The Committee on Health and Human Services was called to order at 6:15 p.m., on Tuesday, April 6, 1999. Chairman Vivian Freeman presided in Room 4100 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All Exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

COMMITTEE MEMBERS PRESENT:

Mrs. Vivian Freeman, Chairman

Mrs. Ellen Koivisto, Vice Chairman

Ms. Sharron Angle

Ms. Merle Berman

Ms. Barbara Buckley

Ms. Dawn Gibbons

Ms. Sheila Leslie

Mr. Mark Manendo

Ms. Kathy McClain

Mr. Kelly Thomas

Ms. Kathy Von Tobel

Mr. Wendell Williams

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

A simultaneous videoconference was held in room 4412, Grant Sawyer State Office Building, 555 East Washington Avenue, Las Vegas, Nevada.

Following roll call, Chairman Freeman opened the hearing on A.B. 586 and announced the proponents would be given 20 minutes to present their remarks, the opponents would have 20 minutes, and a rebuttal would follow.

John Klein identified himself as a research analyst with the Nevada Service Employees Union (SEIU), Local 1107. He said few health care measures had come before the Nevada Legislature with a more solid scientific basis for action than A.B. 586, the Quality of Care Act of 1999.

Three decades of academic studies had demonstrated conclusively that hospital nurse staffing levels were directly linked to patients risk of complications or worse. Staffing was a critical element of the quality of health care that people received in Nevada's institutional facilities.

Recently a federal study had shown that for each 30 minutes of registered nurse (RN) care delivered to a patient, there was a 4.5 percent decrease in urinary tract infections, a 4.2 percent decrease in post-operative pneumonia, a 2.6 percent decrease in blood clots, and a 1.8 percent decrease in pulmonary compromise. Nursing care made a difference.

It was understood hospitals faced enormous cost pressure in a changing health care system; however, cost pressure should not necessarily have an impact on the quality of care. For that reason, SEIU and the Nevada Nurses Association (NNA) proposed A.B. 586. The bill had primary goals as followed:

• Required hospitals for the first time to disclose the quality information they already kept about hospital-acquired infections, medication errors, patient falls, and so on. That information was vital for consumers interested in getting the best care possible. It had not been currently available to the public.

• Protected health care workers who advocated for their patients. The bill stated if a person came forward with a complaint to an appropriate legislative body, law enforcement body, or even the public, they could not be retaliated against on the job. Created a system of staffing standards; the most controversial aspect of the bill. Amendments had been presented that required the licensed owners or operators of a hospital or nursing home to have a system to assess every patient's needs for care. A plan had to be in place to base staffing on those assessed needs.

• Required an internal committee in each hospital composed of at least 50 percent of RNs who delivered direct nursing care to oversee the validation of the patient assessment system.

• Required enforcement to ensure hospitals and nursing homes were meeting their staffing plan criteria.

• Provided recourse for "whistle blowers" if they were retaliated against.

Mr. Klein summarized arguments he had heard against the bill which included:

• Significant increase in healthcare costs.

The proponents believed the measure to be a preventive public health measure. There would be testimony from patients whose length of hospital stay increased due to complications arising from insufficient nursing care. Those increased hospital stays increased health care costs. Although the bill might save money for the entire health care system, any costs associated with the bill would be concentrated at the level of the facilities.

The bill would enormously benefit individual patients, the insurance companies, and the large employers who purchased health care in the state by giving them the data they needed and ensured adequate staff to provide quality care. Even if there were no financial benefits to preventing infection, which there were, the real and tangible benefits of preventing suffering and in some cases death warranted spending money. The proponents believed the money was in the system. An analysis of the cost to provide an additional one half hour of RN care over a 4 year period to every patient in Nevada's hospital was $57 million, a lot of money. However, an examination of the earnings by the same hospitals for the same period revealed profits of nearly $400 million.

• There was a nursing shortage and it was impossible to provide higher staffing levels.

The bill's proponents believed that was not the case. Although the labor market for nursing was tight in Las Vegas, the real nursing shortages were in those hospitals who chose to understaff. University Medical Center, St. Rose, and other facilities that had reputations for good quality care also had reputations among the nursing community for adequately staffing their hospitals. Those hospitals were able to get nurses.

Mr. Klein cited a recent article in the Review Journal in which Bruce Wiggins, of Pennsylvania-based Universal Health Services, operator of three Las Vegas hospitals, was quoted to have said, "When they took over Desert Springs Hospital staffing levels were reduced…cutting excess nursing hours helps the hospital remain affordable." Mr. Klein wondered what happened to those nurses, because, further on, in the same article, Mr. Wiggins argued "Even if the hospital desperately wanted to add nurses to every shift it just wouldn't be possible because there aren't enough nurses in southern Nevada to go around."

