Archive for April, 2012

Texas Nurse Has Served 3 Administrations

Posted in Nursing, Nursing News

Image of the Texas State Capitol courtesy of adpal3180 via Flickr

One of Tim Flynn’s first duties as the first full-time nurse for the Texas State Capitol was to give then-Governor Ann Richards a flu shot. He was nervous enough that he forgot to bring a band-aid, which led Gov. Richards to warn him that he better not let any blood sully her $300 silk blouse!

He did his job carefully and well and her blouse was safe. His job was safe too evidently, because he’s been the Capitol nurse for the two decades since then, according to this profile of Mr. Flynn in the New York Times.

Through the administrations of Ms. Richards, George W. Bush and Rick Perry, Mr. Flynn has been at the Capitol to dispense flu shots, treat sinus infections, and provide patient education to lawmakers.

Everyone in the Capitol knows him and trusts him. Representative Rick Hardcastle says, “He knows I have bad allergies because he’s seen me before. It’s like going to see your family doctor.”

Even though he loved his job, he did get frustrated that he wasn’t able to write prescriptions or diagnose illnesses. So he decided to go back to school and become a nurse practitioner, graduating from the University of Texas in 2002.

As a state employee, Mr. Flynn does not charge patients. His Capitol clinic operates on a first-come, first-served basis. When children on school trips fall down, they go to him. State employees drop by when they have headaches.

“I love my job,” he said. “After being here 20 years, I know most of the folks that work here. I know their medical histories, their idiosyncrasies. This is my community. That’s why I call it my Capitol.”

In emergencies, Mr. Flynn is one of the first on the scene, providing life support until paramedics arrive. In 1999, when a Capitol parking guard was found slumped over his desk and suffering from gastrointestinal bleeding, Mr. Flynn treated him for shock before paramedics arrived and saved the man’s life.

Responding to emergencies is the smallest part of his job, Mr. Flynn said. He spends most of his time on procedures like treating strep throat, saving patients a trip to their primary care providers.

His job takes on added importance during the biennial legislative sessions, when lawmakers convene for 140 days at the Capitol.

“When it’s crunch time, I don’t have to call a doctor; I can go down to Tim’s office,” Mr. Hardcastle said. “When you have the flu during the night and you’re working on legislation, you need treatment. His job is vital to what we do.”

Letting Debt Collectors in the Front Door

Posted in Nursing, Nursing News

Image courtesy of AMagill via Flickr

Debt collection agencies have been embedding debt collectors as employees who run interference in emergency rooms and visit patients’ bedsides to demand payment, among other aggressive tactics.

The Minnesota attorney general, Lori Swanson, revealed that Accretive Health, one of the nation’s largest collectors of medical debts, has been engaging in these tactics. The New York Times notes that this raises concerns that “such practices have become common at hospitals across the country.”

Hospitals are increasingly desperate to recoup payments as their unpaid debts mount. To patients, the debt collectors can blend right in with hospital employees, yet these staff members focus on demanding that patients pay outstanding bills and may even discourage them from seeking emergency care at all. For example, they will sometimes purposely “stall” a visitor to the emergency room in an attempt to get payment before the patient receives any treatment. Their focus is on getting money, not the patient’s health.

Additionally, these workers (who are not actually medical staff) sometimes have access to health information, possibly in violation of Hipaa (the Health Insurance Portability and Accountability Act). Accretive employees may also have broken the law by not clearly stating that they were debt collectors.

As hospitals struggle under a glut of unpaid bills, they are reaching out to companies like Accretive that specialize in collecting medical bills.

Hospitals have long hired outside collection agencies to pursue patients after they have left hospital facilities. But financial pressures are altering the collection landscape so that they are now letting collection firms in the front door, according to Don May, the policy adviser for the American Hospital Association, a trade group.

To achieve promised savings, hospitals turn over the management of their front-line staffing — like patient registration and scheduling — and their back-office collection activities.

Concerns are mounting that the cozy working relationships will undercut patient care and threaten privacy, said Anthony Wright, executive director of Health Access California, a consumer advocacy coalition. “The mission of these companies is in direct opposition to the supposed mission of these hospitals.”

Still, hospitals are in a bind. The more than 5,000 community hospitals in the United States provided $39.3 billion in uncompensated care — predominately unpaid patient debts or charity care — in 2010, up 16 percent from 2007, the hospital association estimated.

Accretive is one of the few companies specializing in hospital debt collection that is publicly traded. Last year, it reported $29.2 million in profit, up 130 percent from a year earlier.

Late last month, Fairview Health Services, a Minnesota hospital group that Accretive provided services to, announced it was canceling its contract with Accretive for back-office debt collection. After Accretive informed investors, its stock plunged 19 percent in a day. On Tuesday, the company’s shares closed at $18.49, down 2.7 percent.

Accretive says that it trains its staff to focus on getting payment through “revenue cycle operations.” Accretive fostered a pressurized collection environment that included mandatory daily meetings at the hospitals in Minnesota, according to employees and the newly released documents. Employees with high collection tallies were rewarded with gift cards. Those who fell behind were threatened with termination.

