Suzanne Gordon; Author, Lecturer and Patient Advocate

Anyone who is serious about genuine health care reform should immediately go to Amazon — or preferally their local, independent book store - and buy/order Philip Longman’s excellent book “Best Care Anywhere: Why VA Health Care Is Better then Your’s”  The book is much more than an exploration of the kind of care delivered at the nation’s largest public health system.  It explains precisely why “socialized” systems like the VA,  and other countries’ national health systems are the only ones that have an incentive to deliver better care and do it at lower costs than private systems.  Although right wing politicians excoriate “socialized” medicine, it turns out that almost half of our health care system is “socialized.”  (Note can we get rid of the bogeyman once and for all and realize that what “socialized” really stands for is “socially responsible.”)

In Longman’s book we learn that the VA has pioneered some of the most extraordinary health care information technology that is now used internationally as well as in the private sector.  This technology keeps patients much safer and it’s a direct result of the efforts of innovators who were working for the government.  Yes, that’s right, the government does actually do some things right.

We also learn that the VA delivers much more preventive and health maintenance services than private insurers.  Why?  Because the VA takes care of its patients from the moment they enter the system to the moment they die.  This long-term perspective gives the VA an incentive to deliver better care and to actually prevent or manage chronic illnesses that is utterly lacking in the private insurance market.  Why is it lacking?  Because the enrollees in private insurance plans turn over almost entirely every seven to ten years.  That means an investment in the long term care of patient A enrolled in insurance company B makes no economic sense because that investment will probably benefit insurance company H — the company the patient will land in twenty years down the road.  The same is true of private employers.  They have little incentive to initiate wellness programs for their employees.  “It makes no financial sense,” Longman writes,” for their employers to spend money to help them put off or avoid, for example, the various chronic diseases of old age, because most of these workers will be retired or moved on to a new job before anyone realizes the benefit of such an investment.”

The VA has an incentive to make a long-term investment in quality care– including prevention and health mainteance — because its patients stay in the system over the long-term.  That’s why, Longman, tells us, the VA will often purchase more expensive rather than cheaper medications because they are better and more effective and their perspective extends over years and is not fixed on the quarterly profit statement.  The VA also does more work with diabetics on nutrition and exercise and can actually tout it’s care of the sick because taking good care of people makes not only human but economic sense.

If hospitals and insurers advertise the fact that they have better services for sick people, like say diabetics, what happens?  They are punished for their good deeds.  They are inundated with sicker patients but not reimbursed commensurately.  Longman relays amazing data on why private insurers and hospitals don’t advertise their initiatives for chronically ill patients..”Suppose an HOM takes a more idealistic attitude and decides to invest in improving the quality of its diabetic care anyway.  Then not only will it risk seeing the return on that inevestment go to a competitior, but it will face another danger.  What happens if word gets out that this HMO is the best place to go if you have diabetes?  Then more and more costly diabetic patients will enroll there, requiring more premium increases, while its competitors enjoy a comparatively large supply of low-cost healthy patients.”  Ditto hospitals.  Why is it that insurers and hospitals only advertise pictures of healthy people.  Because they don’t want too many sick people to crowd the corridors.  Moreover, if hospitals initiate programs that make people healthier, then they are paid back by losing revenue.

Not so the VA.

This book, as I said before should be required reading for all policy makers and anyone interested in health care reform.  It should also encourage us all — not just vets and the families of vets - to support or local and national VA health care institutions.  Turns out, we are all benefiting from the innovations of this wonderful service and its dedicated workers.  Maybe instead of Medicare for all, the motto should be VA care for all.

Tonight is the last episode of the first season of Nurse Jackie and I, for one, will be very sorry to see it go.  As critics have pointed out, this is the one of the best, if not the best, shows on television and it’s about a nurse.  I know,I can hear nurses complaining that Nurse Jackie is not how nurses want to be presented on TV.  Some nurses are down on Nurse Jackie because she has so many problems.  Some nursing groups have complained — rather than congratulated — Showtime because Jackie isn’t picture perfect.  What they ignore is how real Jackie is.  Anyone who wants a nursing show that is “a love song to sensitive nurses”, as Boston Globe TV critic Mathew Gilbert wrote in today’s review of the show will be disappointed.  To desire such a “love song” would also be deeply misguided.  TV shows don’t do lovesongs and if they do, they don’t last.  Gone are the days of Marcus Welby MD.  We now have, god help us Grey’s Anatomy and The Practice.  Perhaps the best show to which to compare Nurse Jackie is Rescue Me.  Along with nurses, firefighters routinely garner the highest scores on public trust.  But Rescue Me doesn’t depict a bunch of saints sitting around the firehouse.  The characters are a group of deeply dysfunctional men and women.  They drink too much, fight too much, and live amidst the debris of failed relationships.  They even disobey the rules when fighting fires and rescuing victims.  But they are unfailing pros who exhibit courage,compassion and expertise when those alarms go off.  Which is why firefighters like the show and why firefighting organizations don’t launch protests against it.

