Nursing Notes

July 21, 2011

Inglis: West Texas story has sleaze, drama – sadly, it’s real

Filed under: Nursing — Shirley @ 11:31 am
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Here is another article by Toni Inglis about the Winkler County nurses and the whistleblower case that rocked the nation.  She is a wonderful writer and I love that I can share here another chapter of this story as seen by Toni.  Enjoy.  This is from the Austin American Statesman here in Austin.


We’ve seen the beginning of the 
Winkler County whistle-blowing nurses movie so many times, but it still doesn’t have an ending.

It has an all-star cast. Winkler County nurses Anne Mitchell and Vickilyn Galle; town doctor Rolando G. Arafiles Jr.; hospital administrator Stan Wiley; former Winkler County Sheriff Robert L. Roberts; Winkler County Attorney Scott M. Tidwell; Attorney General Greg Abbott; state Sen. Jane Nelson, R-Flower Mound; and state Rep. Donna Howard, D-Austin.

A good setting: A dusty, isolated West Texas town, Kermit in Winkler County. Thick good-ol’-boy culture. Squat courthouse. Twenty-five bed community hospital.

Plot: It’s 2007, and the small town is desperate for a doctor. Arafiles rides into town. He’s an affable guy hired despite the red flag of a stipulation on his Texas medical license. The town sheriff quickly befriends the doctor, and they become golfing buddies.

According to published reports, the doctor’s colleagues become increasingly uncomfortable with his standards of practice. The doctor sells a dubious nutrition supplement called Zrii to his patients as a sideline, following up with emails. They question his examining and billing for genitalia exams of people coming to the ER with maladies such as sore throats and headaches.

By 2009, the doctor’s fellow practitioners have had enough. They report him to the Texas Medical Board. Two who anonymously report him were the no-nonsense hospital quality assurance nurses, Mitchell and Galle, who between them had 46 years of experience at the hospital and immense respect.

When notified of the report, the doctor becomes outraged and enlists his buddy the sheriff to find out who made the report. The sheriff obtains confidential information from the medical board through fraudulent means, and the reports are traced down to the two nurses. The hospital administrator, Wiley, instantly fires the nurses.

The story gets really weird here. What transpired next is something that has not happened in any state. In a stunning display of prosecutorial might, the nurses are indicted on felony charges of misuse of official information. If convicted, they face a maximum of 10 years in prison and/or a $10,000 fine. The case makes national headlines.

The two nurses and their families wait nearly a year for their trial. They have lost their jobs and incomes. Galle retires early. Mitchell, who is 15 years shy of retirement age, finds another county job, but not as a nurse. She takes a $35,000 annual pay cut, just as her son enters college.

The criminal charges against Galle are dropped, but Mitchell endures a four-day trail before the jury acquits her after less than hour of deliberations. Once again, the case makes national headlines.

After Mitchell’s acquittal, Abbott opens an investigation into the case. In January, the doctor, sheriff, county attorney and hospital administrator are indicted on charge of retaliation against the nurses.

Roberts, the former sheriff, and Tidwell, the county attorney, each face six counts — two counts each of misuse of official information and retaliation (third-degree felonies) and official oppression (class A misdemeanor).

Wiley, the hospital administrator who hired Arafiles and fired the nurses, is indicted on two charges of retaliation. In March, he pleads guilty to abuse of official capacity for his role in the firing of the two nurses and promises to cooperate with the prosecution.

Last week, after a seven-day criminal trial and less than two hours deliberation, a Midland County jury convicted Roberts on all charges. He was sentenced — and unable to appeal — to four years of felony probation, $6,000 in fines and 100 days behind the bars of the same jail he ran for 20 years. He will be removed from office and must surrender his peace officer’s license. He will also retire from the county — with full benefits. Wiley testified during Roberts’ trial.

Two defendants await trial: Tidwell and the doctor. Arafiles continues his $200,000 job at the hospital even after the indictments. His contract is not renewed, and he is now practices in Grand Saline. If convicted of a felony, he will lose his medical license.