“We’ve started firing people that aren’t getting with the program,” a member of Accretive’s staff wrote in an e-mail to his bosses in September 2010.

Collection activities extended from obstetrics to the emergency room. In July 2010, an Accretive manager told staff members at Fairview that they should “get cracking on labor and delivery,” since there is a “good chunk to be collected there,” according to company e-mails.

Employees were told to stall patients entering the emergency room until they had agreed to pay a previous balance, according to the documents. Employees in the emergency room, for example, were told to ask incoming patients first for a credit card payment. If that failed, employees were told to say, “If you have your checkbook in your car I will be happy to wait for you,” internal documents show.

Employees at Accretive’s client hospitals ask patients to make “point of service” payments before they receive treatment. Until she went to Fairview for her son Maxx’s ear tube surgery in November, Marcia Newton, a stay-at-home mother in Corcoran, Minn., said she had never been asked to pay for care before receiving it. “They were really aggressive about getting that money upfront,” she said in an interview.

Ms. Newton was shocked to learn that the employees were debt collectors. “You really feel hoodwinked,” she said.

While hospital collections at Fairview increased, patient care suffered, the employees said. “Patients are harassed mercilessly,” a hospital employee told Ms. Swanson.

Patients with outstanding balances were closely tracked by Accretive staff members, who listed them on “stop lists,” internal documents show. In March 2011, doctors at Fairview complained that such strong-arm tactics were discouraging patients from seeking lifesaving treatments, but Accretive officials dismissed the complaints as “country club talk,” the documents show.

Ms. Swanson said that the hounding of patients violated the Emergency Medical Treatment and Active Labor Act, a federal law requiring hospitals to provide emergency health care regardless of citizenship, legal status or ability to pay.

In the January lawsuit, Ms. Swanson said that by giving its collectors access to health records, Accretive violated the Health Insurance Portability and Accountability Act, known as Hipaa (pronounced HIP-ah). For example, an Accretive collection employee had access to records that showed a patient had bipolar disorder, Parkinson’s disease and a host of other conditions.

In addition, she said, the company broke state collections laws by failing to identify themselves as debt collectors when dealing with patients.

Late Tuesday afternoon, Accretive announced it won a contract to provide “revenue cycle operations” for Catholic Health East, which has hospitals in 11 states.

When a Nurse Should Hire an Attorney

Posted in Nurse Safety, Nursing, Nursing News

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Most nurses can expect to face at least one instance where legal representation becomes necessary in the course of their career. Although most healthcare institutions carry malpractice insurance for nurses and will provide their own in-house counsel or insurance counsel, there may be times when nurses feel they need their own private lawyer to protect their interests.

Generally, the amount of malpractice insurance an institution carries will suffice for protecting a nurse from personal financial loss, but in high liability areas of nursing practice, such as nurse midwifery and surgery, nurses should carry an additional policy. Several companies offer professional liability insurance and the Nursing Service Organization offers several types of insurance policies that are tailor-made for the nursing profession.

Two key instances where a nurse should always seek outside counsel are: 1) any time a complaint has been made with the state Board of Nursing, which includes notice of investigation by the Board of Nursing and, 2) any time a nurse has been given notice of being a named party in a lawsuit.

Patients and family members, upon filing a lawsuit, will name every person that has come into contact with the patient as a party to the action. Parties are discharged as the investigation uncovers which healthcare providers are most likely to have caused the alleged harm to the patient. The process can be upsetting and affect a nurse’s practice, but the investigation is a necessary element in the process of resolving the matter.

Nurses may also wish to retain counsel in matters concerning their employers. This can range from a simple review of a contract before hire, to more serious instances involving action taken by employers, supervisors and physicians. Situations in which a nurse should hire outside representation aren’t always clear however. Consider the following situations and advice from Medscape’s “Ask an Expert” before seeking your own legal counsel:

Forced overtime. Several states prohibit employers from requiring nurses to work overtime, but employers mandate the overtime just the same. Employers may threaten a nurse with patient abandonment, which can cause loss of the nursing license. A nurse should consult an attorney in this situation.

Inadequate staffing. Short staffing can lead to dangerous outcomes for patients, but in this situation, a nurse should first work up through the chain of command and bring the situation to the attention of supervisors and the director of nursing. It’s also good to do some background investigation of state laws for minimum staffing levels, which can add credence to the nurse’s case for proper staffing levels. If the facility is a Magnet hospital, it may also be in violation of the requirements to keep Magnet status.

Derogatory or critical supervisor. Derogatory statements can be actionable if they involve discrimination or harassment. A critical supervisor may focus comments more on the nurse’s job performance; these comments are more disparaging than discriminatory or harassing. In this case, the nurse must first examine the reason for the remarks. Is the nurse performing the job as outlined in the job description? If so, the nurse may wish to seek legal counsel who will determine if a cause of action exists.

Termination of employment. Getting fired is usually an emotional situation, but if a nurse believes that he or she was wrongfully terminated, then consulting legal counsel may help recoup financial loss.

