hospital
compromise the close observation status policy and procedure.
There are documented occasions in which the nursing shift
supervisor comes onto the floor to provide close observation
until an additional staff person arrives. Mr. Adler said that
he wasn't aware of the situation related in the e-mail and if it
had been documented in a UOR it would've been investigated. He
noted that he signs every UOR every day and thus is aware of
every safety concern in the hospital.
12:05:01 PM
REPRESENTATIVE SEATON presumed now that Mr. Adler is aware of
the situation related in the e-mail, he will speak with the
physician about it.
MR. ADLER said that he will request the safety officer to run a
cross check on all the UORs submitted by this employee in order
to determine whether a UOR was documented on the matter. If a
UOR did document the matter, then he will review who performed
the investigation and the outcome. Mr. Adler then informed the
committee that the director of nursing, the hospital CEO, and
the medical director participate in morning report on each
patient every morning. At the same time, all UORs within the
last 24 hours are reviewed. If the situation was reported in a
UOR, it would've been addressed with the physician at that time.
Mr. Adler then pointed out that the doctor referred to in the e-
mail is a locum tenens physician, rent a physician, which are in
use due to the almost 100 percent turnover with medical staff
over the past few years. He opined that such a situation
wouldn't happen with any of API's permanent full-time staff
psychiatrists.
CHAIR WILSON related her experience with suicidal patients and
emphasized the need to review the particular situation related
in the e-mail.
12:08:29 PM
CHAIR WILSON turned attention to the e-mail's reference to the
feeling of the lack of appreciation, which she said could easily
be addressed.
REPRESENTATIVE SEATON, recalling a portion of the e-mail, asked
if it's correct that physicians at API have lockers but nurses
don't.
MR. ADLER replied yes, noting that he isn't sure why. He
further noted that was the design of the new facility before he
arrived. Once the issue was raised, there were attempts to
address the issue. However, there isn't enough square footage
to make changes at this point.
CHAIR WILSON opined that the space could be found somewhere.
MR. ADLER said he was putting the locker issue on his to do
list.
12:12:03 PM
CHAIR WILSON highlighted the e-mail's reference to the
assignment of treatment teams based on whose turn it is rather
than based on the patient's needs.
MR. ADLER explained that API follows a rotating assignment that
is established in policy and procedure. If a patient and/or
treating physician believe the patient should be reassigned, it
has to go through the medical director. The medical staff, he
related, insist upon such.
CHAIR WILSON posed a situation in which the cycle is such that a
PA is to provide treatment. However, the patient's insurance
doesn't cover treatment by a PA.
MR. ADLER answered that during the normal work week, the medical
director would handle such a situation. Treatment assignments
aren't changed during weekends or holidays. If there was a
reason, whether clinically or financially, for a reassignment,
it would occur. Mr. Adler then related:
I have to be very honest with you, it's much easier
... for me to operate the hospital within the
Department of Health and Social Services if we're
increasing our revenue every year. And there are ...
certain customer bases in Anchorage that come our way
because ... those facilities don't support their own
free standing psychiatric units. The two bases are
very good examples of that. They ... exclusively use
API and I don't believe it's the right thing to offset
public dollars when third party revenue is available.
... I have very strong feelings about that and very
strong management style about it. So, we ... do take
that under consideration.
12:14:53 PM
REPRESENTATIVE SEATON related his understanding that the
military requires a standard of care such that there is a
physician supervisor on the treatment team and private insurance
has a certain standard of care. However, the treatment team is
assigned on a random basis. Therefore, Representative Seaton
expressed concern that the state would be held liable if
something happens.
MR. ADLER began by relating that API is classified as an
institution for mental diseases (IMD), a classification which
prohibits API from billing Medicaid for patients between the age
of 22 and 64. He then informed the committee that the third-
party population at API is very small, only 1-2 percent.
Furthermore, whether the ANP is working for the medical officer
performing history and physicals or working under the direction
of the medical director, that clinical work is peer reviewed on
an ongoing basis. In fact, ANPs are in regularly established
clinical supervision with the physician provider. Therefore,
Mr. Adler said that he doesn't believe ANPs provide a lower
standard of care. Moreover, state risk management knows of the
use of ANPs in this manner, which is standard operating
procedure in many other hospitals.
