Violence against healthcare workers is not breaking news for people who work in healthcare. For many of them – particularly emergency department staff – threats, cursing, screaming, and sometimes even physical assaults are symptomatic of a healthcare delivery system stretched to the breaking point.
As I have noted before, data from the U.S. Bureau of Labor Statistics show that for every 10,000 hospital workers, eight workplace assaults resulted in missed work days. In the overall private sector, by contrast, only 1.7 workplace assaults resulted in missed work for every 10,000 workers.
These assaults on healthcare workers should never be considered routine, or “part of the job.” Nobody trying to make an honest living – especially a healer – should have to put up with abuse. And to their credit, growing numbers of hospitals and other healthcare organizations are adopting zero tolerance policies.
For the most part, however, the public does not understand the extent of the problem. It’s up to the healthcare sector to educate them. The word is getting out, slowly. The mainstream media is starting to pick up the issue, and every article or TV news segment dedicated to the topic will bring that much more public attention to the problem. With the public informed and on your side, good things will happen.
Smart hospital leaders are finding positive, proactive ways to generate publicity about violence against staff, and patients. It’s not difficult to do because hospital security is an important story that resonates with the public.
They are in dozens of hospitals already, and have been for years. However, the Vanderbilt program has generated a lot of news coverage for the hospital. TV and print media, supplied with a compelling angle (and most importantly for TV, a picture), wrote stories about the program, providing viewers and readers with a brief primer on the growing threat of violence in the healthcare setting.
For example, The Tennessean, one of the largest newspapers in the Volunteer State, described a patient who “jerks a metal vent out of a wall, pounds it into a crude shank and brandishes it threateningly. He’s not in a prison. He’s in a hospital emergency room.”
The Tennessean notes that the incident happened at Vanderbilt University Medical Center, but that the hospital “has no monopoly on ER violence. Workplace assaults and threats have risen to the point that Middle Tennessee hospitals are ramping up security measures and teaching ER workers de-escalation techniques. The increased focus on prevention comes after a national organization representing ER workers exposed the hidden scabs behind nurses’ uniforms.”
Of course, this is not good publicity in the traditional sense. Nobody wants their hospital to be described using words usually reserved for the crime blotter or a prison movie. It’s not the warm-and-fuzzy opening of a new maternity ward or a breakthrough, life-saving, high-tech gizmo. And be prepared for TV shots of scrubs-clad hospital employees practicing arm bars and headlocks. That is inevitable – TV needs pictures.
But here’s the rub: It works. By doing it this way, Vanderbilt has sent the message to the public that they are dealing with this undeniable and disturbing reality in a proactive and positive way. With an understanding of the problem, the public will sympathize and demand action to protect healthcare workers, who in every community are their friends and neighbors.
Sign up for a violence prevention program. There are several out there – just ask around. Find one that emphasizes risk assessment and de-escalation techniques. The cost of such a program will likely be made up in improved employee safety and morale, and by the free and positive publicity you will generate when you make public your proactive efforts.
The federal government this week announced new guidelines to protect hospital patients’ right to choose visitors, including same-sex domestic partners.
The rules were finalized by the Centers for Medicare & Medicaid Services last fall and apply to hospitals that take Medicare and Medicaid payments. The guidelines also support the right of patients to designate the person of their choice – including a same-sex partner – to make medical decisions on their behalf should they become incapacitated.
“This announcement is another step toward equal rights for all Americans, and it is another step toward putting the patient at the center of our healthcare system,” CMS Administrator Donald M. Berwick, MD, says in a media release. “All patients should be afforded the same rights and privileges when they enter our health care system, and that includes the same opportunity to see their significant other.”
CMS this week sent a letter to State Survey Agencies, which conduct on-site inspections of hospitals on behalf of CMS, highlighting the equal visitation and representation rights requirements and directing SSAs to be aware of the guidance when evaluating hospitals' compliance.
