MINUTES OF THE meeting
of the
ASSEMBLY Committee on Health and Human Services
Seventy-First Session
April 18, 2001
The Committee on Health and Human Serviceswas called to order at 2:12 p.m., on Wednesday, April 18, 2001. Chairman Ellen Koivisto presided in Room 3138 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. Ellen Koivisto, Chairman
Ms. Kathy McClain, Vice Chairman
Ms. Merle Berman
Mrs. Dawn Gibbons
Ms. Sheila Leslie
Mr. Mark Manendo
Ms. Bonnie Parnell
Mrs. Debbie Smith
Ms. Sandra Tiffany
Mr. Wendell Williams
COMMITTEE MEMBERS ABSENT:
Mrs. Sharron Angle
Mrs. Vivian Freeman
GUEST LEGISLATORS PRESENT:
Assemblyman John Carpenter, District 33
STAFF MEMBERS PRESENT:
Marla McDade Williams, Committee Policy Analyst
Darlene Rubin, Committee Secretary
OTHERS PRESENT:
Nancy Whitman, Director of Business Development, HealthInsight
Shirley Hughes, R.N., SEIU Nurse Alliance
Christine Sawyer, R.N., University Medical Center
Danny Thompson, AFL-CIO
Louis Ling, General Counsel, State Board of Pharmacy
Lisa Black, R.N., Nevada Nurses Association
Carin Franklin, Operating Engineers, Local 3
Larry Matheis, Executive Director, Nevada State Medical Association
Sean Gamble, Clark County Health District
James Wadhams, Nevada Hospital Association
Bobbie Gang, Nevada Women’s Lobby
Chairman Koivisto advised that committee members Mr. Williams, Ms. Parnell, Mrs. Smith, and Ms. Berman would be late. The Chairman then turned the meeting over to Vice Chairman McClain in order to present her bill, A.C.R 7.
Assembly Concurrent Resolution 7: Directs Legislative Committee on Health Care to conduct interim study concerning development of system for reporting medical errors. (BDR R-226)
Assemblywoman Ellen Koivisto, District 14, reported that A.C.R. 7 was one of the recommendations from the Legislative Committee on Health Care that she had requested as a result of a study released in November 1999, by the Institute of Medicine (IOM) entitled, To Err is Human: Building a Safer Health System (Exhibit C). Patient safety was one of the nation’s most pressing health care challenges. The Institute of Medicine report estimated that as many as 44,000 to 98,000 people died in United States’ hospitals each year as the result of errors. Even at the lower estimate, that would make medical errors the eighth leading cause of death in the country, higher than motor vehicle accidents, breast cancer, or AIDS.
Mrs. Koivisto reported that about 7,000 people per year were estimated to die from medication errors alone, about 16 percent more deaths than the number attributable to work-related injuries. Medical errors were responsible for injury in as many as one out of every 25 hospital patients. Errors in health care had been estimated to cost more than $5 million a year in a large teaching hospital, and preventable health care-related errors cost the economy from $17 billion to $25 billion a year. About half of the expenditures for preventable medical errors were for direct health care costs. Errors occurred not only in hospitals but also in other health care settings, such as physician’s offices, nursing homes, pharmacies, urgent care centers, and care delivered in the home. Very little data existed on the extent of the problem outside of hospitals; however, the IOM report indicated that many errors did occur outside the hospital. Errors could occur at any point in the health care delivery system: medication errors, surgical errors, diagnostic inaccuracies, and system failures.
The Agency for Health Care Research and Quality (AHRQ) research had shown that medical errors could result most frequently from systems errors, organization of health care delivery, and how resources were provided in the delivery system.
The purpose of the legislation was to create a subcommittee of the Legislative Committee on Health Care that met during the interim and which she chaired during the last interim. The Legislative Committee on Health Care would appoint the subcommittee, which would be charged to study the system and develop an approach for reporting of errors because the data was needed where, and why, the errors were occurring and where the problems were. Unless the causes could be pinpointed, there was no way to know how to correct the problem.
Assemblywoman Koivisto noted that in order for people to feel free to report information on errors there must be confidentiality. People needed to feel they would not be indicting themselves. She suggested a volunteer reporting system patterned after the aviation safety reporting system that had radically improved safety in that industry. That system was based on a voluntary reporting system. The information reported was protected; it was not disclosable in terms of individual events or individual airports. The individuals who reported into it were protected and given some freedom from liability as a result of participation. What needed to be determined was how that system could be adapted to health care.