Mr. Klein said there was a nursing shortage coming and what would drive that was it was very difficult to do nursing care anymore because of the nursing conditions in the facilities.

Chairman Freeman asked if surveys or studies had been done to determine why nurses were leaving the field. Mr. Klein had not seen any studies on that. He did know, however, that 5,000 nursing licenses had lapsed over the last 4 or 5 year period. There would be anecdotal testimony from nurses who were long time caregivers and were considering leaving the profession. He felt it was an important question to examine.

Theresa Morrow identified herself as a registered nurse, a University of Nevada, Las Vegas graduate in 1982, and before that was a nursing assistant. She had been in the profession for 20 years. She provided her written testimony (EXHIBIT C) which stated in part:

• Nurses, as front-line caregivers, did not command the respect of those who managed and administrated their workplaces.

• Staffing was done by the numbers, by ratios, and direct caregivers had no control over those numbers.

• Critically ill patients in intensive care who deserved and needed one-on-one care did not get it. Nurses time had to be split between many patients to the detriment of all.

• In an effort to maintain profits in healthcare, nursing had been downsized and those who remained shouldered the burden of the cost containment.

Ms. Morrow gave a photographic presentation that showed the infected torso of a patient who suffered from bedsores. The condition required surgery and a hospital stay of 128 days. Ms. Morrow closed by urging support for A.B. 586.

Next to speak was Tricia Hunter, from the Las Vegas videoconference center, who identified herself as the lobbyist for the Nevada Nurses Association as well as a registered nurse. She had served in the legislature, served on a board of registered nursing, and had been both a staff nurse and a manager of health care facilities. She had a masters degree as a cardiovascular clinical specialist. She provided her written testimony, (EXHIBIT D).

She specifically addressed the amendments in the bill regarding acuity. An acuity system for staffing was already required by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) and by the Bureau of Licensure and Certification. An acuity system was a process to determine the amount of care a patient needed and that need then determined the number of personnel required to care for that patient.

However, although having an acuity system in place in the hospitals had been standard for a long time, having the policy did not mean that it was used. Measuring acuity was an ongoing process as patients were admitted to a department or discharged from a unit. Every acuity system required a periodic review of patients to assess staffing needs. A.B. 586 required that acuity was reviewed every shift, was documented, and an explanation for any variance from the staffing requirement be kept. If the records showed consistent problems with staffing, a review committee of administration and staff nurses from the unit would work together to resolve the problem.

Further, A.B. 586 established a "whistle blower" protection for healthcare providers who reported problems with the quality of care, staffing, or other licensing issues. Finally, the bill established a process for the Bureau of Licensure and Certification to collect data to do research on what was happening in the state's institutions and to determine if there were other legislative needs in the future.

Chairman Freeman asked if states required the data collection, who reviewed it. Ms. Hunter said some states had separate departments set up for the purpose, but most of the time it was the Health Department. Most states set up a system that ensured the data was reviewed from a risk status so a hospital with a high mortality rate in open heart surgery, for example, was not impugned because they also took the highest risk patients.

Mrs. Freeman then asked if Ms. Hunter was aware of similar legislation in other states. Ms. Hunter said 11 states had legislation pending related to putting in specific staffing ratios. The bills varied from state to state as to how far they went within those requirements. Mr. Klein said the language in the amendment on acuity based staffing plans was similar to what had been in effect in California for 3 years. Both California and New York had on the books a requirement of 2-to-1 ratio in critical care. Mrs. Freeman asked for a report on the facilities in those states. Ms. Hunter said California had been doing the licensing reviews based on that acuity. The nursing community there decided that was not enough and legislation was going through in California to go to the next step.

Mrs. Freeman next asked how to best answer people who said they did not like ratios in the workplace. Ms. Hunter responded the data collection component of the bill examined staffing. It gave the State of Nevada not only the opportunity to implement an acuity system, which was already the national standard for staffing in hospitals, but also the opportunity to review the data to determine if they wanted to move to the next step of actually requiring ratios. Ratios in the intensive care unit were a national standard. The Association of Critical Care Nurses and the Association of Critical Care Physicians had a strong position and mandated actual minimum staffing criteria in intensive care units (ICUs). Operating rooms in 50 percent of the states had criteria, including Nevada, that there be a registered nurse in every operating room. There had been variations of specific ratios across the country. In A.B. 586 the compromise that was put forward was requiring the enforcement of an acuity system that was a standard already accepted in Nevada. The bill went the next step to ensure there was some review to say that was actually happening. It was the first step, then the data could be collected and examined to determine if it was working. The legislature could then make the decision whether they wanted to move another step or whether that adequately ensured the appropriate personnel to protect the patient's safety in Nevada.