Before hiring an attorney, nurses should investigate whether the attorney has experience in handling employment or malpractice issues. It can also help a lot to do some investigation of the applicable laws and regulations before contacting a lawyer — you may discover that the matter can be handled without legal representation, thereby saving hundreds and maybe thousands of dollars.

Irrational Health Care

Posted in Nursing, Nursing News

nebari –

Dr. Otis Brawley is concerned how health care is currently consumed. He’s written a book called “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America” that examines and explains these concerns.

Tara Parker Pope of the NYT’s Well blog spoke to him about his book and how broken he considers the United States health care system to be. He states that “failure is in the system” — that no horror stories (and he has some doozies, like a woman with untreated breast cancer who brings in her breast for re-attachment after it falls off) should be dismissed as an aberration.

He doesn’t just blame hospitals, health care workers, or insurance companies though. He also thinks that patients demand overtreatment, and that this contributes to the bloat and inefficiency of the current health care system.

He says he decided to write the book after listening to the debate over the Affordable Care Act. He says, “The talk should not be about rationing health care but about rational health care. So much of what we do in health care is irrational.” When asked to describe an example of irrational health care, he says:

There was a man with colon cancer who went to a wonderful hospital with a wonderful reputation. He got surgery and was referred to a medical oncologist who has a wonderful reputation as a doctor to the rich and famous in Atlanta. That medical oncologist started giving him chemotherapy and two other expensive drugs. When this man lost his insurance, the oncologist basically dropped him, and the guy ended up being seen by me at the county hospital. A doctor who is training with me to be an oncologist immediately realizes that this guy is getting a chemotherapy regimen for colon cancer that we stopped using about 15 years ago. His medical oncologist was practicing the best medicine of the late 1980s, but we were in 2006. The other drugs he was being prescribed were totally unnecessary. But the doctor could get a substantial markup and make a substantial amount of money by selling them. The oncologist had known just enough to be greedy and prescribe drugs he can make money off of, but he didn’t know enough to prescribe the chemotherapy that would have given the patient a much better chance of surviving his cancer.

I’ve seen that so many times, where doctors really have failed to evolve and failed to learn as the profession and the scientific evidence have changed over time.

But in reading the book, you don’t just blame doctors for being greedy. You blame patients for being gluttonous. Can you explain?

Another patient of mine had early colon cancer. Three doctors had told her she should not get chemotherapy. She decided she wanted it, and she went doctor-shopping until she found a doctor who would give it to her. Her insurance had no way to object to her getting this inappropriate chemotherapy because privacy laws prevent disclosing the stage of the disease to the insurance company. She was referred to me by a relative who was concerned about what she was doing. She readily admitted that she had three different medical opinions that said she should not get chemotherapy, but she wanted chemotherapy. So a doctor made $10,000 off that six months of chemotherapy, and she got an increased risk of leukemia for the rest of her life, not to mention losing her hair and everything else, with no scientific evidence that the treatment reduced her risk of the colon cancer coming back.

I blame patients, I blame doctors, I blame hospitals, I blame drug companies, I blame insurance companies. Our health care system is messed up because the system is designed to fail, and everybody is responsible for health care failing as it is now.

The story about the woman whose breast fell off was horrible. What were you trying to tell us with that example?

We so frequently talk about breast cancer almost as if it’s a boutique disease or trendy. I feel some people have forgotten how terrible this disease can be. This lady – I saw a lot of things in her background that were lessons for society about what we need to do if we want to defeat breast cancer. When she realized she had something growing in her breast, she had insurance, but logistics having to do with her job and child care and a little bit of denial kept her from going to the doctor and getting this thing diagnosed and treated when it was likely curable. Later on, when she wanted to see a doctor, she couldn’t because her insurance had gotten so expensive that she had to drop it. If she had come in when she first found this thing 9 or 10 years earlier, I probably could have cured it, and it would have cost about a tenth of what we spent when she was uninsured and receiving free care from the hospital. She lived for about two years after I met her. That’s a failure of medicine to educate people.

In the book, you talk about a conversation with a hospital marketing executive who talks about drumming up business with free prostate cancer screenings at a mall health fair. How did that affect you?

That was the beginning of Otis Brawley becoming a loudmouth in the prostate cancer screening debate. We’re making promises to patients and making them think we know things we don’t know and making money off of them. There is a subtle little corruption in medicine. We’re selling chemo to people who don’t need it, giving prostate screening when it might save lives, but we make them think it definitely does, and then I see a lady whose breast is falling off who couldn’t afford to see a doctor when she wanted to see one.

Is there any hope that things might improve someday?

I am trying to get folks, through this book, to talk a little more about rational use of health care and realize that we are actually hurting people with overtreatment. Health care needs to be consumed in a wiser way that is much more concerned about allegiance to the science. We need to be more concerned about the welfare of our patients. There was a recent report, the 45 tests we do too much, that I was thrilled to see. People are starting to realize that we need to be a little wiser in our use of health care.