Despite the legal vindication, the nurses have lost their careers, half of their incomes and their quality of life.

The case prompted legislative action to protect nurses from criminal prosecution for patient advocacy. Howard and Nelson co-sponsored successful legislation to keep this nightmare from happening again. The governor should sign this bill.

Oh, if only this were all a movie script and not real life.

Inglis is an editor and a neonatal intensive care nurse with the Seton Family of Hospitals.

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July 15, 2011

New Study Adds to Evidence—California’s RN-Patient Ratios Law Improves Nursing, Patient Care

NEW YORK, NY - JUNE 22:  Members of the nurses...

Image by Getty Images via @daylife

Here is a press release from the nurse’s union, National Nurses United about the effect of California’s nurse-to-patient ratio has had on the number on nurses in California as well as the effect on patient outcomes.  This is an interesting press release, and yes, maybe it is self-serving, but I had just read another article on newswire about this exact same thing which I will post in a few days.

Let me know what your thoughts and feelings are about mandated ratios, won’t you.  I’d love to start a conversation here with all of you about the pros and cons of such a national law.


Health Affairs study on achievements of California safe staffing law

Another major study has reinforced a growing body of evidence that California’s landmark law requiring minimum, specific nurse-to-patient staffing ratios enhances registered nurse staffing and the quality of patient care.

The latest study, conducted by eminent University of Pennsylvania and Arizona State University researchers, appears in the July 2011 issue of Health Affairs.

Titled, “Contradicting Fears, California’s Nurse-To-Patient Mandate Did Not Reduce The Skill Level Of The Nursing Workforce In Hospitals,” the report <>  refutes worries promoted by healthcare industry opponents of the 1999 California law that hospitals might respond by disproportionately hiring lower-skill licensed vocational nurses.

In fact, following implementation of the law in 2004, the results have gone in exactly the opposite direction, the study concludes. California hospitals have added registered nurses, dramatically increasing patient access to professional RN care, a factor long associated with positive patient outcomes in a broad range of care barometers.

“This study brings home once again what California nurses could readily tell you. The safe staffing law has improved the quality of care in California hospitals, ensured that RNs have more time to spend with patients, respond to patient care incidents, and reduced the nursing shortage by keeping experienced, professional RNs where they belong, at the bedside,” said Deborah Burger, RN, a co-president of National Nurses United and the California Nurses Association.

CNA, an affiliate of NNU, the largest union and professional association of RNs in the U.S., sponsored the California law and fought off efforts by the hospital industry and former Gov. Arnold Schwarzenegger to roll back the law.

Overall, the authors write, “we found that the staffing mandate resulted in roughly an additional half-hour of nursing per adjusted patient day beyond what would have been expected in the absence of the policy.”

The study directly compared California hospitals to institutions in New York, Texas, Florida, and Pennsylvania – the five states with the most hospitals. While many states nationally saw increases in nurse staffing the past decade, in the period following implementation of the law, California readily surpassed the national average, and California had  five times as many registered nursing care hours as New York hospitals and twice as many as Texas hospitals.

Authors of the new study include Matthew McHugh and Douglas Sloane of the University of Pennsylvania’s Center for Health Outcomes and Policy Research in Philadelphia, UPenn nursing professor and well known RN researcher Linda Aiken, and Lesly Kelly, RN assistant professor at Arizona State University in Phoenix.

Aiken in particular is one of the nation’s foremost RN researchers and just last year led a study comparing California hospitals to facilities in Pennsylvania and New Jersey which documented that New Jersey hospitals would have 14 percent fewer patient deaths and Pennsylvania 11 percent fewer deaths if they matched California’s 1:5 ratios in surgical units.

In the new study, McHugh, Aiken, and the others note that the intent of the California Legislature in passing the CNA/NNU-backed law was to “improve quality of care and patient safety, and to retain nurses in employment in hospitals. Another primary goal of the law was to avoid high patient-to-nurse ratios, especially for registered nurses.”

