In our recent conversations with executives, we’ve heard that the workforce crisis continues to be the most urgent issue confronting health systems.
It’s a many-sided problem: early retirements hitting the nursing staff, leading to an overall loss of experience; early and mid-career nurses choosing to work for temporary staffing agencies for much higher pay, resulting in increased labor costs and resentment among remaining nurses; and a rising vacancy rate made more challenging by difficulty competing for talent against others offering higher pay and less stressful work environments.
But one factor undermining frontline nurse engagement hadn’t occurred to us, until we heard a chief nursing officer describe it this week. The lingering supply chain crisis is forcing hospitals to change where they purchase basic items—think IV tubing and bags, surgery kits, some basic drugs—which in turn forces nurses to adapt to using unfamiliar supplies on the fly, making for a less predictable work environment. On a busy and staff-constrained nursing unit, even small changes to standard procedures can be incredibly frustrating for nurses, and even lead to patient safety issues. Just another way in which the current environment is creating unprecedented pressure on healthcare workers, with little prospect for improvement anytime soon.
Some pundits claim that current reporting on COVID hospital admissions is overly pessimistic, failing to account for a distinction between patients admitted explicitly “for COVID”, and those admitted for other reasons who also, incidentally, have COVID. The latter now comprise up to half of some health systems’ COVID patients.
In an article in The Atlantic this week, reporter Ed Yong rejects this dichotomy, on the grounds that it ignores both the significant number of people for whom COVID exacerbates underlying chronic conditions, as well as the challenges any patient with COVID poses to hospitals. As he points out, those patients still require isolation and special safety measures, further worsening the burden on an already-strained staff.
The Gist: For hospitals, dealing with endemic COVID will mean establishing strategies to manage COVID-positive patients without postponing much needed non-emergency care, and without overly taxing a stretched workforce. Downplaying the burden of “incidental COVID” is not helpful, but sustaining operations while on perpetual crisis footing will prove untenable.
The healthcare industry’s staffing shortage crisis has had clear consequences for care delivery and efficiency, forcing some health systems to pause nonemergency surgeries or temporarily close facilities. Less understood is how these shortages are affecting care quality and patient safety.
A mix of high COVID-19 patient volume and staff departures amid the pandemic has put hospitals at the heart of a national staffing shortage, but there is little national data available to quantify the shortages’ effects on patient care.
The first hint came last month from a CDC report that found healthcare-associated infections increased significantly in 2020 after years of steady decline. Researchers attributed the increase to challenges related to the pandemic, including staffing shortages and high patient volumes, which limited hospitals’ ability to follow standard infection control practices.
“That’s probably one of the first real pieces of data — from a large scale dataset — that we’ve seen that gives us some sense of direction of where we’ve been headed with the impact of patient outcomes as a result of the pandemic,” Patricia McGaffigan, RN, vice president of safety programs for the Institute for Healthcare Improvement, told Becker’s. “I think we’re still trying to absorb much of what’s really happening with the impact on patients and families.”
An opaque view into national safety trends
Because of lags in data reporting and analysis, the healthcare industry lacks clear insights into the pandemic’s effect on national safety trends.
National data on safety and quality — such as surveys of patient safety culture from the Agency for Healthcare Research and Quality — can often lag by several quarters to a year, according to Ms. McGaffigan.
“There [have been] some declines in some of those scores more recently, but it does take a little while to be able to capture those changes and be able to put those changes in perspective,” she said. “One number higher or lower doesn’t necessarily indicate a trend, but it is worth really evaluating really closely.”
For example, 569 sentinel events were reported to the Joint Commission in the first six months of 2021, compared to 437 for the first six months of 2020. However, meaningful conclusions about the events’ frequency and long-term trends cannot be drawn from the dataset, as fewer than 2 percent of all sentinel events are reported to the Joint Commission, the organization estimates.
“We may never have as much data as we want,” said Leah Binder, president and CEO of the Leapfrog Group. She said a main area of concern is CMS withholding certain data amid the pandemic. Previously, the agency has suppressed data for individual hospitals during local crises, but never on such a wide scale, according to Ms. Binder.
CMS collects and publishes quality data for more than 4,000 hospitals nationwide. The data is refreshed quarterly, with the next update scheduled for October. This update will include additional data for the fourth quarter of 2020.