Regarding liability insurance which hospitals were required to have, Mrs. Freeman asked if having an acuity system in place affected the insurance rates. Ms. Hunter said it should affect them positively. She handled many programs across the nation regarding legal liability for nurses. Her experience had shown when adequate personnel had taken care of patients the liability was reduced. Hospitals were sued when patients got infections, bedsores, or an adverse reaction to a wrong medication. Research had shown that having appropriate staffing for patients reduced those issues.

The next to speak from Las Vegas was Bobbi Gilmore, a mother and wife of Billy Gilmore, pastor the Friendship Church of God In Christ, and she had been a resident of Las Vegas nearly all her life. She related what she termed was a "horror story" concerning the prolonged illness and hospitalization of her husband that had began with a brain aneurysm. He checked into the Sunrise Hospital and was operated on later that night. The ensuing events had devastated their lives. There had been many complications including a stroke, a pick inserted in his brain, and being put on a respirator. After the 50th day of his hospital stay he was transferred to the Vencor Hospital. Shortly after that he developed a bedsore and from nurses' conversations she realized it was very serious. When she finally observed the bedsore she was horrified; it was large enough to put her fist into and went as deep as the bone. It had become infected, he had a high temperature, and he was still in a coma as a result of the brain aneurysm surgery. Mrs. Gilmore was at the hospital every day, nearly all day, to give care and tend to her husband because there was not enough nursing staff available to provide even the basic care he needed to keep him clean or change his badly soiled bedding. When she complained to the doctor she was told to go to the head of staff. She went to their meetings to express her feelings. There was no improvement.

One night while cleaning up her husband she happened to speak with a nurse's aide who told her he had 19 patients. She was shocked. The next day a nurse told her that her husband had been given the wrong medicine. She looked at the IV bag and saw another man's name on it.

She then went to the administrator and demanded her husband be moved to Valley Hospital. His condition deteriorated. After a month he was moved to University Medical Center to the burn care unit to deal with the infected bedsore. It had been negligence and inattention that had caused the bedsore. Her husband finally returned home after 8-1/2 months. She was approached to tell her story to illustrate the desperate conditions in hospitals and in closing Mrs. Gilmore urged support and passage of A.B. 586.

Next to speak from Las Vegas was Joan Reyes, a registered nurse for 33 years. In those years she had worked in a variety of settings in hospitals, urgent care centers, and nursing homes. She provided her written testimony (EXHIBIT E) which stated in part:

• While working part time at Valley Hospital, assigned to the intermediate care unit, she had six patients spread out all over the unit. Two patients were on ventilators that required almost constant monitoring and assistance. She was unable to give only minimal care to her other patients. After that experience she refused to work at Valley Hospital again.

• She did go back to Valley Hospital, as a patient diagnosed with lung cancer, for surgery. It was successful and she received excellent nursing in the surgical intensive care unit. The day following surgery she was transferred to another unit. The unit was so short-staffed she received almost no care or attention. A bad reaction to pain medication resulted in pneumothorax (collapsed lung) and crepitus. There was one RN and one licensed practical nurse (LPN) on duty who were so busy with other patients that her many episodes of vomiting went unnoticed. Eventually her medical condition was brought to the attention of a surgeon and pulmonologist, she was treated and placed in a private room, but even there the care was substandard due to lack of adequate staff.

• The staffing problem went on at many other hospitals besides Valley. The nurses tried to care for their patients but when there were not enough nurses on duty, they could not deliver the kind of care patients needed.

• The Quality of Care Act would begin to set standards to improve the quality of hospital care. It was not too much to ask that hospitals have a plan to staff according to patients' needs, to involve direct caregivers in developing the plan, and to be accountable for sticking to it.

Chairman Freeman next invited the opponents of the bill to speak.

First was Jim Wadhams, a lobbyist representing the Nevada Association of Hospitals and Health Systems, who stated there were several individuals who would address the committee in regard to hospital activities, the regulations that applied to hospitals, and how those regulations were administered by the caregivers in the hospitals.

Mr. Wadhams placed a dozen or so books on the table representing what he described as just a sample of the rules and regulations hospitals were required to follow. The hospital industry was currently the most regulated.