MN Union Responds to Nurse Uniform Plan

Posted in Nursing, Nursing News, Nursing Specialties

Artistic Endeavor -

A Minneapolis-based hospital group will require that their employes wear matching uniforms distinguished by colors starting in May, one color per job category. Think Star Trek, but in a more Earth-bound (and medical) setting.

Nurses get navy scrubs. Licensed practical nurses will wear eggplant. Respiratory therapists get olive green.

The idea is to make it easier for patients and family members to identify their care team by the color of their uniform. However, unionized nurses are not happy that the change has been imposed from on high, without any negotiation. Many of them also disagree with the new uniform plan. This article in St. Paul Pioneer Press quotes oncology nurse Cristin Betzold of Blaine as saying that her patients appreciate the variety of bright colors she wears. “I have many patients comment on how at least they see a little bit of color in what they see during the day from my uniform,” she said.

They also question whether the color-coding would actually help patients.

So, amidst the discord, the Minnesota Nurses Association has filed a grievance over the uniform policy. The uniform policy will still go into effect on schedule but may roll back later depending on result of the arbitration process.

A survey of hospitals across the Twin Cities finds that there’s no uniform position on color-coded outfits.

There’s no requirement for matching scrubs at St. Joseph’s Hospital in St. Paul, Methodist Hospital in St. Louis Park or medical centers in the Minneapolis-based Fairview system.

To address concerns that hospital patients sometimes struggle to recognize who’s caring for them, Fairview workers get pointers on introducing themselves. Workers at St. Joseph’s, meanwhile, wear super-sized name tags called “badge buddies” that clearly identify their skill set.

But other medical centers have switched to standardized uniforms.

About five years ago, Woodwinds Health Campus in Woodbury started requiring navy blue scrubs for its RNs. Nurses selected the color in a vote after hearing from an advisory committee that matching outfits would be helpful to patients, said Cindy Bultena, the chief nursing officer at Woodwinds.

Regions Hospital in St. Paul has required workers in the same job category to wear the same color for at least a decade and is in the process of again affirming the policy. Over the past few years, workers have started wearing patterned scrubs within their given color, but solids will be required as of Jan. 1, said Jon Henkel, a hospital official.

At the Mayo Clinic in Rochester, Minn., uniforms are color-coded within work units but not across all clinical areas. That means, for example, that not all nurses wear the same color, but all workers in obstetrics wear teal green scrubs.

“The dress code is always under review and we are currently entertaining administering a patient study which will help identify their needs specific to dress,” said Kelley Luckstein, a clinic representative, in an email.

Allina officials say their hospital in Buffalo first experimented in 2010 with what’s now been dubbed the “uniform initiative.” The medical center saw its patient satisfaction scores improve following the change to standardized uniforms.

The health system started talking with employees last year about the switch, which will apply at the system’s 11 hospitals. In December, about 5,500 employees cast ballots for their favorite colors.

“Some employees networked across the entire Allina system to say, ‘Let’s pick these as the top three choices,’ ” said Sorbel, the United Hospital official. “The larger groups got the colors they wanted.”

Even so, the change has proven divisive.

Patients respond to variety, especially pediatric patients, said Bernadine Engeldorf, a nurse at United who also is first vice president of the Minnesota Nurses Association. She added that nurses like the freedom of being able to choose their outfits.

In contrast to the cheery colors some nurses currently wear, navy blue seems “somewhat muted, dark,” she said.

“People take a lot of pride in what they wear to work,” said Betzold, the nurse from Blaine. “I think people don’t agree (with the change), but obviously nobody wants to be terminated because they chose not to wear navy blue.”

The change is being felt in the pocketbook, too, although there are different estimates of the magnitude.

The average uniform costs $80 to $100, said John Nemo, spokesman for the Minnesota Nurses Association. Full time nurses need five to 10 sets of uniforms, he said, because they can only be worn one day before washing. Replacement occurs every six to 12 months, Nemo added, depending on the quality of garments.

Allina officials, however, quote a range of $20 to $50 for scrubs, adding they have negotiated special discounts for workers who purchase from a preferred vendor. The health system is providing up to $80 in vouchers to workers to help defray costs.

“We do recognize that in making a change, there is a financial burden to our employees,” said Tracy Kirby, the director of nursing at Abbott Northwestern.

As the labor dispute plays out, some wonder why navy seems to have become the new color of nursing.

Sure, it’s a color that doesn’t show spots or evoke strong emotions, said Helen Strike, the chief nursing officer at St. Joseph’s Hospital. But there was a time when all nurses wore uniforms, Strike said, and the color always was white.

“Even today, kids who are 3 or 4 years old have this idea that a nurse wears white,” she said. “There’s something very positive about that historical perspective, and I wonder why we don’t utilize that more in nursing.”

White also has been linked with doctors through their historic use of white coats. The new Allina policy, however, won’t apply to physicians, since many aren’t directly employed by the health system.

Kirby, the nursing director at Abbott Northwestern, added: “Patients tend to really know who their doctors are.”