Tara L. Borelli, an attorney with Lambda Legal, says the new rules and guidance are “a step in the right direction, but we need to make sure that they are consistently followed. Lambda Legal knows from its work, which has included representing same-sex life partners who were treated as mere strangers by emergency room personnel, that there is still an enormous education job ahead about the new rules,” Borelli told HealthLeaders Media.
Borelli says Lambda Legal’s cases, including in Florida and Maryland, illustrate that “confusion persists and families are irreparably harmed when they are disrespected in times of medical crisis.”
“While these cases predate the new rules and guidance, they illustrate that confusion and disrespect of same-sex couples in times of medical emergency is an entrenched problem,” Borelli says.
The rules updated CMS’s Conditions of Participation (CoPs) that apply to all patients even if they are not on Medicare or Medicaid. The CoPs require hospitals to explain to all patients their right to choose who may visit them during their inpatient stay, regardless of whether the visitor is a family member, a spouse, a domestic partner (including a same-sex domestic partner), or another type of visitor, as well as their right to withdraw such consent to visitation at any time.
CoPs protect the rights of hospital patients to have representatives who can act on their behalf. HHS has updated the guidance for these rules to emphasize that hospitals should give deference to patients’ wishes concerning their representatives, whether expressed in writing, verbally, or through other evidence, unless prohibited by state law. The guidance issued this week is intended to make it easier for relatives, including a same-sex domestic partner, to make informed care decisions for loved ones who have become incapacitated, HHS says.
Borelli says the biggest obstacles to compliance are states that ban same-sex marriages. “That invites confusion and disrespect by others,” she says. “This occurs even when the law offers same-sex couples a lesser status with protections, such as domestic partnership or civil union.”
A federal appeals court on Thursday overturned a lower court and rejected Virginia's challenge to the federal healthcare reform law, ruling that the state lacked the standing to proceed with the suit.
The 4th Circuit Court of Appeals court tossed aside a ruling by U.S. District Judge Henry Hudson last December, who had sided with Virginia's Republican Attorney General Kenneth Cuccinelli and ruled that the individual mandate in the Affordable Care Act was unconstitutional. The appeals court sent the suit back to Hudson and told him to dismiss it.
Also on Thursday, the appeals court rejected a separate lawsuit from Liberty University in Lynchburg, VA, that challenged the constitutionality of the individual mandate. The appeals court judges ruled that the university had no legal standing to challenge the mandate because it has not yet gone into effect.
In the Virginia challenge, Cuccinelli argued that the individual mandate to buy health insurance or pay a penalty conflicted with the Virginia Health Care Freedom Act, which says that state residents are not required to buy health insurance. The law enacted in Virginia in 2010 as Congress was debating the Affordable Care Act.
The appeals court disagreed.
"Under Virginia's standing theory, a state could acquire standing to challenge any federal law merely by enacting a statute – even an utterly unenforceable one – purporting to prohibit the application of the federal law," Judge Diane Gribbon Motz in her opinion.
"The VHCFA regulates nothing and provides for the administration of no state program. Instead, it simply purports to immunize Virginia citizens from federal law. In doing so, the VHCFA reflects no exercise of 'sovereign power,' for Virginia lacks the sovereign authority to nullify federal law," Motz wrote.
The judges in the 4th Circuit Court of Appeals -- all of whom were appointed by Democratic presidents -- did not comment on the merits or the constitutionality of the healthcare reform laws. Still, it was a clear procedural victory for the Obama administration in a case that is expected to be heard next year in the U.S. Supreme Court, with a ruling expected next summer.
The law is the subject of multiple suits by Attorneys General in 26 states, most of whom are Republicans. For a status update on the various legal challenges to the healthcare reform law, click here.
Understaffing at Carlisle Regional Medical Center did not play a role in the deaths of two emergency department patients in June, the Pennsylvania Department of Health said.