Mr. Wadhams introduced Barbara Reynolds, associate administrator of performance improvement at St. Mary's Regional Medical Center.

Ms. Reynolds identified herself as a registered nurse with more than 25 years experience in the healthcare field in Nevada and California. Most facilities collected any number of data: performance improvements, outcomes, and activities. There were key agencies that drove many of the data collection processes, the Bureau of Licensure and Certification, the Joint Accreditation was another, the Safety Committee, the Medical Executive Review Committee, and many more. There was a board quality committee at most hospitals in some form that received a version of a report card of quality indicators the hospital chose to report. In those reports were indicators such as mortality.

The performance improvement department that was her area of responsibility did not exist 20 years ago, but the joint commission outlined the need to have it. Within that department were several areas:

• Risk management: examined and handled malpractice claims, reviewed and trended data collected by incident reports that for the most part were generated by nursing staff.

• Infection control: monitored hospital-acquired infections. The rate of those infections across the country had stayed at a national level so that the Center for Disease Control had stopped collecting a lot of information.

• Pharmacy and therapeutics: required to collect information on adverse drug reactions in conjunction with risk management. Wrong doses of medications were collected and put into a data base and shared with the hospital operations and medical staff.

• Survey information available from patients, physicians, and employees. That information was taken along with risk management to examine, identify, and address concerns.

Ms. Reynolds said there was on staff a patient ombudsman or some sort of patient complaint tracking mechanism so if a patient or family member had a concern there was someone with whom to speak.

The performance improvement role in the organization was to provide monitoring activity. If the acuity levels indicated errors directly related to a decrease in the required number of staff to care for the patients, that would come out in the data. Ms. Reynolds believed there were sufficient mechanisms and processes in place in each facility and they should be examined as it existed now.

Chairman Freeman asked if the information was available to the public so that the patients knew that going into the hospital. Ms. Reynolds suggested the internet where mortality data was available that compared the various hospitals in the state. There were also web pages and websites. The information was put on the internet by various state or Federal Government agencies.

Mrs. Freeman then asked Mr. Wadhams how many agencies provided that information on the internet. Mr. Wadhams did not have an answer but said he would find out and report back.

Assemblywoman Buckley said it was clear from the attention the issue had received and the involvement of the nurses that they felt in recent years they were asked to do more with fewer nurses, and that patient care suffered as a result. That was the reason for proposing the bill. The people who got hurt when there was not good nurse-hospital relations was the patient. She asked for a comment on why was there such an initiative behind the issue, and why had the relationship deteriorated to the extent the nurses felt the patient was being shortchanged. Ms. Reynolds responded that probably a lot of it had been driven by technological advances. There was a tremendous increase in the technology available and the skill and competency level required of nurses today was different than 25 years ago. That coupled with a lot of attention to the cost factor and the driving reimbursements added another level.

Ms. Buckley asked what was wrong with having "whistle blower" protections for nurses. Ms. Reynolds said any member of the staff could call the Health Department in Reno and anonymously report any kind of event or report to OSHA an event. Ms. Buckley asked why anonymously, why not use their name and not fear retaliation. Ms. Reynolds said they could give their name. Ms. Buckley asked if there was protection under the law. Ms. Reynolds did not know the answer.

Chairman Freeman commented to Ms. Reynolds and Mr. Wadhams that she felt they were not getting the message of the nurses. The nurses understood the importance of data collection, but the frustration she had seen and felt from the nurses had to do with the standard of care they had been trained to give and expected to practice wherever they worked. Many of them went home feeling they simply had not been able to deliver the kind of care they expected on behalf of their patients and themselves in terms of the job being done. The hospitals and the state had not been willing to talk to the nurses about their concerns to see if something could be done about it. She said nurses did not strike very often over wages or even working conditions, but when it came to the specifics of the type of care one was able to deliver on behalf of her patients, they did not know what to do about it. Ms. Reynolds deferred to nursing administration to answer that.

Assemblywoman Gibbons asked the procedure for using nurse's aides in proportion to registered nurses. Mr. Wadhams introduced Mary Shelfant to answer those questions.