Poor ratios, they note, are widely associated with “a number of negative patient outcomes, such as higher surgical mortality and higher complication rates due to errors” as well as to “job dissatisfaction and burnout” that drive nurses away from the patient bedside.

“The California law has clearly met all the goals, a major reason why safe RN ratios is considered the gold standard by direct care RNs across the nation,” says Burger.

Nurses throughout the U.S. continue to campaign for similar state and federal legislation, usually against the opposition of hospital corporate lobbyists.

NNU is sponsoring federal legislation, S 992, the National Nursing Shortage Reform and Patient Advocacy Act, in the Senate, and a companion House bill, HR 2187.

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July 12, 2011

Documentation, anyone?

Filed under: Nursing — Shirley @ 7:48 pm
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Here is an email I received that I thought was interesting

enough to post here.  I received it from the Nursing Center

e-News.  Feel free to check them out and get yourself added

to the email list.  I frequently get really good information and alerts from this source.


Inaccurate or incomplete documentation can lead to serious legal trouble. I’d like to share the following “red flags” to avoid in your documentation. These are from Stay Out Of Court With Proper Documentation in the April issue of Nursing2011.

Avoid the following in your documentation:

Read more about legal issues by exploring the articles in More Resources. You can also browse recent issues of JONA’s Healthcare Law, Ethics, and Regulation.

Our next issue will focus on hypertension and will include a new selection of CEs and articles. Be sure to check it out!

Lisa Bonsall, MSN, RN, CRNP
Clinical Edito

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July 8, 2011

Rep. Schakowsky Introduces Bill to Improve Patient Care & Curtail Nurse Shortage

Filed under: Nursing — Shirley @ 3:39 pm
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Here is an article from FierceHealthCare that I found about the government’s attempt to get nurses some protection and encourage nurses back into the profession.  On the one hand, I applaud the actual attempt to set some minimal staffing ratios for hospitals and nursing homes.

Nurses across the board are overworked and overwhelmed.  Nurses are leaving this profession in large numbers due to burnout, stress, fear of  being sued, fear of making a critical mistake and causing harm.  Nurses want to be able to help patients heal.  Period.

On the other hand, this article doesn’t really state what the actual bill would identify as a minimal staffing ratio.  Asking the administration of said hospitals to meet with staff nurses to determine minimum staffing is a joke.  That’s like telling the fox to guard the hen house.

Hospitals have to make a profit to stay in business, whether they are for-profit or not.  Nurse staffing is the singe largest expense that any hospital has after equipment.  There is no way that the hospital administrators will staff according to the nurses working for them.

Anyway, read this article and then let me know what you think, won’t you?


WASHINGTON, DC (June 15, 2011) – Representative Jan Schakowsky (D-IL) today introduced legislation to address increasing hospital mortality rates and preventable medical errors caused by nurse understaffing. The Nurse Staffing Standards for Patient Safety and Quality Care Act of 2011 would establish a federal minimum standard in all hospitals for direct care registered nurse-to-patient staffing ratios.   The bill would greatly improve patient care while helping to restrict the nursing shortage that has left hospitals across the country dangerously understaffed.

“Nurses are overworked and hospitals are understaffed, leading to disastrous results for patients everywhere,” said Representative Jan Schakowsky.  “By creating a workplace in which nurses are asked to do the impossible, we drive nurses away and jeopardize the quality of patient care. The bill is a common-sense solution to improve the quality of patient care and address the nursing crisis in our hospitals.”

The Nurse Staffing Standards for Patient Safety and Quality Care Act of 2011 would require that hospitals work with their direct care nurses to develop safe staffing plans that meet but can exceed  minimum nurse-to-patient staffing ratios.  The legislation would provide whistleblower protection and give nurses the ability to speak out for enforcement of safe staffing standards.