Michael Wolf, the department's acting deputy secretary for quality assurance, said in a letter to Carlisle Regional CEO John Kristel that "the department has carefully examined several patient medical records, documentation, and additional information provided by the Hospital. We now relay that the patient deaths related to staffing as reported in the media appear unfounded and not based on the documentation."
It was not immediately clear what caused the patients' death. However, Kristel made the state's letter public and said in prepared remarks that the findings "substantiate what we have known all along: These patients received prompt and appropriate care by a dedicated team of physicians and healthcare professionals."
The state launched an investigation at Carlisle Regional, which is owned by Naples, FL-based Health Management Associates, Inc., following several complaints, and the deaths of two emergency department patients there.
On June 5, a critical care patient died while undergoing a CT scan. An employee told state investigators that the patient was sent for imaging without a nurse because only four nurses were on duty to service the overflowing emergency department.
On June 11, a patient in the emergency department complained of chest pains, and light-headedness died at the hospital more than seven hours after a cardiologist recommended that the patient be transferred to Harrisburg Hospital for an aortic valve replacement.
The state report reviewed documents from the hospital and includes interviews with at least 18 unnamed employees who complained about poor and unresponsive management and retaliation against "troublemakers."
Carlisle Regional said that a review of medical records found that allegations made by employees who spoke with the state were not accurate, and that the ED patients had, in fact, received prompt and appropriate care before their deaths.
In addition, Carlisle Regional said there was no evidence to suggest that employees who spoke out on hospital issues faced retaliation. The medical center said it encourages employee feedback and has a hotline, operated by a third party, by which employee concerns may be reported anonymously. Only one issue has been reported in this manner this year, Carlisle said in an e-mail to HealthLeaders Media Thursday.
The state also approved Carlisle Regional's correction plan to address deficiencies found in the state's June 22 survey. Wolf said the state has conducted onsite surveys at Carlisle Regional every day, including weekends, since August 19, and has not cited any material deficiencies.
Carlisle, however, in an e-mail to HealthLeaders, called the term "'Plan of Correction' a bit of a misnomer," and described the document as "merely the communication tool used between the hospital and the Department of Health to provide additional information to the State."
Kristel said the state's ruling validates his skepticism of the initial report.
"It has been disappointing to see the reputation of our hospital and its dedicated team of professionals harmed over the past weeks by the inaccuracies contained within the survey, but we are comfortable that our patients know us, and we thank them for their continued confidence," Kristel said.
"We have refrained from commenting publicly until now because we respect the regulatory process. It must be based on fact and evidence, and not on people jumping to conclusions before a proper investigation can be conducted. We have worked closely with the Department of Health and provided all documentation to support our position."
There were 83,466 physician assistants practicing in the United States in 2010, a 100% increase over the past 10 years, according to a survey from the American Academy of Physician Assistants.
A further breakdown of the survey found that nearly 30% of PAs practice in single-specialty physician group practices, and 40% have been in their current primary specialty for at least six years.
The census also shows that 66% of PAs said they are satisfied or mostly satisfied with their career. Female PAs outnumber male PAs by nearly 20,000. More than 30% of PAs practice in primary care, making it the largest specialty for PAs, AAPA said in a media release.
"PAs are the only healthcare providers educated and credentialed with a primary care focus, providing a strong foundation for any specialty in which they may choose to practice," said AAPA President Robert Wooten, PA-C. "The information from AAPA's salary and census reports clearly confirm what PAs and the healthcare world have known for years: The PA profession is growing rapidly, and it is key to expanding access to quality healthcare for millions of Americans."
PAs earn a median annual salary of $90,000, up 2.8% from the 2009 survey. The three states with the highest salary increase in 2010 were Rhode Island, South Dakota and Missouri, all with increases of more than 9% over 2009, the survey found.
While most PAs are in clinical practice, an estimated 5,079 PAs work either alone or in healthcare education, administration, research and public health – a figure that Wooten said demonstrates the growing role PAs play in healthcare.