Mary Shelfant identified herself as the assistant chief nurse executive at Desert Springs Hospitals and a nurse for 20 years in Nevada and Ohio. Every hospital had its own methodology for staffing, but at Desert Springs Hospital staffing was done by acuity and was specific to each area. They had developed staffing grids used to determine the average number of staff for a particular unit based on the acuity history of the patients in that area. Those grids allocated RNs, LPNs, and certified nursing assistants (CNAs). Acuity levels were higher today than years ago, and patients admitted to hospitals now were in need of the entire gamut of nursing care. Each level of caregiver were responsible for different tasks in that care. The RN drove the care, made the assessments, and planned the care for those patients. The charge nurse was the one responsible for a given number of patients and a specific number of staff. The charge nurse determined the acuity and made specific assignments based on the acuity. She could also determine if additional staff were needed during the shift. Acuity was not static, it changed, and the charge nurse could simply request additional staff if the acuity warranted. She also had the ability to close beds on her unit based on her allocation of staff and the acuity of patients. In response to Ms. Gibbons question about CNAs, Ms. Shelfant said one of the things patients needed today was direct care and time. That encompassed baths, turning a patient every 2 hours to preserve skin integrity, mouth care, ambulating, and so on. Those were time consuming but very important tasks because they were often the basis of patient satisfaction. CNAs were critical to answering those needs for patients. CNAs and LPNs were critical in allowing the RN to do her job.

A real issue was how to allocate staff. At Desert Springs there were times when there had not been enough staff, or the staffing available had not met the acuity. In such situations staff was pulled or floated from one area to another, per diem nurses were brought in, and also staff was hired through local agencies. "Travelers" or short term nurses also came on staff for a period of 13 weeks.

Assemblywoman Leslie followed up on Ms. Buckley's concern about the "whistle blower" provision. She asked if a nurse at Desert Springs thought the acuity plan they had developed was not being implemented on a consistent basis, was there a process in the hospital where they could realistically address that, and where would Ms. Shelfant suggest they go. Ms. Shelfant said that at Desert Springs the nurse had an avenue to express her opinion without fear of reprisal. They had acted on suggestions by staff based on the fact they were the ones on the front lines. Ms. Leslie asked how many complaints Desert Springs had from nursing staff in the past year. Ms. Shelfant said the complaints she had heard were that the acuity system was time consuming; but they also said it was very important. Ms. Leslie pressed for a more specific answer about the acuity plan not being implemented. Ms. Shelfant said she had not heard that complaint herself nor had she heard it from others. Ms. Leslie again asked where a nurse could go if she did not feel comfortable complaining within the hospital. Ms. Shelfant believed the agencies like Health Care Financing Administration (HCFA), the joint commission, or other regulatory agencies were places the nurse could call and simply state her case. Finally, Ms. Leslie asked if a nurse would have any reason to fear retaliation for making a complaint to an outside investigator. Was the "whistle blower" protection really needed. Ms. Shelfant had not seen the need for that at Desert Springs Hospital. She recalled one incident where a nurse had made a complaint about another situation and was adamant there were no reprisals against her.

Vice Chairman Koivisto asked if any nursing staff from Desert Springs Hospital would comment. Mr. Wadhams asked to conclude his portion prior to the other side speaking. He introduced Dr. Philip Landis, chairman of the quality improvement committee and medical director of quality services at Washoe Medical Center.

Dr. Landis said he was also an internal medicine specialist in private practice and was formerly chief of staff at Washoe Medical Center and was responsible for 800 physicians and the quality of care they provided.

Quality of patient care was his "passion" and he felt A.B. 586 compromised the ability to maintain or improve quality of care. He addressed the peer review process which he believed was one of the most important and valuable methods of improving patient care. Anyone could report an occurrence to the medical staff office to trigger a review to remedy what had occurred. That information became part of the peer review data that was examined every 2 years when physicians had to go through a recredentialing to be put back on to the medical staff of the hospital.

Next to speak was Dee Hicks, chief nurse at Sunrise Medical Center. She had been a nurse at Sunrise since 1969, working in several capacities. As chief nurse she made rounds and tried to visit with at least 50 patients and/or families per week, which she felt was important in order to gain a perception of what they felt. What the patients felt overwhelmingly was the need for the nurse at the bedside. In Ms. Hicks review of A.B. 586 she felt it duplicated many things already in place and would therefore take time away from nurses they could spend with patients.

Every hospital in the country looked for opportunities to recruit and retain nurses and wanted to know what it took to keep the nurse at the bedside. The duplication and multitude of paperwork was part of the frustration. Ms. Hicks felt further the language regarding fear of reprisal for calling in a complaint should not be in the bill. There were laws and regulatory bodies that prevented retaliation.

