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Detective, nurse altercation could spur review of hospital policies
In a case that’s gone viral, a Salt Lake City nurse endured a police detective’s rough treatment, handcuffing, and threat of arrest to uphold her hospital’s policy of not allowing police to draw blood from a patient without an arrest, a search warrant, or the patient’s consent.
The incident is likely to spur hospital administrators to evaluate their policies surrounding police access to patients, said Jennifer Mensik, a nursing instructor at Arizona State University and vice president of continuing education for OnCourse Learning.
“I hear nurses all the time say it’s a lot easier not to argue with law enforcement and just draw blood,” Mensik said. “They don’t realize they are putting themselves at risk.”
The incident, captured by police officers’ body cameras, involved Alex Wubbels, a burn unit nurse at University of Utah Medical Center, refusing to let Salt Lake City Police Detective Jeff Payne draw blood from an unconscious patient who was severely burned in a car crash. During the encounter, Wubbels consulted via speakerphone with her supervisor, Brad Wiggins, who stated the hospital’s policy bars blood draws in such situations.
The U.S. Supreme Court ruled last year that police must obtain a warrant to test the blood of motorists suspected of drunken driving. In the Salt Lake City case, the patient, a reserve police officer, reportedly was driving a truck when his vehicle was struck head-on by a man in a pickup truck who was trying to evade police. He was not a suspect in any crime.
Mensik said police requests to draw blood from patients without an arrest, a warrant, or consent are common around the country. Nurses and emergency department staff often go along because they are busy or don’t know their hospital’s policy.
During the July 26 encounter, Wubbels, who’s worked at the hospital since 2009, calmly told Payne he couldn’t proceed with the blood draw. After Wiggins, the burn unit manager, said over the speakerphone that Payne was making a mistake by threatening a nurse, Payne is seen trying to swat the phone out of Wubbels’ hand, grabbing her by the arms, pulling her arms behind her back and handcuffing her.
“Help,” she screamed. “Help me. Stop. You’re assaulting me. Stop. I’ve done nothing wrong. This is crazy.”
Payne then strapped her into the front seat of his car. Another officer arrived and told her she obstructed justice.
“I’m also obligated to my patients,” she replied. “It’s not up to me.”
Wubbels was released without being arrested after hospital COO Dan Lundergan contacted police officials.
Wubbels and her attorney held a news conference last Thursday to describe the incident and play the 19-minute video taken from the officers’ body cams.
Salt Lake City Mayor Jackie Biskupski and Police Chief Mike Brown apologized on Friday for the conduct of Payne, who, along with another officer on the scene, reportedly has been placed on administrative leave. The police department, the district attorney, and the sheriff are conducting a criminal investigation into any misconduct that may have been committed by police during the incident.
Biskupski noted that Wubbles was “simply doing her job.”
“I just feel betrayed, I feel angry, I feel a lot of things,” Wubbles said during her press briefing. “And I’m still confused.”
Following the July 26 incident, the University of Utah Medical Center worked with the Salt Lake City police department to craft an agreement on how to handle police requests for blood draws and medical information from patients, said hospital spokeswoman Kathy Wilets.
Now, law enforcement personnel register at the hospital’s front desk and make their requests through hospital administrators rather than asking front-line providers directly.
Wilets called Wubbles a “rock star” for the way she stuck to hospital policy in that tense encounter with police. “We’re grateful to her. She put the needs of patients first and set a great example for everyone.”
The Same Agency That Runs Obamacare Is Using Taxpayer Money to Undermine It
The Trump administration said on Thursday that it would slash spending on advertising and promotion for the Affordable Care Act, but it has already been waging a multipronged campaign against it.
Despite several failed efforts by Republican lawmakers to repeal it, the Affordable Care Act remains the law of the land. But the Department of Health and Human Services — an agency with a legal responsibility to administer the law — has used taxpayer dollars to oppose it.
Legal experts say that while it is common for a new administration to reinterpret an existing law, it is unusual to take steps to undermine it. Here are three ways the health department has campaigned against Obamacare.