More Nurses to Be Trained To Treat PTSD, TBI

Posted in Nursing, Nursing News, Nursing School, Nursing Specialties

Straight 8 Photo -

The White House is leading an initiative to improve health care for former troops and their families. The White House’s Joining Forces campaign includes an agreement with 150 nursing organizations and 500 nursing schools to educate nurses on combat-related injuries.

There will be additional coursework and training opportunities regarding injuries such as post-traumatic stress disorder and traumatic brain injury.

The effort aims to reach 3 million nurses on the “front lines of health care,” as Joining Forces Director Navy Capt. Bradley Cooper is quoted as saying in this article in the Air Force Times.

“The goal is to raise awareness among every nurse throughout the country to recognize the signs and symptoms and lower the stigma of getting care,” said Amy Garcia, chief nursing officer for the American Nurses Association.

The White House estimates that 300,000 Iraq and Afghanistan veterans suffer from traumatic brain injury, PTSD or other combat-related mental health issues, such as depression.

About half have sought care from the Veterans Affairs Department, leaving about 150,000 former service members seeking civilian care, Cooper said.

Joining Forces is a campaign designed to raise awareness of the needs of military personnel, veterans and their families. It was launched a year ago this week.

Obama and Biden will unveil more details on the new initiative when they speak Wednesday at the University of Pennsylvania School of Nursing.

In January, Mrs. Obama announced a similar pledge by 135 medical schools to educate future physicians and increase research on what are commonly referred to as the “invisible wounds” of war — PTSD and TBI.

Garcia said no federal funding is being used for the effort.

According to Garcia, one out of every 100 Americans is a nurse. Many don’t work in fields where they would be exposed to head injury or behavioral health disorders. Educating all nurses on these injuries and illnesses would lead to better veterans’ care, she said.

“We want to make sure they understand about new treatments and new science so they can make appropriate referrals,” Garcia said.

The professional education and training opportunities that will be offered through the initiative will be voluntary, she added.

Flavor Is a Health Issue

Posted in Nursing, Nursing News, Obesity

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Dr. David Eisenberg, an associate professor at the Harvard Medical School and the Harvard School of Public Health in Boston, Massachusetts, is the founder and chief officiant of an annual event called “Healthy Kitchens/Healthy Lives.” This is an “interfaith marriage,” as he calls it, that brings together physicians, public health researchers and distinguished chefs. The program seeks to tear down the wall between “healthy” and “crave-able” cuisine.

Health care providers are on the front lines of America’s diabetes and obesity crises, but many of them have little knowledge of nutrition, let alone cooking.

To Dr. Eisenberg, son of a Brooklyn baker, “flavor is a health issue.” He thinks that it’s vitally important that people know how to cook healthy food that is enjoyable to eat. And he’s striking a chord; the “Healthy Kitchens/Healthy Lives” event is now in its eighth year, and typically sells out, according to this article in the New York Times. It is an example of a major shift in attitude among a young generation of medical professionals who grew up with farmers’ markets. As a physician participating in the event says, “I want to help my patients not need my services… I’d love to be put out of work.”

For Dr. Eisenberg, 56, a passionate cook who spent weekends as a child filling cream puffs and sprinkling cinnamon and nuts on rugelach in his father’s bakery, deprivation in the form of low-fat diets and bland overcooked vegetables is an enemy of doctors and patients. “For years we’ve told people ‘Don’t eat that’ or ‘Here’s your problem,’” he said of the physicians’ party line. “Sometimes,” he added of his own thrice-yearly yearning for steak, “you have to feed your inner jerk.”

His commitment to healthy food began when his father, a cake artist who “always smelled like a cross between a cinnamon stick and a whiff of Old Spice,” died of a heart attack when Dr. Eisenberg was 10. An expert on integrative medicine, Dr. Eisenberg was one of the first United States medical exchange students to the People’s Republic of China. He started “Healthy Kitchens/Healthy Lives” in partnership with the Culinary Institute and the Harvard School of Public Health, based on the radical notion that if doctors could learn to channel their inner Julia Child (sans butter), they could serve as role models and cheerleaders for their patients.

It’s not about ego. Over the years, research has shown that doctors who practice healthful behaviors like exercising, using sunscreen and not smoking have a greater likelihood of advising patients to do the same. A study last month in the journal Obesity reported that overweight doctors may be less prone than other physicians to discuss diet and exercise with their patients. “We’re all human,” said Dr. Matt Everett, a now-gangly 55-year-old physician from Marysville, Ohio, who was inspired to lose weight after seeing patients in their 40s and 50s having strokes and heart attacks. “We all struggle with the same things.”

For doctors like Martin Abrahamson, the chief medical officer for the Joslin Diabetes Center in Boston, there were revelations within Greystone’s cool, monasterylike stone walls, where chefs in white glide up and down staircases with nary a glance at the school’s historic corkscrew collection. “I’ve never cooked in my life,” he said, wearing a pinstripe suit beneath his apron, his hands drenched in marinade.