Concerning staffing shortages, Ms. Hicks said because Las Vegas was growing so rapidly she had experienced hospitals being full for the first time. When nurses called in sick, and registry nurses or travelers were needed and were not available, the methodology used had been to limit admissions until the hospital could provide the care. The focus had been to recruit registered nurses to provide for those vacancies. In hospitals where vacancies were not filled it required admissions being limited. She expressed concern from a consumer standpoint that any laws would prevent having open access to a facility.

Ms. Hicks said nursing had been her life and very much sympathized with Mrs. Gilmore who had testified earlier. She felt, however, there were mechanisms in place to assure patients and families the kind of care they needed. There were laws and protection that already existed.

Chairman Freeman asked if hospitals had ombudsmen who worked only with patients. Ms. Hicks said they had ombudsmen at Sunrise and had always had a patient advocate department. Nurses at the bedside really had the power to determine when help was needed. Mrs. Freeman wondered why no one had helped Mrs. Gilmore in her difficult situation.

Ms. Hicks said she did not know if Mrs. Gilmore asked for help, but she could have picked up the phone and called HCFA. Hospitals were frequently visited by major regulatory bodies and there were special interest groups on those regulatory boards who served as oversight.

Assemblywoman Leslie said her mother and sister were RNs and she had been around nursing a long time. Her concern was still on the "whistle blower" aspect, and she said if there were even a perception of retaliation then there was a problem. Whether the provisions were in place or even if the hospital administrative staff did not think there was a problem was not as relevant as that the nurses felt there was a problem. Ms. Leslie then asked if Ms. Hicks had a specific objection to section 11 (the "whistle blower" language). Ms. Hicks believed there were enough safeguards in place and avenues where a nurse could report a complaint.

Chairman Freeman remarked there was a definite lack of communication between nurses and hospitals.

Vice Chairman Koivisto asked how many patients coming into the hospital knew there was a patient advocate, an ombudsman, or that they could phone HCFA. How many patients even knew what HCFA was, and how many were told to call an ombudsman if they had a problem. Ms. Hicks said nurses cared about their patients, and if issues on patient care were expressed they would be investigated. One of the reasons she made rounds was because she had not felt everyone who had a complaint would express it, and she had tried to determine those things on her own. Education was needed, and when a patient was admitted those things were or should be explained. She knew from the comments heard when she made her rounds that those mechanisms were in place. She felt it did not need to be mandated by law, what was needed was for chief nurses and RNs to explain the process and intent of providing quality care. It should be done every shift, every day, to the patient and the family. Some things that if put into law would take away from the bedside hands-on.

Ms. Koivisto reiterated her question: Did patients coming in to the hospital know to call HCFA, did they know there was an ombudsman they could contact. Ms. Hicks said she did not know if they knew to call HCFA. They did know there was a mechanism in place if they had a concern or complaint, and many had. Ms. Koivisto asked who told the patient. Ms. Hicks said the nurse told them. Ms. Koivisto said, "Guess again! My husband spent 10 days at Sunrise and nobody said if you have a complaint here's who you call. It didn't happen."

Mr. Wadhams said NRS 449.710, the patient's bill of rights, had been adopted by the State of Nevada. It was a statutory obligation, it could be done again, but once it was in the law it should be effective. Regarding Ms. Leslie's "whistle blower" concern, Mr. Wadhams said there was a legal consideration that should be taken in to account. Over the years the peer review process was found to be critical to the dynamic of improving the quality of care onsite among the caregivers who gave the care. To create a "whistle blower" statute encouraged avoidance of that process. The legislative body should carefully consider anything that would undermine the cooperation and collaboration by those who were actually responsible for the care and encouraging that peer review process. In closing, Mr. Wadhams said care was given by people not by numbers, and quality care was a function of caring people.

He recited a personal experience at University Medical Center, trauma center, where he found two nurses uncooperative, but a third nurse Tana Wiznitsky, was outstanding and rendered the kind of care of which all nurses were proud. It represented that quality care was a function of caring people.

Mrs. Freeman called the committee's attention to the written testimony (EXHIBIT F) provided by Richard Panelli, Chief, Bureau of Licensure and Certification, which outlined new regulations and other changes put into place by the Board of Health in connection with staffing ratios. Ms. Leslie had a question for Mr. Panelli who was in the audience.

Ms. Leslie asked how many investigations the bureau had made in 1998 through the Health Division's authority in regard to the fifth item on page 2 of his written testimony. Mr. Panelli said every facility to which they went adequate staffing in terms of patient outcomes was examined. In long-term care facilities, of which there were 44, all facilities were visited at least once, and 90 percent of the facilities were visited twice.