1. REDIRECTING PROMOTIONAL FUNDING
Instead of using its outreach budget to promote the Affordable Care Act, the department made videos critical of the law.
In June, the health department posted 23 video testimonialson YouTube from people who said they had been “burdened by Obamacare,” including families, health care professionals and small business owners.
While it’s not certain where the money for the videos came from, several former health officials who worked in the Obama administration said that they suspect it came from the budget meant to promote the Affordable Care Act.
“There’s no other budget that makes sense,” said Lori Lodes, who oversaw outreach efforts under Mr. Obama.
The Trump administration defended the videos, saying that they were produced to inform Americans about the need for change so that people would have access to affordable health care.
“As evidenced by these important and educational testimonials, the status quo has made that impossible for millions of Americans,” a department spokeswoman, Alleigh Marré, said in July. “The administration is committed to reforming the current health care system to bring down the cost of coverage, expand health care choices, and strengthen the safety net for generations to come.”
The Daily Beast reported in July that one of the participants in the videos said he felt he was being pushed “for a harder line against Obamacare.”
While the health department refers to these testimonials as “educational videos” produced to inform Americans on the need to overhaul health care, some experts question whether they fit that definition.
“The lines between what is partisan, what is propaganda, and what is educational are nightmarish and subjective,” said Michael Eric Herz, a professor at the Cardozo School of Law in New York who has written about social media and the government.
2. ATTACKING THE LAW
The department targeted the Affordable Care Act with a marketing campaign as Republicans in Congress tried to repeal the legislation.
In addition to the YouTube videos, the department has used Twitter and news releases to try to discredit the health law. Since being sworn in as health secretary on February 10, Tom Price has posted on Twitter 48 infographics advocating against Obamacare, all of which bear the health department’s logo.
“Here, it’s an agency trying to destroy its own program because it opposes it,” said Kathleen Clark, a law professor at Washington University who is an expert on government ethics. “It is inconsistent with the constitutional duty to take care that the law is faithfully executed.”
The bulk of Mr. Price’s Twitter posts were from late June to mid-July, when Senate Republicans were trying to pass a bill to repeal and replace the Affordable Care Act. Once, Mr. Price tweeted five infographics in a single day.
Around the same time, the Trump administration ended $23 million worth of contracts with companies that help people sign up for coverage.
In August, five congressional Democrats wrote a letter to Mr. Price demanding detailed information about his plans for marketing and outreach. “Rather than encouraging enrollment in the marketplaces, the administration appears intent on depressing it,” the letter said.
3. DELETING INFORMATION ONLINE
The department removed useful guidance for consumers about the Affordable Care Act from its website.
Under the Obama administration, the health department’s website contained information to help consumers learn about the Affordable Care Act and how to obtain coverage through the health insurance marketplaces. Much of that information is now gone. Some was removed within hours of President Trump’s inauguration.
A link to a page about the Affordable Care Act disappeared from the health department’s home page the evening of the inauguration, according to a comparison of the sites, shown below.
Obstacles await as Congress resumes health care fight
Republican hopes for repealing and replacing former President Barack Obama’s health care law are still twitching in Congress, though barely.
Leaders lack the votes to pass something and face a fresh obstacle — the Senate parliamentarian ruled Friday that Republicans only have the ability to dismantle the law with 51 votes until the end of the month.
It’s among several health issues lawmakers face when they return from summer recess, even as fights over the budget and helping Texas recover from Hurricane Harvey grab center stage.
WHEN WE LEFT OFF IN LATE JULY
Senate Majority Leader Mitch McConnell, R-Ky., tried to push three plans through his chamber erasing the 2010 law called Obamacare. Republican defections denied him the 50 votes needed, with Vice President Mike Pence ready to seal victory with a tie-breaking vote.
The excruciating last roll call failed 51-49. Three Republicans voted “no,” one more than McConnell could afford to lose. President Donald Trump used August to insult McConnell for that flop, even suggesting he might need to relinquish his leadership post, inflaming tensions between the White House and congressional Republicans and lacerating party unity.
