Monday, March 31, 2008

Ambulatory Nursing Shortage, alive or dead?

In Denver, 78-year-old Mary Heidenreich died when a nurse who had flunked a medication competency test accidentally gave her a fatal dose of intravenous drugs.

In Wichita, Kan., 38-year-old Deedra Tolson bled to death after an emergency hysterectomy when her nurse, busy caring for 12 other patients, failed to hear her feeble cries for help.

In Alliance, Ohio, 30-year-old Lisa Vitale was waiting to give birth when she felt searing pain rip through her abdomen. An overworked nurse misread Vitale's fetal monitoring strip and failed to notice that her baby was in serious distress. Born hours after an emergency cesarean section could have saved his health, Vitale's son suffered severe brain damage that left him unable to drink from a bottle and required round-the-clock medical care.

In Florida, William T. Fain, 80, fell, hit his head, suffered brain damage and died two weeks later, an autopsy report said all while under the care of an agency nurse at Westside Regional Medical Center. Fain came to the ER after a seizure on Super Bowl Sunday in 2006, his family said in a negligence suit filed last month. Doctors ordered nurses to send Fain to the ICU and, in the interim, take steps to prevent him from falling from his bed, the suit said. They were to put up bedrails, lower the bed and check him more often. The agency nurse on his case did none of those steps, the suit said. After he spent 12 hours in the ER, and shortly after his family left for the evening, nurses found Fain on the floor. He fell, hit his head, suffered brain damage and died two weeks later, an autopsy report said.

Realizing all of these incidents were Acute Care related, how long can we dodge this National Nursing Shortage in the Ambulatory Care setting?

• No matter what your historical staffing vacancy rates have been, it is time we all begin to plan for the inevitable. There is fewer nursing students entering the field than there are vacant positions needing filled. According to the Nurses Coalition, only one position out of ten vacancies are being filled by nursing graduates, leaving a 90% vacancy on the books to be filled by other means than a permanent full time nurse.

• Some argue that the Ambulatory Care setting is one of several culprits to this shortage that hazardously impacts the inpatient/acute care settings. This highly debatable theory is relatively squashed knowing of the nursing shortage we have in the ambulatory environment.

• One could speculate that many nurses could not argue the fact that patients do receive better quality care when the care is delivered by familiar staff, staff well trained in the facilities’ systems and protocols.

Ambulatory Surgery Centers deliver more cost effective care to the patient than that care of the hospital setting. We realize this to be true; our patient satisfaction scores validate this as a fact. The lower vacancy rates that the ASC industry presumes has a direct correlation to the scores of our patient’s satisfaction. What are we doing to safeguard this within our own industry? How do we work harder today at our retention rates to dodge the sting of the shortage needle?

A quick guide to consider as action items you and your surgery centers can employ to withstand the outbreak of this epidemic, infecting your surgical centers:
> Provide new hires with the appropriate number of hours towards a secure, documented, and effective training schedule under the direction of a preceptor.
> Ensure that any new hire is paid according to your salary scale with years of experience comparable to those other nursing staff members.
> Ensure that no newly hired staff nurse is walking into the position at a higher rate of pay than those presently employed.
> Provide a formal structure whereby the nursing staff meet regularly, with pay, to look at opportunities for streamlining processes that l reduce their workload, providing them more hours at the bedside.
> Ensure that all members of management provide positive feedback frequently, and constructive critism at the time of the event while maintaining their privacy.
> Provide timely evaluations to the staff and ensure raises are paid annually, if not more frequently.
> Participate in frequent and employee observed salary scale validation.
> Strive towards self-directed nursing staff groups, reducing the need for management hours.
> Adopt and Implement a nursing friendly charting program that invites the nursing staff to chart only the exception and what actions were taken to resolve.
> Insist that the nursing staff take their yearly vacations and not allow the organization to demerit the importance.

If employing outside agencies to meet your nurse to patient ratios dictated by state regulations, then try to minimize any adverse events or effects by:
> Hiring staff for long term assignments, i.e. travelers or local nurses
> Contacting with an agency that prides’ itself in their retention rates of their registry staff
> Require the agency to provide you data on the nurse that comes to work for you in your facility, i.e. performance evaluations, references to the last assignment worked, etc.
> Require the registry staff to take and pass the competency skills assessment test you and your governing board has adopted as the organizations’ minimum expectation for the interim position.
> Ensure that the registry contract is without the nuisance of a large buy out clause if you and your registry nurse would want to be placed as a permanent staff member, employed by the center.

The time has come for each of us to participate in objectively looking at our staff and the vacancy of any open positions. We must work just as hard at retaining those that do deliver quality care so that we might dodge the need to subject our surgical patients to the dangers of placing those registry nurses that do not.

Sunday, March 16, 2008

Surgery Center Design and Sq Feet used as a political weapon -

Troy Lair, PhD and CEO of The Compliance Doctor, LLC based out of Los Angeles writes this story and becomes headlines to the Missouri Times as "Political Weapons, Surgery Centers are now a target. Beware!"

This morning's news reported that the State of Missouri is considering legislation that will require existing abortion clinics (there are four of them) to conform to standards of 'ambulatory surgical centers' in order to continue offering their services. Proponents of the law call it 'common sense' and necessary for safety while abortion rights advocates decry it as a backdoor attempt to shut down abortion clinics.

Regardless of how you personally feel about the issue of abortion, this situation vividly shows how political architectural space can become. 'Ambulatory surgical centers' require 6 foot corridors and 12 x 12 examination rooms. One of the existing abortion clinics in Missouri has 5 foot corridors and 10 x 10 foot examination rooms. The new law would require the facility to essentially gut the majority of their spaces in order to comply-- about $650,000 of changes including plumbing, ventilation and other systems. The governor calls it one of the strongest pro-life laws ever put in place. Three of the four abortion clinics will have to make changes in order to comply with the new law. One doctor describes this will make it "difficult if not impossible to get abortions in this state".

Again, I bring up this issue not to necessarily spark a debate about abortion, but to point out that what we do as surgery center designers for space and patient flow for processes sometimes becomes a larger issue than first meets the eye. It is said that architecture is the manifestation of intention, and this intention embraces functional, spiritual and philosophical goals in addition to budgetary and tangible space issues. Oh, what tangled webs humans can weave.

Source: National Public Radio Morning Edition, March 14, 2008 · "Missouri Pro-Life and Anti-Choice Square Off" by Kathy Lohr. A federal judge is reviewing a Missouri law that requires abortion providers to become licensed as Ambulatory Surgical Centers. To do so requires retrofitting offices to meet codes. The new law is criticized as a bid by anti-choice legislators to make it difficult for women to get abortions.

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