In hospitals, they investigated complaints in 9 facilities that were directly related to staffing. Those 9 facilities were not joint commission accredited. They conducted 2 annual inspections of acute care hospitals in nonaccredited facilities as they were required.

Ms. Lesie then asked about item 2 on page 3 of EXHIBIT F that talked about a complaint system in place for all facilities, how many complaints had been received in 1998. Mr. Panelli responded they received 38 complaints specifically related to staffing in acute care facilities. In long-term care he did not have the figures, but said it was probably the number one complaint they received. Ms. Leslie asked what was the typical result of their investigation. Mr. Panelli said if the complaint was substantiated and had to do with care issues, they cited the facility under the state law, or federal regulations, asked for planned correction and gave the facility time to correct. There were also monetary penalties, all dependent upon the nature of the findings and the outcome of the patient. If the outcome was bad the sanction was higher. Ms. Leslie then asked, if the public wanted to delve into the issue more deeply, did the Health Division publish the information in a report. Mr. Panelli said it was not published routinely. The information was available and all complaint investigations were also available along with surveys of facilities, and so on. The only kind of report routinely given to the public was for long-term care facilities and skilled nursing facilities published at least annually. It was called the "Long Term Care Survey Report Card."

Mrs. Freeman asked Mr. Panelli to make that report available to the committee members. She also asked him about his testimony that the bureau inspected only the nonaccredited facilities. Mr. Panelli said they only went to 10 to 15 percent of those nonaccredited facilities annually except when they received complaints. On accredited facilities, they did not go into those routinely as long as the accreditation reports were available to the state Health Division.

From Las Vegas, Deborah La Fave identified herself as a RN who presently worked at Desert Springs Hospital, in the maternity center, and at Sunrise Hospital, in the maternal care unit. She provided written testimony (EXHIBIT G), which stated in part: Staffing issues were problems at the industry level. As managed care took over, hospitals were under enormous cost pressure. The response was corporate consolidation, staff cuts, and repeated attempts to allow unlicensed personnel to perform nursing tasks. Little more than a year ago Pennsylvania-based Universal Health Services owned the 417 bed Valley Hospital. Today they controlled nearly 800 beds in three hospitals: Valley, Summerlin, and Desert Springs. Since the takeover at Desert Springs they had been told to do things the "Universal Way," i.e., unreasonable workloads.

She continued saying there were periods of time in her unit when staffing was unsafe; it was a daily issue. On one recent day when another nurse called in sick, Ms. La Fave was assigned 12 patients and additional duties normally handled by the secretary or a CNA. All too often since Universal took over, nurses had to take care of too many patients, or patients who were so sick they needed more attention than available staff could give them. As a SEIU union steward she received reports from all over the hospital. Medical floor RNs now cared for 9-10 patients regardless of acuity, increasing the risk of adverse patient outcomes. The operating room lost more than a dozen full time staff in the past 2 years and not all had been replaced.

Desert Springs nurses were resisting those changes in the interest of good patient care. To protect their licenses nurses must object to assignments they felt were unsafe. The nurses had been documenting the situation meticulously for months, one nurse filing dozens of incident reports and "assignment despite objection" forms, all to bring the administration's attention to the problems. Even union meetings with management brought no satisfaction. The nurses understood the cost pressures on all hospitals, but it should not be an excuse for staffing levels that increased the risk of adverse outcomes. The public had the right to know the quality records of Nevada's hospitals. Nurses and other caregivers needed to be able to advocate for their patients without fear of reprisal.

Vice Chairman Koivisto asked if she had heard and would comment on Mary Shelfant's testimony. Ms. La Fave said she could comment specifically to her department. She knew they did not staff by acuity, they staffed solely by numbers. They were told that acuity was based upon what the manager of their unit decided. Their service was delivered on guidelines called "The Perinatal Guidelines." Ms. La Fave's manager had told her the guidelines were suggestions they were not written in stone and whether she chose to follow those guidelines was up to her. If she chose to expand the number of patient care that was the way it would be done in her department and if she (Ms. La Fave) did not like the philosophy in her department she could leave. Ms. La Fave also presented several hundred post cards from healthcare workers across the valley urging support of A.B. 586.

Assemblywoman Von Tobel thanked Ms. La Fave for coming forward. She then asked about the amended version of the bill sections that talked about staffing requirements and would she have the time to do the documentation required in the proposed plan. Ms. La Fave answered that in her department they had computerized charting which decreased the amount of paperwork. In other facilities it was time consuming because the nurses were not taught how to do it. But once learned it would not take more than 5 to 10 minutes to assess what patients were doing and see if extra help was needed.