The AAPA annual census surveys both AAPA members and nonmembers. The data collected are used to track PA workforce issues, calculate summary statistics and describe the salary information. AAPA represents more than 81,000 certified PAs across all medical and surgical specialties in 50 states, the District of Columbia, most U.S. territories, and in the military.
Federal authorities on Wednesday detailed an eight-city sweep by the Medicare Fraud Strike Force that netted 91 suspects -- including 11 doctors and two nurses – for various fraud schemes involving false billing.
The value of the sweep represented the single highest amount of false Medicare billings in the four-year history of the Strike Force, which used more than 400 investigators from the Department of Justice, FBI, Health and Human Services -- Office of the Inspector General, and state and local law enforcement agencies for the raids, federal authorities said in a joint media release.
“Today’s arrests are a powerful warning to those who would try to defraud taxpayers and Medicare beneficiaries,” HHS Secretary Kathleen Sebelius said. “These arrests illustrate close cooperation between the Medicare program that identified these fraudsters and the law enforcement officials who acted swiftly to cut them off. And our efforts to stop criminals don’t end here because the Affordable Care Act gives us new tools to prevent Medicare fraud before it is committed – better protecting seniors and the integrity of the Medicare program for generations to come.”
Federal prosecutors detailed the allegations in each city:
In Miami, 45 people, including a doctor and a nurse, were charged in various fraud schemes involving a total of $159 million in false billings for home healthcare, mental health services, occupational and physical therapy, DME and HIV infusion. In one case, 24 people are charged with participating in a community mental health center fraud scheme involving more than $50 million in fraudulent billing. The defendants allegedly paid patient recruiters to refer ineligible beneficiaries to the mental health center. In some instances, beneficiaries who were residents of halfway houses were allegedly threatened with eviction if they did not attend the mental health center.
In Houston, two people were charged with fraud schemes involving $62 million in false billings for home health care and DME. One defendant allegedly sold beneficiary information to 100 different Houston-area home healthcare agencies in exchange for illegal payments. The indictment alleges that the home agencies then used the beneficiary information to bill Medicare for services that were unnecessary or never provided.
In Baton Rouge, LA, 10 people were charged in schemes involving more than $24 million related to false claims for home healthcare and DME. According to one indictment, a doctor, a nurse and five other co-conspirators schemed to bill Medicare for more than $19 million in skilled nursing and other home health services that were medically unnecessary or never provided.
In Detroit, 18 people, including three doctors, were charged last week for schemes to defraud Medicare of more than $28 million. According to an indictment, 14 of the defendants participated in a home healthcare scheme that submitted more than $14 million in false claims to Medicare.
In Brooklyn, three people, including two doctors, were charged for a fraud scheme involving more than $3.4 million in false claims for medically unnecessary physical therapy.
In Dallas, two people, including a doctor, were charged in a scheme to defraud Medicare of approximately $2.1 million, DOJ said.
In Chicago, four people, including a doctor were charged for their alleged roles in schemes to defraud Medicare of more than $4.4 million.
In Los Angeles, six people, including two doctors, were charged in a scheme to defraud Medicare of more than $10.7 million.
Since its inception in March 2007, Strike Force operations in nine cities have charged more than 1,140 people who collectively have falsely billed the Medicare program for more than $2.9 billion.
An El Segundo, CA-based medical billing company has agreed to pay the federal government $4.6 million to settle fraud allegations stemming from overcharges at the company's Medicare and Medicaid operations in California and Louisiana, the Department of Justice said.
Federal prosecutors alleged that Janzen, Johnston & Rockwell Emergency Medicine Management Services Inc. inflated claims that it had coded on behalf of emergency room physicians in Louisiana and California.
From approximately 2000 through 2007, JJ&R used a coding formula that tended to generate claims for a marginally higher level of evaluation and management service than physicians had actually provided. JJ&R also routinely added charges to the evaluation and management claim for minor services, such as pulse oximetry, which had been provided by hospital nurses or physicians, DOJ said in a media release.