“It is important to note that CMS provided a blanket extraordinary circumstances exception for Q1 and Q2 2020 data due to the COVID-19 pandemic where data was not required nor reported,” a CMS spokesperson told Becker’s. “In addition, some current hospital data will not be publicly available until about July 2022, while other data will not be available until January 2023 due to data exceptions, different measure reporting periods and the way in which CMS posts data.”
Hospitals that closely monitor their own datasets in more near-term windows may have a better grasp of patient safety trends at a local level. However, their ability to monitor, analyze and interpret that data largely depends on the resources available, Ms. McGaffigan said. The pandemic may have sidelined some of that work for hospitals, as clinical or safety leaders had to shift their priorities and day-to-day activities.
“There are many other things besides COVID-19 that can harm patients,” Ms. Binder told Becker’s. “Health systems know this well, but given the pandemic, have taken their attention off these issues. Infection control and quality issues are not attended to at the level of seriousness we need them to be.”
What health systems should keep an eye on
While the industry is still waiting for definitive answers on how staffing shortages have affected patient safety, Ms. Binder and Ms. McGaffigan highlighted a few areas of concern they are watching closely.
The first is the effect limited visitation policies have had on families — and more than just the emotional toll. Family members and caregivers are a critical player missing in healthcare safety, according to Ms. Binder.
When hospitals don’t allow visitors, loved ones aren’t able to contribute to care, such as ensuring proper medication administration or communication. Many nurses have said they previously relied a lot on family support and vigilance. The lack of extra monitoring may contribute to the increasing stress healthcare providers are facing and open the door for more medical errors.
Which leads Ms. Binder to her second concern — a culture that doesn’t always respect and prioritize nurses. The pandemic has underscored how vital nurses are, as they are present at every step of the care journey, she continued.
To promote optimal care, hospitals “need a vibrant, engaged and safe nurse workforce,” Ms. Binder said. “We don’t have that. We don’t have a culture that respects nurses.”
Diagnostic accuracy is another important area to watch, Ms. McGaffigan said. Diagnostic errors — such as missed or delayed diagnoses, or diagnoses that are not effectively communicated to the patient — were already one of the most sizable care quality challenges hospitals were facing prior to the pandemic.
“It’s a little bit hard to play out what that crystal ball is going to show, but it is in particular an area that I think would be very, very important to watch,” she said.
Another area to monitor closely is delayed care and its potential consequences for patient outcomes, according to Ms. McGaffigan. Many Americans haven’t kept up with preventive care or have had delays in accessing care. Such delays could not only worsen patients’ health conditions, but also disengage them and prevent them from seeking care when it is available.
Reinvigorating safety work: Where to start
Ms. McGaffigan suggests healthcare organizations looking to reinvigorate their safety work go back to the basics. Leaders should ensure they have a clear understanding of what their organization’s baseline safety metrics are and how their safety reports have been trending over the past year and a half.
“Look at the foundational aspects of what makes care safe and high-quality,” she said. “Those are very much linked to a lot of the systems, behaviors and practices that need to be prioritized by leaders and effectively translated within and across organizations and care teams.”
She recommended healthcare organizations take a total systems approach to their safety work, by focusing on the following four, interconnected pillars:
Culture, leadership and governance
Patient and family engagement
For example, evidence shows workforce safety is an integral part of patient safety, but it’s not an area that’s systematically measured or evaluated, according to Ms. McGaffigan. Leaders should be aware of this connection and consider whether their patient safety reporting systems address workforce safety concerns or, instead, add on extra work and stress for their staff.
Safety performance can slip when team members get busy or burdensome work is added to their plates, according to Ms. McGaffigan. She said leaders should be able to identify and prioritize the essential value-added work that must go on at an organization to ensure patients and families will have safe passage through the healthcare system and that care teams are able to operate in the safest and healthiest work environments.
In short, leaders should ask themselves: “What is the burdensome work people are being asked to absorb and what are the essential elements that are associated with safety that you want and need people to be able to stay on top of,” she said.
To improve both staffing shortages and quality of care, health systems must bring nurses higher up in leadership and into C-suite roles, Ms. Binder said. Giving nurses more authority in hospital decisions will make everything safer. Seattle-based Virginia Mason Hospital recently redesigned its operations around nurse priorities and subsequently saw its quality and safety scores go up, according to Ms. Binder.
“If it’s a good place for a nurse to go, it’s a good place for a patient to go,” Ms. Binder said, noting that the national nursing shortage isn’t just a numbers game; it requires a large culture shift.