From Las Vegas, Belan Gabato, RN, identified herself and said she had been a staff nurse, charge nurse, head nurse, and a department head, in industry and in hospitals. She thanked the committee for giving nurses the opportunity to speak in support of A.B. 586. She asked to address the issues of the opponents, and remarked there should be no opponents because both sides were for quality care. She commented on Mr. Wadhams presentation of voluminous manuals and rule books and said it was not logical to infer that we should look at those and not pass the bill because of the paperwork. According to testimony of their own people they were already doing the paperwork. What was needed was to put "teeth" into the proposition so caregivers could really follow what was already there. It should not be so difficult to implement because they knew it was the right thing to do. Further, regarding Ms. Hicks statement that to pass the bill would create duplication. The proposal was not for anything very new, it was the same "whistle blower" protection, the same patient acuity guidelines that now existed, they just had to implement them. The staff nurses who worked in the trenches wanted the existing regulations implemented and that was what they were asking the Committee on Health and Human Services to do.

Ms. Gabato said they had no quarrel with the issues brought forward by Barbara Reynolds. The nurses simply wanted management to see the connection between patient falls, wrong medications, infections, and so on, to not following their acuity staffing guidelines now on the books.

Finally, she addressed the "whistle blower" issue. Mr. Panelli had said there were only 38 reports from nurses reporting unsafe conditions. The reason was that when a nurse called the bureau she had to report in what unit the incident had occurred. It would not take a "rocket scientist" to figure out who was in charge of that unit. Ultimately if the conditions were improved the nurses would be satisfied and would stay in the profession. The reason nurses were leaving the profession in numbers was because those conditions were not improved.

From Las Vegas, Wallace Henkelman identified himself as an RN for 20 years working as a staff nurse and an ICU clinical nurse specialist. He had seen dramatic changes take place, mainly from being community-oriented or religious-oriented hospitals to having mutli-national billion dollar corporations controlling healthcare. The focus had changed from patient care to cashflow as the main concern. As a result, there had been downsizing and replacing staff with less qualified persons who were less costly. The downsizing or job eliminations were not always handled in an appropriate or respectful way and included being escorted off the premises by security guards. Regarding "whistle blower" protection, he said he was considered in some hospitals to be a troublemaker because he was an advocate for patient care and had been marked down in some evaluations because of that, which had affected him financially. That protection was essential. In summary, the legislation was urgently needed and was a vital step in protecting and preserving the health of the citizens of Nevada. He and his colleagues urged a do pass on A.B. 586.

Chairman Freeman asked the opponents to wrap up their rebuttal briefly.

Mr. Klein thanked the committee for its time and tried to clarify the grid process outlined by Ms. Shelfant. Their plan would require the system to be more flexible and respond more often on a day to day basis on issues of acuity. On the staffing issue, the documentation should be done on a managerial level.

Theresa Morrow commented on the increased technology demands which she said increased their workloads and required they have more help. However, the increase in technology did not substitute for quality human contact, and that in the end could prove cost effective.

Assemblywoman Von Tobel asked if A.B. 586 was passed and in law, what teeth would the law have if those same conditions existed. Mr. Klein said the bureau currently had the ability to impose escalating sanctions. What they had not had was a clear statutory mandate to look systematically at staffing and take a broader view. Where there were systematic problems the bureau could impose significant sanctions. They wanted to give the bureau the tools it needed to protect patient care.

Ms. Von Tobel asked if he had an amendment for those items. He did and would present it the following day to the committee. Ms. Von Tobel said it was a very important issue, and it was the desire of legislators not simply to pass additional regulations, but to pass legislation that had some kind of enforcement sanction.

Mrs. Freeman asked Mr. Wadhams to wrap his side's testimony.

Mr. Wadhams expressed surprise at the alternating opportunities and felt the position they had tried to present had been misunderstood. He said Mr. Panelli testified there was an abundance of public information although most of it not published specifically for the public, it was nonetheless available. He felt the laws already in place should be examined and made to work better.

Mrs. Freeman stated the committee worked frequently with Mr. Panelli and acknowledged the Bureau of Licensure and Certification existed on fees. There was no general fund money for the agency, and they had trouble getting done what was asked of them. She suggested if Mr. Wadhams wanted greater enforcement of the laws now existing, perhaps he could help with the money committees to get funds into the bureau in order to commit more time and resources to doing the things that needed to be done.

With no further business before the committee, Chairman Freeman adjourned the meeting at 8:30 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin,

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

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