Nurse Jackie fits precisely into this mold, only in my opinion the show is a lot better.  Why do nurses want an angel in the hospital?  Why don’t they understand the difference between early 21st TV drama and a public service announcement for the profession?  I wonder if it has to do with the fact that Nurse Jackie — perhaps inadvertently — reveals one of the profession’s closest held secrets.  That many nurses treat themselves — and each other  –as badly as Nurse Jackie treats herself.  In his review of Nurse Jackie in the Boston Globe (http://www.boston.com/ae/tv/articles/2009/08/24/nurse_jackie_wraps_up_a_compelling_first_season/) points out, the compassion Jackie shows her patients “never extends to herself.”  He also notes correctly, that those around her don’t seem to notice how she is self-destructing.  In other words, no one nurses the nurse.

This is one of  the fundamental fact of nursing today — perhaps of nursing perenially.  Nurses are expected and do — as nurse Jackie does –  sacrifice themselves on a daily basis for their patients.  But they don’t take care of themselves and the institutions that employ them all too often treat them like machines rather than valued professionals.  In fact, sometimes hospitals treat their machines better than they treat their RNs and other nursing staff.  Hospitals maintain their high tech equipment far better than they maintain their nurses.  Just ask any nurse when she/he last had her/his lunch break on time or whether she’s/he’s had a UTI recently because of not being able to go to the bathroom and you’ll find that out pretty quick.  When our cars are on empty we fill them with fuel.  When are nurses are running on empty we just ask them to run further.  The result is a lot of nurses who have problems similar to those of Nurse Jackie.  They may not be popping uppers and downers.  But they have more depression, hypertension and other stress related illnesses than the rest of the population.  And just look at the obesity epidemic in nursing.  It’s frightening.  That’s probably because nurses are in chronic stress which means higher cortisol levels, lower immunity, and higher craving for food.

I am saddened every time I talk to nursing audiences about Nurse Jackie and learn that nurses don’t like the show.  What saddens me even more is how many nurses comment negatively about Nurse Jackie but haven’t even watched one episode.  It’s not too late.  The show will certainly be out on DVD and it will, thank you Showtime and Edie Falco and all those who have worked on the show — be with us next year.  I personally can’t wait.

another great review on the show was in USA today

http://www.usatoday.com/life/television/reviews/2009-08-23-nurse-jackie_N.htm

I have great respect for the IOM and am sure that the folks on the committee that is exploring the future of nursing have excellent intentions.   But here’s the problem, if you check out who is on this committee it includes only high level management and corporate representatives.  One of the people on the committee is John Rowe, who is the former CEO of Aetna.  According to researchers on health care overhead and administrative costs, Rowe  — a former geriatrician –earned more than $200,000 a day as CEO of Aetna.  I did the math and turned that into an hourly wage — assuming that Rowe worked a ten hour day — and came up with guess how much he earned each hour?  Over $18,000 an hour.  Is anyone on earth worth that?  So one man earned, in say three hours, more than the average nurse makes in a year.  I am sure Rowe is well-intentioned, but like the traders on Wall Street who are now guaranteed bonuses without regard to performance, such corporate compensation without regard to how an insurance company like Aetna performs for its subscribers/patients strikes me as a disqualifier for someone talking about the future of nursing.  Aetna was obviously very profitable for Rowe, but like other insurers it routinely denied sick patients needed services, forced  them to wait for hours on 800 lines, and routinely denied coverage because of preexisting conditions.

Check out who is on the committee.  There is no staff nurse representation .  No union representation even though unions make up the majority of nurses who belong to an organization within nursing.  More to the point, IOM recommendations tend to be exclusively voluntary.  I am therefore dubious that this committee, well intentioned as it maybe, will be able to grapple with the serious issues that face the profession.  What are some of those issues?

Well of the most crucial ones is work intensification — i..e  nurses are constantly asked to do more with less, while their CEOs  seem to be rewarded for doing less with more.  Today, I was reading an article in the New York Times about Wall Street firms guaranteeing bonuses to traders — even if they lose money for a firm or client.  Seems that Wall Street firms — who have done so much to advance our well-being economically and otherwise — are so eager to attract talent that they will tell traders they are assured say an extra $100 million even if they screw up.  Yet, our society, which supposedly values and trusts nurses is not willing to even guarantee a nurse a day’s pay.  Nurses all over the country come to work only to be told to go home when there aren ‘t enough patients.  Or they’re told not to come in on a scheduled day and take a sick, vacation or personal day instead.  Is this the way we treat a valued professional?  When I cancel an appointment with my massage therapist less than 24 hours in advance I have to pony up the entire fee for the hour I missed.  But RNs with years of educaiton and experience are supposed to live on air and altruism.  Will the new IOM committee consider this?