CHAIR WILSON noted her agreement that just because an APN
provides the care, it doesn't mean the standard of care is
different than it would be under a physician. The situation is
created by the insurance company determining what standard of
care it will cover.
MR. ADLER informed the committee that [the procedure with the
ANPs] is written within the bylaws of API. The medical staff of
a joint commission accredited hospital oversees the clinical
operations. If the joint commission determines that the
hospital isn't meeting a clinical standard, then medical staff
meeting minutes are reviewed to determine whether there were
changes approved by the medical staff. The medical staff
insists that the mid-level practitioner has ongoing supervision
and peer review by a licensed physician.
12:19:54 PM
REPRESENTATIVE SEATON referred to the e-mail and the nurse's
observations that physicians tended to choose more aggressive
treatment and have better results than ANPs. The
aforementioned, he opined, seems to indicate a difference in the
standard of care. Therefore, he expressed the need for Mr.
Adler to determine whether there is a difference in the standard
of care when it's an ANP versus a physician.
MR. ADLER related his understanding that the nurse who penned
the e-mail is referring to the aggressiveness of the licensed
provider in medicating patients, which is a point of contention
in the industry. Mr. Adler explained that some physicians want
to place patients on the maximum dosage right away, which may
come at the risk of the individual experiencing side effects
some of which may be profound. However, some physicians place
patients on a slow uptake with medication. Mr. Adler said that
the nurse practitioner referred to in the e-mail took a holistic
approach to treatment and often ordered counseling and
psychotherapy in addition to medication management. Therefore,
Mr. Adler opined that it's more a matter of style and a practice
pattern than a standard. He further opined that there's a place
for both.
MR. ADLER informed the committee that API has taken a treatment
approach that recognizes that if patients don't meet the
criteria for forced medication, it's the patient's right to
determine how and when and how much medication he/she will take.
Furthermore, there's a seductive process in working with
patients who have an illness that tell them not to trust
providers. Part of that process is building the trust and
orienting to classroom activities that relate to wellness and
disease management in order that they understand the real
concepts of recovery. The aforementioned seems to be the
approach followed by the ANP referenced in the e-mail. Mr.
Adler acknowledged that such a treatment approach may result in
a longer stay in API. However, if patients agree to be the
authors of their own treatment and recovery plans and the
hospital can demonstrate that the right combination of
treatments can work, then people may come into the hospital less
often.
REPRESENTATIVE SEATON said he is fine if it's the standard of
practice and the medication rate of the supervising physician.
However, if the ANP is utilizing a standard of care that's not
within the supervising physicians' standard of care, then it's
problematic. He indicated his belief that the aforementioned is
what the e-mail seems to relate.
MR. ADLER offered to research and provide to the committee the
position description of an ANP and the medical staff bylaws. In
response to Chair Wilson, Mr. Adler specified that API employs
seven physicians and two ANPs, one of which is functioning as a
replacement for one of API's vacant physician positions. He
stated that API hasn't had positive experiences with locum
tenens physicians.
12:29:40 PM
REPRESENTATIVE CISSNA opined that there is artistry in providing
human services and just because physicians have a degree doesn't
necessarily mean that they will always heal. She indicated that
she likes the notion of different perspectives and allowing
people having a say in their treatment. She then asked if API
is doing any longitudinal research on the outcomes of the
different therapeutic programs and styles of care.
MR. ADLER pointed out that API doesn't have the research
department to review such. However, it's certain that people
need choices, which is what API tries to provide. He informed
the committee that API's consumer and family specialist performs
an exit exam of every patient with regard to patient safety,
dignity and respect, and satisfaction with services. The
aforementioned is reported into the research component of a
national database. Furthermore, it's mandatory that API report
seclusion and restraint data.
12:35:13 PM
REPRESENTATIVE CISSNA asked if the aforementioned database
tracks the quantity of psychotropic drugs.
MR. ADLER replied no, but added that API is tracking the amount
of court-ordered forced medication orders per month. He
explained that API doesn't care whether a patient is on
medication or not but rather if his/her symptoms are reduced.