Dr. Abrahamson and his cronies listened raptly as the chef Tucker Bunch talked about “the little worm that unfurls” in overcooked quinoa (he advocates toasting it). “Doctors treat salt like an exacerbator of disease,” Mr. Bunch observed somewhat wryly. “So they under-season food with religious fervor.”

Nevertheless, they soaked up the dazzling feats of culinary derring-do, especially when the chef Patrick Clark sliced an onion in 10 seconds that fell into Sydney Opera House-like curves on the cutting board.

The collaboration between the Culinary Institute and Harvard epidemiologists and nutritionists goes back to 2002, when Dr. Willett, chairman of the institute’s scientific advisory board, began researching the health benefits of the Mediterranean diet. The team is now working with chefs from mega-chains like Applebee’s, Starbucks and Subway, to encourage them to reduce sodium and add more whole grains, nuts, legumes and healthier oils to their menus.

Dr. Eisenberg would like to see teaching kitchens in the places that need them most: medical schools, hospitals, universities, public schools and military bases. “What if teaching kitchens were as prevalent as computer labs in schools?” he asked. (He is working on a prototype.) Nutritionists often don’t know how to cook, Dr. Eisenberg pointed out, “which is a little bit like psychiatrists who are all screwed up.”

Yet after three days of thinking deep thoughts, all the while gorging on aromatic wheat-berry salads and peanut limeade (sounds revolting, tastes great), there was a palpable sense of a wellness tide turning.

For instance, Dr. John Principe of Palos Heights, a Chicago suburb, said that he seriously thought about quitting medicine, fed up with “a pill for every ill.” Fantasizing about a second career as a chef, he attended “Healthy Kitchens” five years ago and realized that he might be able to combine the two.

He now holds a culinary boot camp in the 2,400-square-foot kitchen and lecture room he built below his medical office, where he teaches people how to whip up cauliflower crust pizza and other dishes. (The sessions qualify for insurance under the group medical appointment model.) “Instead of being in the downtrodden mode, it’s given me a zest for life,” he said.

At the Baylor College of Medicine, Jasdeep Mangat, a 24-year-old medical student, was a founder of Choosing Healthy, Eating Fresh (CHEF), enlisting a chef from a local bistro to teach classes for 20 students using five portable gas burners in the student lounge. “We need to walk the talk,” he said.

And seven years ago, Dr. Daniela Connolly, now 40, and her husband, Patrick, bought a farm in Chester, N.H., to feed their five children healthy and reliable food.

She often runs into her patients while selling eggs at the farmers’ market and sometimes when they unknowingly show up at the house to pick up their Field to Fork Farm C.S.A. boxes. They are invariably surprised by how dirty she is.

After three days of “Healthy Kitchens,” she is now convinced she needs to teach her patients healthy cooking. “In a perfect world, I would have my patients meet me at the farm,” she said. “That would make me a really happy doctor.”

The Social Media Challenge in Nursing

Posted in Nursing, Nursing News

Audrey Kurehin -

These days, your social life is never farther than your desktop, laptop or phone. Through a variety of devices and social platforms, not only can you stay in touch with all your friends from college, but also the ones from high school, grade school, Sunday school and your gym.

Unfortunately all of this intermingling of social spheres often leads to an information seep, where what you plan for only some people to see is in fact seen by many others. Information that was meant only for family, say, can often be easily seen by acquaintances, coworkers, or clients. Once you’ve shared information online, it can be disseminated across the globe with a quick click of a button or sometimes, simply doing nothing. No matter what the privacy settings are on your social media account, if a friend’s settings do not carry the same restrictions, there’s no telling who has access to your information.

All of this presents two big challenges to nurses who use social media. First, patients, family members and co-workers may find information that you’d prefer they not have. Second, even complaining about a tough day at work could put you at risk for violating the Health Insurance Portability and Accountability Act (HIPAA).

For the generation that has grown up with websites such as MySpace, YouTube, Facebook and Twitter, social media has become as ubiquitous as email. So it is easy to lose sight of the fact that sharing work challenges for a limited audience may become global information depending on the discretion of the audience and individual privacy settings. The expression “if you don’t want it all over the internet, don’t put it anywhere on the internet,” holds true for every venture into social media. That includes one-on-one conversations.

When Congress enacted HIPAA in 1996, it did so primarily to enforce an ethical responsibility to protect the privacy of patients and their information. A posting from a nurse on Facebook about a difficult day with the patient in room 213 because she “just couldn’t make him happy,” could result in discipline if not outright dismissal from the job. If a patient, family member or any other private citizen can see the nurse’s employer from her profile and knows the name of the person in room 213 on that day, the patient has been identified. Job loss is a real threat, and what one nurse may think is a harmless complaint about an unnerving day could land her on the unemployment line for violating a Federal mandate.

Hospital and healthcare organizations have adopted internal policies regarding the use of social media and although most of them ban any use of the electronic social venues during work hours, there are professional advantages to using social media. Discussions on research, new technology, practice and professional development can all be accomplished through social media forums. A nurse’s professional online presence may foster network building and lay the groundwork for mentoring relationships. And as this article indicates, smartphones are increasingly being used for things like quickly looking up drug interactions.