Although the resolution did not specify the membership of the subcommittee, Mrs. Koivisto suggested that representation from the medical societies, nurses, pharmacists, insurers, and hospitals, as well as legislators was needed. Additionally, she felt the trial lawyers should be a part of the discussion in order for it to work.
Nancy Whitman, Director of Business Development for the State of Nevada with HealthInsight, spoke in support of A. C. R. 7. She was accompanied by Sandie Barrie, Patient Safety Project Coordinator, Reno office, and Fern Percheski, Grant Coordinator, Las Vegas office. Ms. Whitman explained that HealthInsight was a private, nonprofit organization dedicated to improving the health care system in Nevada and Utah. HealthInsight was most recognized in the state of Nevada as the Medicaid and Medicare peer review organization (PRO) contractor since 1988. Its mission was to increase the capacity of the health care system and to make improvements. It was a local, neutral catalyst for change. They also brought expertise and experience and process improvement as a discipline. Their role placed them in an ideal position to influence the health care community. In pursuit of that mission, HealthInsight had become a recognized leader in health care quality improvement, partnering with the hospital community as well as Medicaid to improve the rate of pneumonia and flu vaccinations in the state.
Ms. Whitman reported that HealthInsight had also worked with Utah and Nevada hospitals on initiatives to prevent strokes, improve blood transfusions and treat heart failure more effectively. In the outpatient setting they worked with local clinics to improve diabetes care, mammography rates, and to more effectively use antibiotics. HealthInsight also had significant experience working in the field of patient safety. Under the auspices of the Medicare PRO contract, HealthInsight had worked successfully on projects with hospitals in Utah and Nevada. In 1997, two years before the Institute of Medicine report was released, HealthInsight coordinated the first community-wide improvement collaborative on preventing adverse drug events in Utah hospitals. Hospitals that participated in the pilot project were able to make substantive changes in their respective processes and systems that resulted in a 25 percent reduction in observed errors. Those results were later published in the Joint Commission Journal on Quality Improvement in June 2000.
Late last year, Ms. Whitman noted, HealthInsight was awarded a special project by the Health Care Financing Administration (HCFA) to develop and test an approach to patient safety improvement, which built upon human factors research models developed to improve safety and other hazardous work environments and applied them to the hospital setting. That project was just getting underway and eight of the twelve urban hospitals in Nevada had committed to participate. As a precursor to the project, HealthInsight hosted a patient safety summit on March 29 to 30, 2001, in Las Vegas. More than 100 health care leaders in Nevada participated in the educational forum with national and international speakers.
Ms. Whitman said that HealthInsight’s purpose in testifying before the committee was first, to express support for the efforts of the committee to improve patient safety and prevent medical errors. Second, to encourage the committee to focus its efforts on ways to improve the processes and systems, not simply count errors. Preventing errors meant designing a safer health care system at all levels. The IOM report highlighted the need to create a culture of safety. By collaborating with Nevada leaders who were committed to patient safety across all health care disciplines, that culture of safety would be created. Ms. Whitman provided her written testimony and a packet of information (Exhibit D).
Shirley Hughes, R.N., SEIU Nurse Alliance, Local 1107, representing 8,000 health care workers in southern Nevada, reported that last session their union nurses approached the committee with concerns over short staffing in local hospitals. Through testimony from patients, family members, nurses, and others, it became clear that the industry faced systemic problems that resulted in patients getting the wrong medications and becoming more ill from hospital-acquired infections. She noted that Ruth Mills, chairwoman of the Health Care Project, wrote of her own personal problems, which occurred during a hospital stay. Ms. Mills’ letter was provided in the packet of information, including the “To Err is Human” IOM report, and other data (Exhibit E).
In a recent survey of registered nurses in Nevada, 41 percent reported not enough time to properly assess each patient on every shift, 46 percent reported delayed or missed treatments and/or medications, 7 percent reported that in the previous week they had personally committed or knew of others who committed errors of delivering wrong medications or wrong doses, 47 percent reported once a week or more, patients went without proper assessments by nurses. Of those reporting, 51 percent were medical surgical nurses, 61 percent of the errors were reported by intensive care nurses, 237 acute care nurses randomly selected in Nevada were surveyed and a 35 percent increase in last year’s errors was reported.