It seems that the courts agree with this philosophy as evidenced
by changes to its statutes on this issue. Over the past three
years, he related, API has reduced forced medication issues by
two-thirds. The aforementioned is a dramatic reduction. He
mentioned that pharmacists are requesting pharmacological
studies of medication, but API isn't funded to do so and moves
beyond API's core mission.
MS. WILLER informed the committee that for non-hospitalized
psychiatric, mentally ill, and substance abusing clients, there
is an outcome measure instrument referred to as the client
status review. At entry and exit clients are asked questions
about nine different life domain variables, including
interactions with emergency rooms, police, and family supports.
This has been a very useful tool that provides information
related to the good API is doing by diagnosis, problem, region,
and type of client. She noted that there has been discussion
with regard to expanding the aforementioned to include
psychiatric patients.
MR. ADLER related that API tracks medication errors and slips
and falls, and has infection control benchmarks.
12:40:13 PM
CHAIR WILSON requested that Mr. Adler address the charge that
there is no safe place at API to place violent patients.
MR. ADLER pointed out that the Taku Unit is a medium security
forensic unit that has very skilled staff for managing patients
with criminal behavior and those who are assaultive. The Taku
Unit is often used as a behavior modification unit. However, he
noted that the Taku Unit isn't expressly reserved for competency
restoration and evaluations. In further response to Chair
Wilson, Mr. Alder explained that if there is a problem with [a
violent patient] during the night shift, staff should contact
the nursing shift supervisor who calls the physician on-call who
can make decisions related to patient and employee safety. He
highlighted that both patients and staff are at risk in a
violent situation.
CHAIR WILSON requested that Mr. Adler address the assertion that
patients [of varying and different levels of illness] are mixed
together in one unit under one program.
MR. ADLER indicated that it would be great to have different
categories of illness in separate units, but it isn't how it
works in the industry. The challenge is to individualize
treatment within a heterogeneous population, particularly with
acute patients. He agreed that the situation is frustrating.
12:42:52 PM
CHAIR WILSON referred to the e-mail's reference to the lack of
information being shared with [nurses] in a constructive manner.
Chair Wilson indicated that perhaps there could be improvements
within this area.
MR. ADLER commented that there is no question that the nurse who
penned the e-mail is a quality individual. However, there seems
to be a communication gap for which he has some of the
responsibility, he said.
12:44:42 PM
CHAIR WILSON recalled Mr. Adler's comments regarding providing
extra staff and she highlighted the benefit of it, especially
for the night shift.
12:46:23 PM
REPRESENTATIVE SEATON related his understanding that Mr. Adler
will provide the committee with the number of mandatory overtime
hours worked.
MR. ADLER reviewed that the committee had asked for the
following: the rules for breaks on mandatory overtime; a
comprehensive breakdown of mandatory overtime by month, staff,
and shift; ways that nurse appreciation is achieved; issues and
hospital policy related to suicidal patients; lockers for
nurses; position description and medical staff bylaws for ANPs;
review of all issues being benchmarked; and the plan to add an
on-call nurse.
REPRESENTATIVE SEATON asked if Mr. Adler could provide the
committee with the number of nurses that leave per month in
order to address retention and how many positions are filled
with permanent or temporary employees.
REPRESENTATIVE CISSNA inquired as to whether there have been
conversations regarding the least restrictive care alternatives.
She explained that during the construction of API, she promised
that API [and the funds it receives] would be reviewed in order
to ensure that community care institutions aren't hurt.
Therefore, she surmised that there must be ways in which to
reduce the number of admissions through alternative community
placements.
CHAIR WILSON inquired as to the ages of patients at API.
MR. ADLER answered that API has a teenage unit that treats
adolescents between the ages of 13-17. At age 18, the
individual has to move on to an adult unit. In state, children
are treated at the Northstar Unit.
CHAIR WILSON requested that Mr. Adler let the committee know of
anything that the legislature can do to help.
12:52:58 PM
ADJOURNMENT
There being no further business before the committee, the House
Health, Education and Social Services Standing Committee meeting
was adjourned at 12:54:07 PM.
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