All the while, JJ&R allegedly often failed to comply with Medicare's coding rules governing claims for teaching physicians, resulting in claims that were not properly payable. The coding practices had a relatively small impact on the reimbursement of any particular claim. Over time, however, they generated significant overpayments from Medicare and Medicaid, DOJ said.
"Inflating individual healthcare claims by even small amounts can cause significant losses to Medicare and Medicaid," Tony West, Assistant Attorney General for DOJ's Civil Division, said in a media release. "Taxpayers should not be on the hook for charges that shouldn't have been added or claims that shouldn't have been submitted."
Attempts by HealthLeaders Media to contact JJ&R on Tuesday afternoon were not successful.
The settlement resolves whistleblower allegations brought by Le Jeanne Harris, a former employee of JJ&R, who will get $774,450.
DOJ said it has used the False Claims Act to recover more than $5.9 billion since January 2009 in cases involving fraud against federal healthcare programs.
A study showing that hand washing increases among medical professionals when the organizational emphasis is on patient safety is hardly breaking news, but it should be a key motivator for other infection control practices, one infection control advocate says.
Russ Olmsted, president of Association for Professionals in Infection Control and Epidemiology, Inc., said in an email to HealthLeaders Media he was "encouraged" to see social scientists "share an interest in the behavioral aspects of patient care" and Olmsted said he welcomed additional research.
The study Olmsted cited,It's Not All About Me: Motivating Hospital Hand Hygiene by Focusing on Patients,found significantly better compliance with hand hygiene when hospital signage encouraged healthcare professionals to consider the health and safety of their patients, rather than themselves. The study will appear in Psychological Science.
"Clearly we have a healthy supply of products to support hand hygiene. The 'missing ingredient' however is perhaps a better understanding of human behavior in the healthcare environment and then the application of interventions that use findings such as this from social sciences," Olmsted said.
"The knowledge from social sciences can also be applied to other interventions aimed at preventing cross infection, such as use the of personal protective equipment when caring for patients on isolation precautions, implementation of infection prevention "bundles" for devices needed for patient care, e.g. central venous catheters, and even hygiene for the inanimate environment," he said.
The study posted one of three signs – each with a different emphasis -- at 66 hand-washing stations at several hospitals. The signs read: "Hand hygiene prevents you from catching diseases;" or "Hand hygiene prevents patients from catching diseases," or "Gel in, wash out." The study measured soap dispenser volumes over two weeks and found that staff used 33% more soap when the signage emphasized patient safety.
While he was encouraged by the study' findings, Olmsted says that emphasizing patient safety first in infection control is not a new idea. It has long been the centerpiece of hand hygiene initiatives adopted by the World Health Organization , the U.S. Centers for Disease Control and Prevention, and by APIC itself.
"Overall therefore while the findings of this study are useful it's important (to) understand there is a fairly high level of penetration of the message that hand hygiene = patient safety across providers in North America and beyond," Olmsted says.
Despite those recommendations from WHO, CDC, APIC and other organizations, study co-author David A. Hofmann said there is no definitive answer for why significant numbers of healthcare professionals continue to neglect hand hygiene.
"That is the $64 million dollar question," says Hofmann, a professor of organizational behavior Kenan-Flagler Business School, University of North Carolina at Chapel Hill.
"Physicians are potentially overconfident in their own immune systems and the lack of a one-to-one causal between hand washing and them getting sick creates a situation where they don't perceive the risk as that high," he says. "When we shift the sign message to the patient it highlights a very vulnerable person in the context that could be affected by this behavior and it may also trigger going back to the Hippocratic Oath which is 'First do no harm.'"
And while there was an immediate short-term uptick in hand-hygiene that could be related to the signage, Hofmann says it's not clear if the message might become muted over time. "We did a two-week study and found an effect but it does beg the question of 'over time do the signs fade into the environment and no longer impact behavior?'" he says.