Ms. Hughes said staffing levels were intrinsically tied to error rates and the number of hospital acquired infections. They knew errors were occurring and they did their best as frontline caregivers to reduce those errors, however, there were systemic problems that needed to be evaluated and that required a broad-based approach. She quoted the American poet, Nicki Giovanni, who said, “Mistakes are a fact of life. It is response to the error that counts.”
Christine Sawyer, R.N., Chair of the SEIU, Local 1107 Nurse Alliance, expressed support for A.C.R. 7 and the concept of legislators, industry representatives, frontline nurses, and consumers working together to develop a response to system-wide problems. She asked the committee to consider three elements her organization believed would make the bill even more effective. Her group supported the development of a system of reporting errors and making that information available for purchasers of health care. About 20 states had already implemented mandatory reporting systems. Consumers had a right to such information so they could make informed choices about their medical care. They also wanted to make sure employees were protected when they came forward to report errors and the confidentiality of patients was insured. Those were systemic problems; no one was seeking to protect negligent or illegal behavior but nurses could not be singled out either. Finally, they wanted to make sure there were practicing bedside nurses on the committee. There was interest among those nurses; more than 130 nurses signed a petition in support of A.C.R. 7 (included as part of Exhibit E) and in support of the inclusion of a bedside nurse on the committee.
Danny Thompson, who represented the Nevada State AFL-CIO and 8,000 nurses in Las Vegas, as well as a large number of nurses in Reno and Elko, reported the union had long been concerned about staffing standards and levels in Nevada hospitals, and Mr. Thompson acknowledged the committee’s struggle with the issue for some time. He applauded Assemblywoman Koivisto for introducing A.C.R. 7 because it opened the way for the concerns to be addressed in an open forum that could find a resolution to some of the problems.
Mr. Thompson said he knew of nurses who had chosen to leave their profession because of their concern that they were given too many patients to care for and they could lose their license if there was a problem. Conversely, the Nevada AFL-CIO represented 120 different unions in Nevada and all of those unions had health care for their workers, a great many through a trust fund. During the interim Mr. Thompson said he attended meetings with some of the operators of the trust funds and trust fund trustees to discuss the problem of people getting sicker in the hospital, not from a staffing point of view but from the point of view of cost, and what it cost employers who paid into those trust funds when someone went to the hospital and became sicker.
Mr. Thompson concurred with Ms. Sawyer that a bedside nurse should be part of the subcommittee, and that he, too, looked forward to working with the subcommittee. In conclusion, he felt the timing for the measure was very good, and that a positive outcome would result.
Vice Chairman McClain commented that although the measure had not specified who would be on the subcommittee, his desire to be part of it would be included in the record.
Louis Ling, General Counsel, Nevada State Board of Pharmacy, said the board heartily supported A.C.R. 7. They had a “first in the nation” program underway since 1998 where workplace data was being gathered about Nevada’s pharmacies; the actual gathering commenced in January 2000. Mr. Ling said he had recently participated in the Executive Officer Conference for the National Association of Boards of Pharmacy speaking about the issue. Mr. Ling offered his support at the table as part of the subcommittee, or in any other way to provide technical expertise.
Vice Chairman McClain felt his expertise would definitely be useful.
Lisa Black, R.N., Nevada Nurses Association, thanked the committee for the opportunity to provide supportive testimony on A.C.R. 7 that directed the interim Legislative Health Care Committee to study medical errors in Nevada to develop effective reporting mechanisms and systems improvements. The problem of preventable medical mistakes made many providers and institutions in the health care community uncomfortable. They viewed medical errors as a public relations nightmare or a litigation risk and preferred to report mistakes through secretive internal incident reports and other mechanisms that were not referenced in the patient chart or reported to the patient in many cases.
Ms. Black reported that several recent studies including the IOM report on medical errors, and the GAO (General Accounting Office) report on the lack of adequate oversight and evaluation by the Joint Commission on Accreditation in Health Care Organizations had indicated the current mechanisms to identify, evaluate, and correct those problems were inadequate. In the last decade, she noted, health care delivery systems in all settings had undergone tremendous change including new work redesign models, rightsizing, downsizing, outsourcing, and other experimental delivery systems. She said that nurses in Nevada had reported that many of the new work redesign models that had been implemented had resulted in increased medical errors and a lack of continuity and coordination of care. Nurses had reported that they were submitting many more patient incident reports to their managers, but felt they were not seeing adequate evaluation or corrective measures from their facility management to prevent their reoccurrence.