Hospitals need to double down on quality improvement efforts, Ms. Binder said. “Many have done the opposite, for good reason, because they are so focused on COVID-19. Because of that, quality improvement efforts have been reduced.”
Ms. Binder urged hospitals not to cut quality improvement staff, noting that this is an extraordinarily dangerous time for patients, and hospitals need all the help they can get monitoring safety. Hospitals shouldn’t start to believe the notion that somehow withdrawing focus on quality will save money or effort.
“It’s important that the American public knows that we are fighting for healthcare quality and safety — and we have to fight for it, we all do,” Ms. Binder concluded. “We all have to be vigilant.”
The true consequences of healthcare’s labor shortage on patient safety and care quality will become clear once more national data is available. If the CDC’s report on rising HAI rates is any harbinger of what’s to come, it’s clear that health systems must place renewed focus and energy on safety work — even during something as unprecedented as a pandemic.
The irony isn’t lost on Ms. Binder: Amid a crisis driven by infectious disease, U.S. hospitals are seeing higher rates of other infections.
“A patient dies once,” she concluded. “They can die from COVID-19 or C. diff. It isn’t enough to prevent one.”
Facing intense criticism from hospital executives and emergency physicians, the nation’s largest health insurer, UnitedHealthcare (UHC), delayed the implementation of a controversial policy aimed at reducing what it considers to be unnecessary use of emergency services by its enrollees.
The policy, which would have gone into effect next month, would have denied payment for visits to hospital emergency departments for reasons deemed to be “non-emergent” after retrospective review. Similar to a policy implemented by insurer Anthem several years ago, which led to litigation and Congressional scrutiny, the UHC measure would have exposed patients to potentially large financial obligations if they “incorrectly” visited a hospital ED.
Critics pointed to longstanding statutory protections intended to shield patients from this kind of financial gatekeeping: the so-called “prudent layperson standard” came into effect in the 1980s following the rise of managed care, and requires insurance companies to provide coverage for emergency services based on symptoms, not final diagnosis. UHC now says it will hold off on implementing the change until after the COVID-19 national health emergency has ended, and will use the time to educate consumers and providers about the policy.
Like many critics, we’re gobsmacked by the poor timing of United’s policy change—emergency visits are still down more than 20 percent from pre-pandemic levels, and concerns still abound that consumers are foregoing care for potentially life-threatening conditions because they’re worried about coronavirus exposure. Perhaps UHC is trying to “lock in” reduced ED utilization for the post-pandemic era, or perhaps they never intended to enforce the policy, hoping that the mere threat of financial liability might discourage consumers from visiting hospital emergency rooms.
While we share the view that consumers need better education about how and when to seek care, combined with more robust options for appropriate care, this kind of draconian policy on the part of UnitedHealthcare just underscores why many simply don’t trust profit-driven insurance companies to safeguard their health.
An Advocate Aurora Health pharmacist who intentionally damaged 570 doses of COVID-19 vaccine was sentenced to three years in prison, according to NBC affiliate WTMJ of Milwaukee.
Steven Brandenburg worked at Aurora Medical Center in Grafton, Wis., when he removed Moderna COVID-19 vaccine vials from refrigeration twice in December. He told investigators he believed the vaccine could harm patients or change their DNA.
He was arrested Dec. 31 on charges of first-degree recklessly endangering society, adulterating a prescription drug and criminal damage to property.
Fifty-seven people received the vaccines after they were left out, but they will likely experience no harm, according to officials with Aurora Health Care, based in both Milwaukee and Downers Grove, Ill.
After Aurora Health Care investigated the incident, Mr. Brandenburg was fired. He and the Wisconsin Pharmacy Examining Board agreed on his license suspension during a Jan. 13 meeting.
Mr. Brandenburg on Jan. 26 agreed to plead guilty to two counts of attempting to tamper with consumer products with reckless disregard.
On June 8, Mr. Brandenburg was sentenced to three years in prison. After serving his sentence, he will face another three years of supervised release.
Mr. Brandenburg told the court he was “desperately sorry and ashamed” about tampering with the vaccines. He also said Aurora Health Care is a “pillar of the community” and “did not deserve” the incident, according to WTMJ.