Words of caution….
One big disadvantage of maintaining any type of line presence is that you have little control over who can find you. Patients and family members who have read your last name on your badge, might suddenly start following your Twitter feed or send you a friend request on Facebook. The decision to allow this is entirely personal, but blurring the lines of patient-to-nurse care might present challenges with an employer and make future interactions with patient difficult. In the same vein, just as a patient can read public postings, so can an employer. The expression “discretion is the better part of valor” may be a good guide when nurses use social media.

Whistle-Blowers Summon Moral Courage

Posted in Nurse Safety, Nursing, Nursing News

Image courtesy of ElectronicFrontierFoundation via Flickr

Whistle-blowing is both a morally important choice and one that is frequently very difficult. This article on explains that it can be a long and difficult process, that can chip away at a whistle-blowers’ sense of self-worth. They may be shunned by peers or lose their job. It’s not uncommon for people who have been through the whole process to say that if it happened again they’d just look away.

This despite the fact that studies have shown that whistle-blowing is the most important resource for detecting and reporting corporate fraud.

The ANA defines whistle-blowing as is the act of going outside a place of employment to report serious problems, such as those that endanger patients.

Nurses have a responsibility to report these kinds of problems, even when doing so is far from easy. The article lays out some of the things that are important to know, including knowing your options and knowing about organizations like the Whistleblower Support Fund.

Ideally, all organizations swiftly would resolve circumstances that threaten patient or worker health, or are otherwise unethical or illegal. The facility already would have mechanisms through which problems are reported and analyzed so they can be prevented in the future.

“Any place where a nurse works … there’s a responsibility to have a culture of safety as opposed to a conspiracy of silence,” said Cynthia Haney, JD, senior policy fellow for the ANA. Nurses, she added, have a vital role in shaping and supporting this type of environment, known as a “Just Culture.”

Most people know up front how their supervisors will address a serious problem, Murray said.

“They either provide the resources and demonstrate concern for what the individual has brought forward, or they do everything they can to dismiss it, change the topic and ask the individual to let it go,” Murray said. “Most people who go outside have reached a plateau where they’re so frustrated and have endured so much hardship that they don’t see any other option.”

Yet navigating “outside” isn’t easy, either.

Know your options

Multiple government agencies, partners, laws and regulations might come into play.

Among these:

The False Claims Act allows people with direct knowledge of fraudulent claims made by any entity receiving federal funds, such as Medicaid and Medicare, to pursue action. Because most hospitals and nursing facilities, as well as many private physician practices, participate in these federal programs, “it’s really a powerful tool for fighting fraud and abuse,” Haney said.

Anyone with evidence of fraud against a federal agency can seek the aid of an attorney specializing in “qui tam” cases, said Nayna Philipsen, RN, JD, PhD, CFE, FACCE, director of program development and assistant to the dean for legal affairs at Coppin State University’s Helene Fuld School of Nursing in Baltimore. “Qui tam” refers to someone else’s suing on behalf of the government and recovering a substantial portion of funds if the suit is successful.

The Occupational Safety and Health Administration addresses workplace safety. Issues such as exposure to hazardous materials and use of personal protection equipment fall under OSHA’s jurisdiction. Federal law related to job safety includes a protection called the “general duty clause,” which requires employers to provide safe environments for workers. That clause, Haney said, has been extended to include protection against circumstances that create hostile or threatening work environments.

The Affordable Care Act protects whistle-blowers in healthcare settings when patients’ consumer rights under the law are violated, Haney said. For instance, it protects nurses who report insurance company abuses or discrimination against patients with government-subsidized coverage.

The National Labor Relations Board can protect employees, both union and nonunion, who engage in certain “concerted activities,” such as discussing concerns related to safety — false charting and record tampering, for example — or other workplace conditions with colleagues.

Quality improvement organizations. In each state these are designed to ensure the effectiveness, economy and quality of care delivered by providers serving Medicare beneficiaries. These organizations address various complaints related to patient well-being, such as unneeded treatment, and concerns regarding healthcare law and appropriateness of care and billing.

State professional boards. These monitor professional behavior and are charged with protecting public welfare. When two nurses in Winkler County, Texas, thought a physician was providing unsafe patient care, they turned to the Texas Medical Board.

Arduous ordeals

The Texas nurses’ action was just the start of their journey. The two women were fired by the hospital that employed them, and county officials pursued felony charges of misuse of official information against them. The charge against one nurse was dropped, and the other was acquitted. They eventually accepted a $750,000 settlement in a lawsuit stemming from the incident.

Because whistle-blowing can be a long and grueling process, depression is common among whistle-blowers, said Don Soeken, LCSW-C, PhD, a former whistle-blower and founder and president of the nonprofit Whistleblower Support Fund. “They’re facing a terrible onslaught on their minds and bodies because society is set up so you have to have a job” to support yourself and your family, he said. Soeken asks potential whistle-blowers: “Do you have a family that can help support you?”