What about the way that hospitals are racing patients through the hospital bed via computerized bed tracking programs.  Nurses all over the country are complaining that the moment the patient comes into the bed, what concerns their management is not what happens when the patient is actually in the bed, but how quickly the nurse can get the patient out of the bed.  It is critical to consider how  this corporate focus on through-put impacts nursing practice.  “The moment the patient arrives, we have to estimate how quickly they will be discharged,” one nurse told me recently.  What is most important to her managers, she said, was the patient’s exit not what happens to the patient when he or she is in the hospital.  Of course, discharge planning is a crucial part of any attempt at patient management.  But if or when planning for the discharge seems to overshadow planning and delivering exquisite care to  the patient before they leave the hospital, then something is very wrong.  Yet nurses on the ground say this is precisely what is happening.  I am curious to know whether the IOM will look into this.

Perhaps the most distressing thing we see in all this is how the mechanisms of the factory assembly-line are invading health care.  Strategies to intensify work — to get nurses to do less with more –defeat nurses’ attempt to maintain a professional practice.  Although all of these assembly-line strategies come neatly packaged in the rhetoric of patient-centered care,   it is clear that efficiency, defined in classic economic terms as how few inputs can produce a particular output so that the cost is cheaper, often compromises patient outcomes.  Moreover, the industrialization of nursing work also compromises nurses’ sense of job satisfaction and ability to maintain professional standards.  Those who consider themselves to be nursing leaders talk alot about professionalism and professional integrity.  Yet many of the policies they promote Taylorize the work and deprofessionalize the worker.  Moreover, they convince working nurses that management is not merely not on their side but actually against them.  When a computerized bed utilization system was introduced in her hospital, one new nurse– who’d only been out of nursing school for a couple of years– had this to say.  “They (hospital management) hate us. Why do they hate us?”

I’d like to hear from working nurses about these work intensification issues and also let me know what you think about all this.  Do you have experience with new computerized systems?  Do you feel that your workload has increased with the introuduction of computerized systems?  Do you feel supported by management?

If you’re a manager how do you feel about what I’ve said?

The other day a journalist from Modern Healthcare called to interview me about the new
IOM committee on the future of healthcare.  I had lots to say, but of course only a tiny bit made it in to the artcile.  Here’s the article.  and more comments will follow in another post.

Rethinking Nursing
The IOM has convened a nursing initiative to draft a blueprint for nursing, but some say ‘corporate elites’ will only provide toothless recommendations

By Joe Carlson
Posted: July 20, 2009 - 5:59 am EDT

As a wave of reform legislation threatens to upend many certainties in healthcare, the industry’s largest single workforce-nursing-already finds itself at the cusp of significant change.
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Today’s nurses sit in an uneasy state of tension on critical issues, such as: when to expand their scope of practice to meet primary-care needs, whether technology is actually freeing up more time for patient care, and how to train enough new nurses at appropriate educational levels.

Experts say those are some of the key issues that are likely to emerge when an Institute of Medicine commission begins an inquiry that organizers are billing as a ground-breaking study of the profession.

The Initiative on the Future of Nursing, funded by a $4 million grant from the Robert Wood Johnson Foundation, is intended as a critical examination that could shatter existing conceptions of the field and lay out a blueprint for 21st century nursing. “They consider this a transformational opportunity, and they’d like a report that is transformational,” said study commission Chairwoman Donna Shalala, who was an HHS secretary in the Clinton administration and today is president of the University of Miami. “It could be like a torpedo, and cut right through the trees, and the forest, and give us a clear pathway if it’s successful.”

The commission held its inaugural meeting in Washington on July 14, two days before nursing took the national stage as President Barack Obama announced in a pro-reform news conference in the White House Rose Garden, “I should disclose right off the bat, I have a long-standing bias towards nurses.”

Due in fall 2010

Although the IOM commission’s official announcement was swathed in language referencing the ongoing reform efforts in Congress, organizers say that their report is not due out until fall 2010-well after the self-imposed deadlines for reform legislation. Organizers say they want the report to have its impact when providers and payers start scrambling toward the goals enshrined in whatever reform legislation becomes law. “We hope we will get legislation this year for health reform, but I think it’s inconceivable that that will be the last word for health reform,” IOM President Harvey Fineberg said.

Committee members include: Linda Burnes Bolton, chief nursing officer with 914-bed Cedars-Sinai Medical Center, Los Angeles; Jennie Chin Hansen, president of the AARP; C. Martin Harris, chief information officer of the 1,080-bed Cleveland Clinic; Robert Reischauer, president of the Urban Institute; and John Rowe, professor of health policy at Columbia University and former chairman and CEO of Aetna.