Olmsted says he'd like to see a study measuring the longer-term effects of patient-centered signage for hand hygiene. "An investigation of longer duration and perhaps involving a wider range of healthcare facilities would be helpful to verify that their findings can be sustained," he says.
The healthcare sector has again provided about the only bright spot in an otherwise drab report on job growth in August from the U.S. Bureau of Labor Statistics.
Healthcare employment rose by 29,700 jobs in August, and the sector has created 205,100 new jobs in the first eight months of 2011, accounting for 22% of the 930,000 non-farm payroll additions in the overall economy in 2011, BLS preliminary data show.
A further breakdown of BLS preliminary data show that within the healthcare sector, hospitals gained 7,700 new jobs in August, after recording 11,000 new jobs in July. Hospitals lost 1,900 jobs in June, but have created 52,600 new jobs so far in 2011. By comparison, in the first eight months of 2010, hospitals created 15,800 new jobs, BLS data and preliminary data show.
Ambulatory services created 18,100 new jobs in August, and have been responsible for 58% (119,600) of new jobs in healthcare so far in 2011. Ambulatory services created 110,900 new jobs in the first eight months of 2010, BLS data and preliminary data show.
Physicians' offices reported 5,600 payroll additions in August and 30,600 new jobs so far in 2011. Physicians' offices created 39,600 new jobs in the first eight months of 2010, BLS data and preliminary data show.
BLS data from July and August are preliminary and may be considerably revised in the coming months.
Nearly 14.1 million people worked in the healthcare sector in August, with more than 4.7 million jobs at hospitals, more than 6.1 million jobs in ambulatory services, and more than 2.3 million jobs in physicians' offices, BLS preliminary data show.
Beyond the healthcare sector, nonfarm job growth in the larger U.S. economy was flat in August. The stagnant job market was blamed largely on a two-week strike affecting about 45,000 telecommunications workers at Verizon who were taken off the payroll in August. Those workers are now back the job.
The nation's unemployment rate remained essentially unchanged at 9.1%, where it has been since April, with 14 million people unemployed.
The number of long-term unemployed—people jobless for 27 weeks or longer—was 6 million in August, and represented 42.9% of the unemployed, BLS preliminary data show.
Online advertised vacancies for healthcare practitioners and technical occupations increased by 26,300 in August, breaking two consecutive months of declines, The Conference Board reported.
Among the top 10 occupation groups in the overall economy with the largest number of online advertised vacancies, healthcare practitioners and technical occupations posted the only increases in August.
The highly skilled health occupations posted 513,700 online job ads for the month and made up some ground lost from July's decrease of 61,200 postings. However, demand for healthcare practitioners and technicians dropped by 98,800 job postings since January, according to The Conference Board Help Wanted Onlinereport.
The board's Help Wanted Online Data Series tracks more than 1,000 online job boards across the United States.
August job posting gains were reported for registered nurses, speech-language pathologists, licensed practical and licensed vocational nurses, family and general practitioners, and occupational therapists. For those occupations, there were more than two jobs available for every job seeker, with an average hourly wage of $34.27.
Healthcare support positions fell by 500 listings to 116,000 in August. There were 2.6 healthcare support job seekers for every job opening, and the positions paid – on average -- $12.94 an hour, The Conference Board reported.
In the overall economy, on line job listings fell by 163,000 listings in August, to 3.9 million. The August decline follows a drop of 217,000 job listings in July and 100,000 job listings in June. There were more than three unemployed people for every online advertised vacancy in July, the latest monthly data available for unemployment.
"Following a very strong first quarter (+763,000), labor demand has fallen off in the second quarter and into the third quarter (-456,000), reducing the earlier gains," June Shelp, Vice President at The Conference Board, said in a media release.
Overall, 2011 has seen a 308,000 increase in labor demand, but the average monthly gain this year (+38,000) is less than last year's average monthly gain at this point (+62,000), Shelp said.