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OBAMACARE REPEAL MEETS THE PARLIAMENTARIAN
Republicans have used a procedure that’s prevented Democrats from killing the health bill by filibuster. It takes 60 votes to defeat a filibuster. Without that special step, Republicans controlling the Senate 52-48 would need support from eight Democrats to repeal Obamacare, impossible given unanimous Democratic opposition.
The safeguard against filibusters was included in a budget for the government’s 2017 fiscal year that Republicans pushed through Congress in January.
That protection expires at the end of September, the Senate’s nonpartisan parliamentarian, Elizabeth MacDonough, has ruled. That’s when the fiscal year ends.
Sen. Bernie Sanders, I-Vt., the ranking member of the Budget Committee, said in light of the ruling, “we need to work together to expand, not cut, health care for millions of Americans who desperately need it.”
That leaves Republicans with only September to nurture their slim repeal hopes unless the GOP-run chamber votes to overrule her.
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A LAST REPEAL PUSH
This repeal push comes from GOP Sens. Lindsey Graham of South Carolina, Louisiana’s Bill Cassidy and Nevada’s Dean Heller.
They’ve proposed funneling Obamacare’s federal dollars directly to states and erasing its requirements that people buy coverage and companies offer it to employees. They’d cut and reshape Medicaid, halt Obama subsidies that reduce consumers’ out-of-pocket costs and repeal the tax on some medical devices.
GOP aides say the proposal is evolving.
There’s no sign sponsors have enough Republicans to prevail and McConnell hasn’t been publicly encouraging. Further reducing its chances, lawmakers need September to prevent a damaging federal default and a government shutdown, help Texas recover from Harvey and craft a GOP tax overhaul.
“If people can show me 50 votes for anything that would make progress on that, I’ll turn back to it,” McConnell said in early August of repealing Obamacare.
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A BIPARTISAN TRY
The brightest hope comes from Senate health committee chairman Lamar Alexander, R-Tenn., and Washington state Sen. Patty Murray, that panel’s top Democrat. They’re seeking a deal on continuing federal payments to insurance companies who reduce costs for lower-earning customers.
Even this will be uphill.
Obama’s law requires the cost reductions and government subsidies to insurers, but a court has ruled Congress hasn’t legally authorized the payments. Obama and Trump have continued them, but Trump keeps threatening to stop, calling them an insurance company bailout. Many conservatives agree.
Yet those payments are a priority for Democrats and many Republicans. They and the nonpartisan Congressional Budget Office say halting the subsidies will force insurers to boost premiums for millions.
In exchange, Republicans want to revise parts of Obama’s law. They’ve suggested making it easier for insurers to avoid some Obama coverage requirements or steps like curbing lawsuits against health care providers.
Alexander wants to extend the insurers’ subsidies for one year while Democrats want two years or more. Another hurdle: Democrats have little interest in relaxing Obama’s law.
“Nobody is going to put their fingerprints on sustaining Obamacare without some sort of reform element,” Rep. Tom Cole, R-Okla., said of Republicans.
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CHILDREN’S HEALTH
Funding for the popular Children’s Health Insurance Program expires Sept. 30. It provided health care to more than 8 million low-income children in 2015.
Democrats and most Republicans want to extend the program and success seems likely. First they must compromise on details like how many years to finance it and at what levels.
Washington pays for most of the federal-state program, and in recent years the federal share was bumped up by 23 percent for each state. Many Republicans want to phase out that boost, but Democrats are resisting.
Some Republicans say Congress needn’t act by Sept. 30 because states have enough money to continue coverage. Democrats and program advocates say without fresh funds by September’s end, some states would be forced to make cuts to wind down services.
When ‘gigging’ healthcare, providers must balance risk with cost
An explosion of innovative tech is disrupting the care-delivery model, aiming for both cost savings and better outcomes. Uber’s partnership with MedStar Health to reduce patient no-shows, a huge cost-sink, and the expansive potential of drones to fill healthcare infrastructure gaps in remote areas are just two examples of ways in which healthcare providers are setting out to provide better care at lower cost.
Cost-saving innovations have also begun to extend to the healthcare employment model — something notably risky when it comes to compliance. One program offers a solution to staffing issues that connects freelance nurses with open positions using an entirely digital platform in an attempt to modernize the business. Others have opted for more ad hoc hiring processes for IT and transcription talent.