Ms. Black advised that in a recent survey conducted by the American Nurses Association, 75 percent of nurses surveyed reported that the quality of care in the facility in which they worked had declined over the previous two years, and more than 40 percent said they would not feel comfortable having a friend or family member cared for in their own facility.
There were many causes of medical errors, Ms. Black noted, ranging from basic shortcomings in quality assurance systems to inadequate staffing and provider communication that made health care settings more susceptible to medical errors than necessary. As health care became more sophisticated it also became more complex. Providing health care to the ill and injured was a noble endeavor but it was also a human one, and humans, including health care professionals, were fallible. The IOM report found that most medical errors were not big mistakes made by one individual, but rather were the result of flaws in the health care delivery system that produced a long chain of small errors by a number of individuals or technologies involved in the care of a patient. To protect patients, Ms. Black said, safer health care delivery systems had to be designed that reduced the possibility that individual caregivers would be placed in situations that made errors more possible. It was necessary to acknowledge that mistakes did occur and health care professionals owed it to their patients to learn from their mistakes, not cover them up. Ms. Black believed it was possible to develop a system of reporting and addressing medical errors that would not result in increased litigation or the blame culture that currently drove the response to medical mistakes.
In closing, Ms. Black stated the Nevada Nurses Association was ready to work with colleagues and meet the challenge, and change the current systems to ensure that patients received the high quality care they expected and deserved. Ms. Black also provided her written testimony (Exhibit F).
Assemblywoman Gibbons asked if there was a “whistle-blower” protection for nurses; did they have a place to go when a mistake was made in a hospital, and would they be protected from retaliation. Ms. Black said that was one of the issues that needed to be addressed in legislation of that type. What was needed was to be able to track the kinds of errors and systems issues leading up to them, without identifying which specific nurse made the mistake. There was no system currently in place, however, she thought the representatives from SEIU and OE (Operating Engineers Union) might be able to answer that question.
Carin Franklin, Operating Engineers, Local 3, said there was no “whistle-blower” protection in place for registered nurses. In fact, she noted, there was a myth that nurses everywhere could report to the State Board of Nursing whenever there was a situation of error or understaffing without reprisal. When a report was made to the board, the individual making the report actually turned herself or himself in and the board then investigated that person; the board did not investigate the hospital.
Ms. Franklin, a registered nurse since 1992, stated the OE was in support of A.C.R. 7. She also provided her written testimony (Exhibit G). She added that medical errors did occur and due to the time constraints placed on health care workers and the short staffing, many if not all nurses in the state worked under handicaps because medical errors occurred on a daily basis. Most errors were not harmful; an error could range from a medication given at the wrong time to a lab draw drawn too late, yet some errors had caused harm to patients and cost health insurance and the patients money and time. Ms. Franklin said she had worked in several hospitals in the western region of the country and in every hospital there was some form of tracking systems for errors. Nurses filled out what most hospitals called an “occurrence report” for anything from a visitor or patient falling, equipment that failed to work properly, or a medication error. They were told not to photocopy the report or to reference it in their patient’s chart, due to the fact that they were at one time not “trackable” in a court of law. Now they were a recoverable piece of paper but nurses were still told not to photocopy or chart it. Some nurses were afraid to complete the report in fear of discipline related to the incident. Nurses had no protection from retaliation if they reported the facility where they worked. The hospitals said they used the system to track errors; however, Ms. Franklin said she had yet to work in a hospital that had brought up that system and told her how she could change. Changes she had seen seemed to be experimental and did not appear to be based on solid data or research.
Ms. Franklin noted that a system for medication errors already existed and the proposed study should tap into the system. Yet the study could not reply on the hospitals and care facilities alone, it must involve the people who gave the direct patient care. They were the ones with the most contact with the patients and due to the fact that all health care professionals were human they did make mistakes. The study needed to look at what type error occurred and how it affected the patient, as well as what the nurse-patient load was that day, and what the acuity level was on that nurse. Only a study that contained all the information would be useful in obtaining an answer to the problem.