As we’ve talked to health system executives about the challenges of rolling out COVID vaccines in their communities, one topic keeps coming up: how difficult it’s been to get hospitals’ own workers fully vaccinated. One system told us recently that only 55 percent of their frontline caregivers have opted to get vaccinated, despite early and easy availability, and ongoing encouragement from the hospital’s leaders.
Healthcare workers, it turns out, are just like the general population, bringing the same diversity of perspectives and concerns about vaccination to work with them from their own communities. Vaccine hesitancy is not a new issue for hospital staffers; getting the workforce to take the flu vaccine is an annual struggle for many hospitals.
But given the risks of COVID-19, why not just mandate that hospital employees get the vaccine, as other employers have started to do? We commonly hear two concerns.
One is a labor relations worry: will mandating vaccination cause workers to quit, or make it harder to hire staff in an already difficult market for talent? And given growing concerns about unionization of healthcare workers, will mandatory vaccination become a flashpoint issue?
The second concern is medical liability: can we force workers to get a vaccine that hasn’t been fully approved by the FDA? Would that expose the hospital to legal challenges down the road, if there turn out to be long-term complications from the vaccine?
Our own view is that the first concern is overblown—we suspect vaccine mandates are going to become more and more common as the economy reopens. As to the second, we’re more sympathetic. But once the FDA does grant full approval for the vaccines, we’d hope hospitals will get tougher about vaccine mandates (with the necessary exemptions for health, religious, and other concerns).
At the end of the day, hospitals are in the patient care business, and they should view vaccine mandates—whether for COVID or for influenza—as a patient safety issue, not a workforce engagement issue.
A patient accused of fatally beating his roomate at Antelope Valley Hospital in Lancaster, Calif., has been arrested and charged with murder, elder abuse and a hate crime enhancement, according to the Los Angeles County Sherrif’s Department.
The victim, an 82-year-old man, was being treated for COVID-19 and sharing a room with the suspect, identified as 37-year-old Jesse Martinez. The victim, whose name has not been released, began to pray in his hospital room on Dec 17. That act upset Mr. Martinez, who allegedly struck the victim with an oxygen tank. The man died of his injuries Dec. 18, police said.
Mr. Martinez is being held at the Twin Tower Correctional Facility in Los Angeles, and his bond is set at $1 million. He’s scheduled to appear in court Dec. 28.
Police said the investigation into the incident is ongoing, and the motive is not immediately clear.
University of Chicago Medical Center has closed its level 1 trauma center for adult and pediatric patients as it prepares for about 2,200 nurses to go on strike next week, medical center leaders announced.
Medical center leaders said UCMC closed its pediatric level 1 trauma program Nov. 18 and its adult trauma program Nov. 20. Its adult and pediatric emergency rooms continue to take walk-in patients.
Nurses are scheduled to strike Nov. 26, two days before Thanksgiving. The nurses also walked off the job Sept. 20 in a strike organized by National Nurses Organizing Committee/National Nurses United. They were allowed to return to work Sept. 25, after the medical center said it fulfilled its contract with temporary nurses to replace the striking ones for five days.
In preparation for the strike, UCMC announced earlier this week that it is moving about 50 babies and 20 children in its neonatal and pediatric intensive care units to other facilities.
UCMC President Sharon O’Keefe is also recruiting about 900 replacement nurses.
However, “it’s exceptionally difficult to hire people who are willing to leave their families during Thanksgiving,” she said in a news release. “At the same time, other hospitals in the city are already at or near capacity, which means they will not be able accept transfers of current inpatients if that need arises when nurses walk out. The combination of the two led us to take the step of temporarily closing our trauma program ahead of the strike.”
UCMC said the hospital was required to offer replacement nurses five days of work “to best recruit qualified and experienced replacement nurses.” Therefore, the nurses on strike will not be able to return to work until 7 a.m. Dec. 1.
Negotiations between UCMC and National Nurses Organizing Committee/National Nurses United began earlier this year. Medical center leaders say incentive pay — and whether the hospital should end the pay for newly hired nurses — is a sticking point in negotiations, according to the Chicago Tribune. The union has continued to express concerns about staffing levels.
The nurses said they plan to strike unless an agreement is reached.
Rural America is stuck in a cycle of increasingly vulnerable patients with declining access to health care.
Why it matters: Rural patients often can’t afford care, are being hounded by hospitals and collection agencies over their unpaid bills, and are facing the reality of life in communities where the last hospital has closed.