Either way, the “gig economy” has reached healthcare — and it looks like it’s here to stay.
What does gig work in the healthcare space look like right now?
Healthcare providers have to manage an employee population with vastly different skill sets. But even in the diverse healthcare workplace, where special rules run rampant, some general guidance still applies.
Typically, the more specialized and trained the worker, the less likely they can be hired on as an independent contractor, Matt Stevenson, partner at Mercer, told HR Dive. And right now, most gig workers are on the lower end of the skill scale — especially in healthcare.
“Because of the way healthcare has been restructured, there’s been an explosion of employment at the low end,” Stevenson said. Increased calls for low-acuity care, like physical therapy and daily caregiving, have heralded the growth of contracted work. Convenience for both patient and provider also plays a part. Telehealth (while not specifically contract work, usually) allows doctors to sign up for specific hours to treat patients via phone or video, while digitization lets those doctors keep all records securely online. It brings a flexibility few office jobs can compete with.
Another bonus: cost.
“Incentives are changing,” Stevenson said. “You are now paying for results instead of the hospital getting paid more for you being in the hospital longer.”
As providers seek better outcomes for a lower price, contract work plays a pivotal role in improving care but keeping barriers low for patients. Caregivers can visit homes and encourage patient compliance, such as taking medicine and completing physical therapy, and hospitals can hire those workers on a job-to-job basis, which is cheaper overall.
Providers must keep liability in mind when hiring out independent gig work, however. Hospitals in need of on-demand talent often retain nursing agencies that take on liability, employee background checks and other major risk issues in exchange for hefty fees. Independent workers tend to be cheaper, but come with much higher risk.
Managing liability and questions of quality
Classification is a perpetual headache for employers in many industries. Simply calling someone an independent contractor doesn’t cut it, Shanna Wall, labor law attorney at ComplyRight, said. Nationally, employers have to satisfy a slew of tests under regulations from the IRS, the U.S. Department of Labor and individual states meant to protect workers from exploitation. Courts have been in on the action, too.
Most tests balance on one key question: How much independence does an individual worker have? More specifically, does an employer focus on a result alone or the job itself? Is the worker using their own equipment and deciding their own hours, or is an employer dictating that? The more control an employer has, the riskier independent contractor classification can be.
But that’s not all. Medical personnel have to deal with strict laws on private health information, such as the Health Insurance Portability and Accountability Act (HIPAA). Contractors must be trained on what those and other rules require.
“How do you ensure the quality of care provided by the gig person is okay?” Stevenson said. “How do you keep costs down but ensure quality? You may pay $15 an hour, but that is low for healthcare.”
Worse, if something goes wrong, the provider is on the hook. By giving jobs to outside workers, providers risk losing strict control over the quality of care and, in the long term, their brand. Employers already struggle to gather data on full-time employees. Gathering data on the success of gig workers is even tougher, since the very nature of the relationship is fairly low-touch.
That’s partly why the agency model has lasted for so long, as they take on most of those risks and give hospitals the ability to up- or downsize when needed. But the costs are real.
In the future: Outsourcing some jobs but not all
For that reason, employers may want to consider their needs on a sliding scale of risk versus efficiency. Joint employer cases are still working their way through the courts. Uncertainty remains the rule of the day. “It’s always best practice to err on the side of an abundance of caution,” Wall said.
As far as the future goes, that uncertainty renders predictions suspect. Digitization has encouraged the contracting out of some support services, including diagnostic work such as radiology. As long as a radiologist has an internet connection, they can read a scan and send their analysis from anywhere.
Innovation continues in the on-demand non-emergency medical transportation space, too. Circulation, a Boston-based provider of medical transportation, recently raised $10.5 million in a funding round that included participation from leading names in healthcare such as the Boston Children’s Hospital, Humana and NextGen Venture Partners. Experts believe that ride-share partnerships could save billions of dollars usually spent by Medicaid.