It’s hard for potential whistle-blowers to imagine the immensity of the challenge they face, said Soeken, who helped launch an Internet archive that catalogues and preserves details of past whistle-blowing cases to inform future whistle-blowers. “What you have are David and Goliath stories,” Soeken said, noting the government, corporations and other organizations can hire top lawyers and tap a wealth of research resources.

Still, Soeken said, whistle-blowers persist because their moral and ethical beliefs override a sense of self-preservation. “They’re almost like soldiers going into war,” he said. “They pay a high price. They do a great service. What we have to worry about is: What are we going to do to help them survive?”

The ABC’s of the Health Care Law

Posted in Nursing, Nursing News

Andy Dean -

The future of the Affordable Care Act is uncertain. The Supreme Court has heard arguments about whether or not the ACA is constitutional or not, and will be announcing their decision in June.

Meanwhile, the ACA itself is quite complex. Gina Kolata of the New York Times spoke with Jonathan Oberlander, an expert in the field, about the law and its future.

Mr. Oberlander starts by explaining what the ACA is, exactly. He calls it “a series of policies and regulations and subsidies and mandates.” He explains that that’s the reason it’s so complex — it has many different parts to it. Rather that starting from scratch, it is building on an “incoherent” medical system, and trying to patch the holes.

That’s not to say that he thinks that the ACA itself is also incoherent — he says that if it is implemented, it would be the biggest thing since Medicaid and Medicare in 1965, and that “it brings us closer to the ideal that all Americans should have access to care regardless of income or health status.”

Can the act be carried out without requiring almost everyone to buy health insurance?

That would be a serious wound, but it would not be fatal. There are many parts of the act, including the expansion of Medicaid, that could be implemented and that have little to do with the mandate. But without the mandate, the Affordable Care Act would cover fewer people and would not be as effective. And it will raise questions about the stability of the health insurance exchanges.

My guess is that if the whole law is thrown out we will see a return to incrementalism, doing small things like expanding Medicaid by a little bit or giving very modest tax credits to some uninsured. Or we will see federalism — turning things over to the states. Or doing nothing, which has been our default for much of the past century.

How you can have health insurance exchanges without a mandate? Wouldn’t the healthy shun them until they become sick, forcing the exchanges to charge prohibitive rates?

There are other things that you can do, but chances are Congress won’t do them. You can tell the insurers that they can charge a penalty to people who do not sign up at first and try to enroll later. It could be like what happens with Medicare prescription drug coverage — if you try to sign up after you are eligible, you pay a higher premium for the rest of your life.

So if the mandate is thrown out, what about other kinds of insurance? Medicare is deducted from my paycheck, right?

One of the things that even the conservative justices said is that tax-financed national health insurance is permissible. That’s why Medicare is O.K. It is a tax, and Congress has the authority to raise revenue. The mandate would require people to purchase private insurance.

In fairness to the Obama administration, at the time the Affordable Care Act was proposed there was an overwhelming legal consensus that the mandate was constitutional. The idea has been around for decades — it was originally a conservative Republican idea as an alternative to national health insurance — and few had raised serious constitutional issues.

If the law stands more or less intact, when will we see some big changes? So far, what has happened seems less than transformative.

June will be the big earthquake. (That is when the Supreme Court will announce its decision.) The next big month is November, with the election. If the law survives those two big challenges, legal and political, the big year is 2014. That is when most of the major changes go into effect.

States will be required to expand Medicaid. All Americans making up to 138 percent of the poverty line — that’s about $15,000 today for an individual — will be eligible for Medicaid. Historically, Medicaid has been linked to demography. It is not enough to be poor. In most states you have to be a pregnant woman, a child, elderly or disabled to be eligible. The A.C.A. will change that.

In addition, insurance subsidies will be made available to help the uninsured and some workers in small businesses buy private insurance through insurance exchanges. Small businesses can buy insurance there, too.

Insurers will be prohibited from denying coverage or charging higher premiums to persons with pre-existing conditions. And most Americans will be required to obtain — and larger businesses will be required to offer — health insurance or pay a penalty.

Doesn’t the Affordable Care Act contain a lot of proposals to get costs under control, like comparative effectiveness studies and reimbursing doctors based on their performance? Will such ideas help contain the cost of medical care?

Most of these ideas are wishful thinking. The evidence is either mixed or just not there that these reforms will rein in spending. They are a sort of faith-based cost control. Other options are more painful, and at the moment there may not be any method for controlling spending that is politically feasible.

The A.C.A.’s capacity to produce reliable cost containment has been exaggerated. Its Medicare savings are significant — it will save an estimated $500 billion in the next decade by slowing payments to hospitals and private insurance plans that contract with Medicare. Outside of Medicare, the cost containment is less impressive.

Do you foresee big changes in the near future — politically difficult decisions that will rein in costs?

I’m a Red Sox fan, so I believe in miracles. But in the short term, the answer is no. We will build on our existing system — it’s what we have, and it is too difficult to move away from it. Two or three decades from now, nobody knows.