The bill would also require the Department of Health and Human Services to consider staffing requirements for licensed practical nurses and the Medicare Payment Advisory Commission to recommend any changes in additional reimbursement needed due to the requirements of the bill.

A recent study reported in the New England Journal of Medicine (March 17, 2011), found that  “when the nursing workload is high, nurses’ surveillance of patients is impaired, and the risk of adverse events increases.”  Other studies found that understaffing was a factor in one out of every four unexpected hospital deaths or injuries caused by errors and result in higher incidences of cardiac arrest, pneumonia, urinary tract infections and complications

The legislation is endorsed by the AFL-CIO, the Service Employees International Union, the American Federation of State, Country and Municipal Employees (AFSCME), the National Nurses United, the American Federation of Government Employees, the United Steelworkers, and the American Federation of Teachers.

Read more: Rep. Schakowsky Introduces Bill to Improve Patient Care & Curtail Nurse Shortage – FierceHealthcare


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July 1, 2011

Patient Classification Systems Address Nurse Staffing Balance

Here is an interesting article from Health Leaders Media that I found.  I have read this article several times, because I am impressed with the information it contains.  It is not often that you come across an article that actually gives nurses and nursing in general any credit for lowering bottom line costs and increasing productivity, while improving customer satisfaction.

As a nurse who has worked in the Sharp system as a travel nurse, I can say that their use of electronic staffing equipment far and away leads the nation.  The nurses working for this system really are satisfied and relatively happy with their current employment.  There is the ordinary stress-related bickering, but if asked, these nurses will mostly tell you that they like where they work.  That is a far cry from the responses I have gotten at other hospitals.

Please read this article and then let me know what you think.  Visit the original site, too, because there are many wonderful nursing articles available there.


Susan Stone, PhD, RN, and Ruth Plumb, MSN, RN, for HealthLeaders Media , May 24, 2011
Determined to achieve meaningful use of electronic health records (EHR), hospitals and health systems will increasingly adopt clinical information technology between now and 2015. This is certainly a welcome development for our economy and patient health. However, because providers are putting larger investments into EHR systems, they are overlooking other strategies to quickly enhance clinical and financial performance and support their pending transformation to accountable care.

While EHR technology is key to reducing costs and improving care quality, safety, and outcomes, providers also can achieve these goals by leveraging patient classification software and managing nursing staff more effectively. When used in parallel or integrated with an EHR, these combined resources give organizations extra tools to realize even greater clinical and financial benefits. This is a lesson that San Diego-based Sharp HealthCare has learned and benefited from over the past two decades.

Since 1990, Sharp HealthCare has used a nursing staff management solution to assign nursing staff and resources appropriately, improve care, and manage RN labor costs and department budgets. Every hospital faces these common challenges, but addressing them successfully is especially difficult for California-based providers struggling to survive the Golden State’s unique and pervasive capitated environment.

Though health systems in other states have not been exposed to capitation, this will change soon with the Patient Protection and Affordable Care Act allowing the Centers for Medicare & Medicaid Services (CMS) in early 2012 to use payment models such as partial capitation. Under this particular model, providers and accountable care organizations will bear some but not all of the financial risk.

In addition to helping organizations better manage their bottom line in a risk-based reimbursement environment, a patient classification system makes it easier for hospitals to comply with nurse-to-patient ratio regulations. Fifteen states and the District of Columbia have passed nurse staffing legislation, according to the American Nurses Association. But with hospitals admitting a higher volume of sicker patients and cutting nursing budgets across the country, RNs and others are increasingly urging lawmakers in other states to pass laws to ensure sufficient staffing to meet patients’ needs.

Having the right skill mix and nurses with the necessary skills readily available to take care of the right patient at the right time is essential to quality of care, patient safety and financial health. Still, it is common for nurses, unions, and state regulators to question hospitals’ staffing level decisions. An intensive care unit RN, for instance, may contend that a patient’s acuity demands his or her sole attention or the services of an additional nurse. This questioning or complaint about inadequate staffing, which tends to increase when facilities institute layoffs in poor economic times, is often emotional.