But as more employers focus on ways to engage employees, contract workers will largely remain outside those efforts, Stevenson said. Gig workers usually seek independence for a reason, be it the flexibility of hours or ability to set their own pay. They prefer autonomy, and don’t want to be bogged down in HR processes.
“If I really cared about engagement, I would bring them in-house,” Stevenson said. But as long as demand is high, treatment of contract workers will have to remain top notch to keep a steady flow of candidates in the pipeline.
The influx of independent work has enabled unprecedented flexibility for workers and access to talent for employers. But above all, employers must be wary of the risks to truly enjoy the perks of independent contracting.
“You think you are safe from compliance because they are gig workers, but really, it’s the opposite,” Wall said.
Wanted: Leaders for tomorrow’s emergency room
http://www.healthcaredive.com/news/wanted-leaders-for-tomorrows-emergency-room/448757/
A conversation with Bill Haylon, CEO of Leaders For Today
Economic anxieties need not correlate with a high unemployment rate. Take it from business leaders across multiple U.S. industries: Their biggest challenge is not a lack of job openings for thousands of qualified candidates — it’s a lack of candidates for thousands of openings.
HR professionals are used to hearing about skill shortages in manufacturingand other blue-collar work, but perhaps more understated are gaps in the STEM fields.
Careers in nursing and medicine, which often require years of additional, specialized education are hard to fill. Physician assistant openings were one of the most in-demand fields near the end of 2016, according to the American Staffing Association. But hospitals aren’t just struggling to find people to staff operating rooms. They face a much bigger challenge in a lack of leadership skills.
HR Dive/Healthcare Dive spoke with staffing firm Leaders For Today’s CEO Bill Haylon about the root of leadership gaps in healthcare, and how hospital HR departments can confront the problem. Our conversation has been lightly edited for length and clarity.
HR Dive: When hospitals come to a healthcare staffing firm like Leaders For Today, what are they asking for?
Bill Haylon: What we’re really doing is helping them find people who have particular sets of skills. We provide staffing on an interim basis. A hospital or healthcare system comes to us and says, “we really need somebody who can fix and lead our case management department,” “we need somebody who’s got certain technical skills and leadership skills.” We’re not actually training individuals, we’re finding people who fill those slots.
We’re going out and finding people, who they can either hire full time or on an interim basis. We’ll look for, on average, a little more than six spots, and we’ll start from a pool of people that we have that we’ve worked with before.
We’re not really doing training, but training is one of the problems in the healthcare world.
HR Dive: When you look for potential staffers, what kind of skills do they have? What stands out the most to the healthcare systems you work with?
Haylon: There are certain skills that go across all positions, and there are certain skills that are specific to a position because we can hire for. For example, we have a team that focuses on OR people, while others focus on case management, hospital finance, physician management, practice management, etc.
Across the board, what we focus on is, first and foremost, trying to find people who have been steady with or who have stayed with an organization for some period of time and developed within that. In other words, we try and stay away from what we call “jumpers” — people that have a job for a year, two years, and then try and go on their next role.
Unfortunately, that’s counter to what occurs in the industry. People in the hospital industry jump all the time.
We try and get some stability in their job, because we believe they learn more that way [when it comes to] both the technical skills and leadership skills. Of course, you look for the basic things: education, undergraduate work, master’s degree and other certifications.
You’re trying to vet the person along, so a lot of time you’re talking about different situations, different experiences, how they’ve handled them in the past or how they might handle them in the future. It could be a difficult position to deal with, a union situation, a quality situation, a safety situation. And you try to understand what their thought-making process is.
HR Dive: What skills are hardest to come by in the medical world, given that a lot of industries are seeing skills shortages?
Haylon: There’s an enormous shortage of talent within the hospital industry in all key levels. It was going on before Obamacare, and now with Obamacare and more people being covered, each organization is seeing a big uptick in the number of patients they see. It’s really gotten to be a very critical moment.
The most difficult job category is the O.R., the second hardest is case management and the third hardest is physician practice management.
From a skill set perspective, it’s leadership. Most of those in leadership positions are people who were nurses or doctors. When you go to school, you do not learn about financial statements, management skills or leadership. You’re learning how to suture, avoid infections and open up rib cages.