The effort already is not without critics. Vanderbilt University School of Nursing Dean Colleen Conway-Welch said nurses already know the answers to most of the questions posed by the group, but those solutions will never become reality until the other fractured healthcare constituencies, like physicians and specialty practitioners, also agree to changes. Labor leaders noted that the 16-member committee lacks a union representative or, for that matter, any member who is an active staff nurse besides a nurse-midwife who graduated with her degree in 2008 (See related editorial, p. 20).

Suzanne Gordon, author of more than half a dozen nursing books, including co-authorship of Safety in Numbers: Nurse-to-Patient Ratios and the Future of Health Care, said she expected no greater impact from this latest IOM commission than what happened after the institute’s 1996 report from its committee called the Adequacy of Nurse Staffing in Hospitals and Nursing Homes. “Like the other IOM report, the 1996 report on staffing, this one suffers from the same problem, which is that you have corporate elites doing the study, and you end up with a series of recommendations that are all voluntary,” Gordon said.

Not so, organizers say. “The work of this committee will not simply sit on a shelf,” Fineberg said. “It is both distinctive and different from what was done in the past.”

When the committee begins its formal inquiry-which will analyze past reports, new data sets and public dialogue from three town hall-style meetings-experts say one of the key subject areas they will discover is the tension between nurses and their fellow healthcare workers in defining the scope of work.

The Robert Wood Johnson Foundation specifically charged the committee with investigating whether advance practice nurses should perform more primary-care services, but resistance to that concept could prove strong down the road. “The reality is there is a great tension between physicians’ organizations and nurses’ organizations in terms of what should be the scope of practices,” SEIU Healthcare Chairman Dennis Rivera said. The physicians’ perspective has been that an increase in nurses’ responsibilities would invade the space of the physicians, he said. Conway-Welch, the nursing dean at Vanderbilt in Nashville, said she hoped that the committee could bring together all stakeholder groups to resolve scope-of-care issues because progress in the past has been stymied by the silo mentality of the various interest groups and their associations. Nurses, physicians, public health officials-those and more-will have to figure out how to come to the table and broker common solutions and concessions in order to achieve the ultimate goal of reform, which she summarized as: “The right provider giving the right care at the right time to the right patient for the right reasons at the right cost in the right setting, for the right reimbursement. If we can do that, we’ll solve an enormous amount of problems,” Conway-Welch said.

Technological advances

Nurses of the future will also have to deal with technological advances. Observers say advanced and ever-changing electronic health-record systems are leading to rapid improvements in nursing informatics, whose practitioners are building vast databases that help define new care models for nurses.

The new information technology doesn’t necessarily lead to time-savings-hospital officials say tasks like bar-code scanning of medications is more time-consuming than drug administration from hand-written orders-but it will become more common as the drive toward quality means eliminating preventable errors.

Discussions of any length on the challenges facing staff nurses eventually all lead back to the classroom. Observers ask why, for example, are the latest advances in healthcare technology still not being taught in many schools if that technology is expected to remain a permanent fixture of the profession?

Observers note that the system of educating new nurses is essentially the same as it has been for decades-which is to say, fragmented from the other healthcare professions and regulated under different standards in the 50 states. Rebecca Patton, president of the American Nurses Association, said it makes no sense that so many different levels of education were available to nurses, including two-year associate degrees, three-year nursing diplomas and four-year baccalaureate programs. Patton favors a single educational standard based on the available scientific evidence, although that has been a difficult argument to make in light of the nursing shortage.

“It’s been a difficult conversation for our industry to have,” Patton said. “To individuals who are uninformed, they don’t understand why you can’t be a nurse in two years. … But the data is showing that patient outcomes are impacted by the educational preparations … and it’s the four-year degree that’s needed.”

Even in the well-trod subject matter of the nursing shortage, the IOM committee may find new solutions. Nancy Korom, the vice president of patient-care services at 236-bed Children’s Hospital of Wisconsin, Milwaukee, said her hospital and others in the area have worked hand-in-hand with nursing schools to enable them to expand student enrollment without adding staff.

Children’s Hospital has agreed to have some of its master’s-educated nurse practitioners teach semesterlong courses at nursing schools, for example. Hospital officials also sponsor students entering nursing programs who make commitments to the facility, and the hospital has agreed to expand its clinical rotation programs for students when the demand is there, Korom said.

The organizations that set up the initiative want the study commission and their eventual readers to remain open to innovative solutions to problems that have been widely discussed in the past. “The issue is how do we really shift the paradigm so that we can rid ourselves of this waxing and waning of shortages, and at the same time prepare them for the 21st century needs that patients have?” Robert Wood Johnson Foundation President and CEO Risa Lavizzo-Mourey said.