A patient classification system enables hospitals to remove emotion from the equation by demonstrating through hard data that its decisions are valid, not arbitrary. The tool applies an evidence-based approach to assign, match, and schedule nurses where they are needed the most based on patient acuity level.

Institutions that use the technology to assess acuity on every shift across all patient care units are able to provide objective documentation showing they are not understaffed, which of course places patients at risk. This proactive assessment of patient acuity helps ensure business continuity when regular charge nurses are out sick or on vacation. Replacements typically are less familiar with a unit’s policies and procedures, which can result in poor patient outcomes and higher costs.

A patient classification system promotes operational consistency by offering data on fill-ins that can be used to run a department efficiently in the absence of the regular charge nurse. More importantly, the process of assessing acuity on every shift gives health systems the ability to act immediately to prevent understaffing and overstaffing, both of which result in higher costs from potential malpractice lawsuits, disputes with employees, lost productivity and overtime.

Lack of awareness among many nurses about the budget process, healthcare financial management principles and how assignments are determined is a major reason for those costs. When bedside RNs are unaware of the financial role they play in managing and determining the fiscal health of their employer, nurses and administrators are pitted against each other.

To eliminate damaging infighting and wasteful spending, Sharp HealthCare, which serves 1.3 million residents of San Diego County in southwest California, has made it a priority to educate nurses how to use the patient classification system to analyze, track, and monitor staffing, productivity, and nursing budgets. Its leaders discuss the critical role that technology, patient acuity, and appropriate nurse assignments play. Every Sharp HealthCare facility shares annual financial targets and justifies its department budget. Hospital executives and RN leadership emphasize that their budget development is comparable to how RNs manage their household finances. In other words, the health system deploys the funds it has to provide care in the most efficient and cost effective manner possible. Like nurses—or anyone else—Sharp HealthCare cannot spend money it does not have.

Today, RNs understand staffing decisions are based on patients’ best interests as opposed to driven by an effort to save money at the expense of quality care. The results are fewer misunderstandings, misconceptions, and conflicts that distract Sharp HealthCare hospitals and nurses from their core clinical mission.

Sharp HealthCare sets goals for facilities partly based on the location and the size of an institution’s nursing staff. As a not for profit healthcare system, the organization’s long-term viability is dependent on its financial health and well being.

Increased nurse awareness and the nurse staffing management system have helped Sharp HealthCare not only weather a weak economy for the past three years, but also post impressive financial results during the same period.

The outreach also gives nurses a clearer view of the economic picture at the facility and enterprise levels, and how their institution compares to local and national peers. Whenever a financial variance occurs in their unit, RNs now can easily pinpoint it and determine the reason why. The software enables Sharp Healthcare to:

  • Deliver accurate patient acuity, skill mix, and census data in real time, ensuring charge nurses and nursing managers have the information necessary to optimize clinical and financial outcomes
  •  Analyze retrospectively whether nursing assignments were a factor in near misses that harmed or placed patients at risk
  • Aggregate information to enhance clinical, financial, and operational decision-making
  • Benchmark internal evidence-based data against national standards for acuity
  • Develop and successfully manage nursing budgets

To further increase time savings for nurses and validity and reliability of data, Sharp HealthCare now is working to integrate the software with its EHR.

With health reform altering reimbursement models and the first of 78 million baby boomers beginning to turn 65 years of age in 2011, staffing, clinical, and financial pressures on providers will only intensify. Since RN labor costs represent providers’ single largest controllable expense and a significant percentage of their operating budget, it is critical to use nursing resources more efficiently and enlist RNs as strategic assets and financially oriented managers. Providers following this path will find it easier to navigate the rapidly changing healthcare ecosystem and meet their goals.

Susan Stone, PhD, RN, is chief nursing officer and Ruth Plumb, MSN, RN, is an acuity nurse specialist at Sharp HealthCare, which comprises four acute care and three specialty hospitals in southwest California.

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