Rural Americans tend to be older, sicker and lower-income than urban Americans. They suffer from higher rates of obesity, mental health issues, diabetes, cancer and opioid addiction, as my colleagues Stef Kight and Juliet Bartz reported.
They’re also more likely to be uninsured or covered by Medicare or Medicaid, which pay doctors and hospitals less than private insurance does.
A small and shrinking population, mostly covered by insurance plans that don’t pay very much, many of whom need a lot of care, puts more financial pressure on providers, especially hospitals. Physician shortages are common.
What they’re saying: “Rural hospitals have long been right there on the edge on average, and we’re seeing more and more of them flip over to red,” said Mark Holmes, a professor at UNC-Chapel Hill and director of the Cecil G. Sheps Center for Health Services Research.
And hospital closures often exacerbate the problems communities were already facing.
Hospitals are often the largest or second-largest employer in a rural community.
These are disproportionately located in the South — the region with the nation’s worst health outcomes, and where most states haven’t expanded Medicaid — leaving hospitals with more uninsured patients.
A 2018 study in Health Affairs found that Medicaid expansion is “associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets.”
The bottom line: “What we have here is not one root cause; there’s multiple things going on here,” Holmes said. “All these sort of modest kind of trends are adding up to something that’s quite considerable.”
Bloomberg Businessweek reported on eastern Montana’s sole psychiatrist, despite being the state with the nation’s highest suicide rate.
The Washington Post detailed a hospital in Missouri’s practice of suing its patients for payment — money that the hospital needed but patients generally don’t have.
Kaiser Health News and NPR have profiled the fallout in a rural community in Kansas after its sole remaining hospital closed, which included a 2-week lapse in nearby emergency care.
In this Oct. 26, 2018, file photo, Sen.Bob Casey, D-Pa., speaks to reporters in the studio of KDKA-TV in Pittsburgh. For years the federal government for years has kept under wraps the names of hundreds of nursing homes around the country found to have serious health, safety or sanitary problems. Lawmakers say the silence calls into question the government’s commitment to families going through the difficult process of finding a nursing home for a loved one. The secrecy began to crack Monday when two U.S. senators from Pennsylvania released the government’s list.
In a turnabout, the government said Wednesday it will start posting a list of some 400 troubled nursing homes , days after senators released the “secret” document along with a report questioning oversight of poor-quality facilities.
Dr. Kate Goodrich, chief medical officer with the Centers for Medicare and Medicaid Services, said the agency soon will post the list and update it regularly. She didn’t set a date.
“We are working actively to get the list posted,” Goodrich told reporters, saying that attention focused on the issue “has amplified a very important national dialogue on nursing home quality.”
The Associated Press reported Monday that Sens. Bob Casey, D-Pa., and Pat Toomey, R-Pa., had found that conditions at the 400 facilities were “indistinguishable” from those at about 80 poor-performing nursing homes that are publicly identified by the government and undergo an additional level of inspections.
In a statement, Casey welcomed the commitment to post the list, but said more work is needed to make sure the government’s program to improve poor-performing nursing homes is running properly and has enough financing.
About 1.3 million Americans live in nursing homes, with more than 15,700 such facilities nationwide. The troubled nursing homes that Casey and Toomey identified are part of the government’s Special Focus Facility program, representing about 3 percent of all homes.
Budget cuts appear to be contributing to the problem by reducing money available for focused inspections, according to documents and interviews.
Agency officials say they currently only have enough money for 88 slots in the special focus program. Those facilities are publicly identified. Consumers can spot them on the government’s Nursing Home Comparewebsite by looking for an icon that resembles a traffic “caution” sign.
But a larger group of some 400 nursing homes are designated as “candidates” for the program, and their names have not been publicly disclosed. The agency says that’s now about to change.
It pushed back against the suggestion it was keeping secrets, saying its nursing home website uses starred ratings that allow consumers to readily identify troubled facilities. Nursing homes with five stars have much better than average quality and nursing homes with a single star are considered to be much below average. Nationwide, there are about 2,900 of the latter.
Goodrich said starred ratings are the best way for consumers to get a sense of quality, but the senators’ report concluded that the ratings can be misleading. For example, nearly 3 in 10 of the 400 “candidate” nursing homes with problems had two stars out of five overall.
The government spends about $400 million a year on all Medicare-related inspections, and Goodrich said most of that goes for nursing home checks. The Trump administration has asked Congress for nearly $45 million more.