You take a person who has been a staff nurse for [a certain number] of years, and they decide they want to go into a leadership role. Because there’s a shortage of people, they are put in those spots well before they’re ready. They don’t have any training; hospitals do not train people for career development or leadership, and so you’re just kind of winging it. You get people who are very quickly over their head in their positions.
HR Dive: What can hospitals change about the way they operate to help develop those skills, or is that simply not possible given their bandwidth?
Haylon: They make it harder than it is. The reality is that hospitals consolidate, so they’re parts of bigger systems. You have a director in the O.R. who could be managing 440 people. That’s a lot of people. This was the case for one hospital we worked with, and the person running that OR had been a staff nurse and morphed to this role. But her [previous] role had been running a small hospital where she had 30 people, and now she’s up to 440 people, and it’s over her head.
So the reality is that they need to start thinking about different skill sets, and the obvious one is an MBA. When you’re the director of a 440-person O.R., you’re not seeing patients anymore. You’re doing hiring and scheduling. You’re developing quality programs and safety programs. You’re trying to get the surgeons on board. You’re never seeing a patient; that’s a different set of skills.
You don’t need to be clinical, you need to be a manager and a leader. It could be an MBA, it could be a master’s in health. But you need more than clinical training.
So what hospitals do [by recruiting for a certain skillset] is totally reactive as opposed to being proactive and developing people.
HR Dive: Do you see a shift in terms of the skills that physicians and other professionals are being taught in school?
Haylon: You’re being taught technical skills, clinical skills, whatever your specialty is. You go to medical school, do your residency, maybe followed by a fellowship, and it’s all technical skills. Physicians [are also] getting way more specialized than they used to be.
Typically the people who have jobs [in healthcare leadership] have gone and gotten additional training and education on their own.
Physicians and nurses are not trained in school to run big organizations. Plus, they’re doing research, and they’ve got to handle anybody that comes into the OR and the ER. It’s hard enough to get training for it, and it’s beyond belief if you don’t have training.
HR Dive: What else should hospital systems be mindful of when looking for leadership in the medical workforce?
Haylon: When you look at survey data from across the hospital industry, you see that people are staying in positions for incredibly short periods of time. Forty percent of people right now in key positions in hospitals have been in their position two years or less. Another 40% expect to leave in the next two years. What happens is that hospitals have a hole, and they need better leaders, so they poach from somebody else.
So the director of a surgical department will be a manager at a small hospital, then become a manager at a bigger hospital, then a manager at a bigger hospital, then a director at a small hospital, then a director at a bigger hospital, and finally a director at a bigger hospital. They just keep poaching from each other.
The problem is it’s the same people who are circling through. The people you’re hiring never had the time to put in place good, quality programs, [including] safety programs and productivity programs, because they’re not there long enough. They can’t make it stick in just two years; these are very complicated things.
And so that’s the result of what you’re talking about. The lack of training and development shows itself in this poaching and job hopping in the hospital world. It is like no industry you have ever seen before.
In other industries, an enormous amount of resources are put into training, so people stay in those industries and move up. You take up greater responsibilities, but they invest a lot in you as a developing person. The hospitals invest almost nothing. It’s up to the individual to go and figure it out on your own. Get your MBA, take this class, get a certification from the hospital association. But you’re not developing your own people.
Other organizations develop their own people because they want to be the best at what they do — they want to differentiate themselves. The only way they can do that is to develop their own people. Because hospitals don’t do that, there really is no differentiation, and hence, they struggle.
So this lack of training and the lack of development ends up creating an industry where everybody knows they’re going to jump all the time. You’ve got hospitals that have hired their sixth CEO in seven years. So the question is: If you’re a patient and you have knowledge of this, would you want to go to that hospital?
If you have that sort of instability at the top spot, then it’s going to trickle all the way down. Healthcare is complicated; it takes a while to figure out orders in place that are going to work. If they have quality problems, or safety problems, you can’t fix them that quickly. You’ve got to have someone who understands the lay of the land and can make a difference.
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HENRY KOTULA 