Assemblywoman Gibbons mentioned she thought the committee had passed a bill in a previous session that required the hospitals to unionize in northern Nevada. Ms. Franklin said she represented nurses in Washoe County and Elko, and they were unionized but still in negotiation, and had been since December 1, 1999, but had no contract to date. She added they were asking for a voice in their staffing levels. She said, too, that there was an ordinance in place currently that mandated all hospitals have an acuity system on which they based their staffing. Acuity, Ms. Franklin explained, meant the level of the patient’s illness; a patient on a ventilator had a higher acuity level than a patient who could move on his or her own. The State Board of Health was looking into that compliance and she believed all the hospitals were mandated to have the system in place by a certain date. Washoe Medical Center had been working on it and did have a PIN (personal identification number) system in place.
Larry Matheis, Executive Director, State Medical Association, expressed support for the resolution and the intent behind it. The IOM, he said, had issued a second report that received almost no attention. It was actually much more substantive, but it lacked the sensational speculation about how many people might have died. That was the one part of the original IOM study that many of his colleagues had problems with, and he termed it “hokey science.” But when the report actually discussed the safety and system problems, there was a great deal of valid material. But, he said, the IOM would not have received national press by simply issuing a report that said there were problems in the health care arena, so they went with their most sensational aspect. What happened as a result was that it created all of the defense mechanisms that the health care system was particularly adept at bringing forward; the fear of liability, the fear of embarrassment, and the fear of losing one’s professional credentials and reputation, because the report seemed to saying that there was a massive cover-up of unnecessary deaths. But that was not what the report stated. What the report had documented was that there was a growing complexity in the health care system that was totally external to the actual health care exchange. However, that exchange itself had become so complex. The ability to provide technology, to provide drug therapy, and to pinpoint it to the actual body of one person were remarkable accomplishments. The number of things that could go wrong grew as the capacity grew. Some of the issues raised could cause large system problems, and many of the things that HealthInsight were working on, in which the State Medical Association had been involved from the start, had demonstrated that what seemed like small changes had very large and very positive consequences for patients and patient safety.
Mr. Matheis reported that in the association’s monthly newsletter to physicians there was a section on patient safety items that had been scientifically proven to reduce problems in any health care setting. For example, the newsletter contained a list of the most common prescription-related errors; words that looked similar, and if one was tired when they wrote them or read them, one might be substituted inappropriately. Another list in the newsletter detailed the dosages most often confused. He felt the use of “Palm Pilots” would eventually remove many of those areas. Identifying problems was important as the profession moved into technological remedies. Accordingly, he felt the interim study was very important and hoped it would become something more permanent, not necessarily legislative, eventually, like a permanent foundation in Nevada to investigate what was going wrong in the system of health care, and how could it be remedied. The first states that jumped on the IOM reports held their own press conferences and announced they were going to do something to address the problem. Those states immediately adopted an error reporting system and as it turned out did not really do very much. State agencies, he said, were not too good at collecting the numbers, but given time they might get good at reporting the numbers, but he was skeptical about the agencies actually using the numbers to make corrections in the system and did not think there had been too many successes over the years.
Therefore, Mr. Matheis added, what was needed was a feedback loop where information was being received that was actually useful to someone who could make a difference by using it. One of the things needed was to try to remove the culture of blame, the fear of the negligence, which could impair fixing the problem. He expressed hope that by the next legislative session there would be some positive results. That was the test the IOM wanted to put out there; that information should be used to make the health care system better. The second IOM report that discussed the systemic problems that led to overall quality problems was even more important and that was the next step to take.
Mr. Matheis added that the Nevada State Medical Association intended to help in the effort, to serve on the subcommittee or advise in any way necessary, and he commended Chairwoman Koivisto for bringing the bill forward.
Sean Gamble, Clark County Health District, spoke in support of the resolution and was eager to assist in whatever was needed to reach the goal being sought. She echoed the ideas that the method of reporting should be effortless, blameless, and voluntary in order to get the participation desired.
James Wadhams, Attorney at Law, representing the Nevada Hospital Association, expressed support for the resolution. He felt it was an important opportunity to take a comprehensive look at the issues addressed by the previous speakers. He agreed with the issue of confidentiality and patient privacy, and the issue of protection for those who had committed the errors. He noted that the association had sponsored efforts to increase opportunities for nurses and those who sought nursing careers, and he hoped those would result in legislation that would encourage the education and development of better nursing. He felt a safer health care delivery system was critical and that came back to the human component, but he was not sure a system could be developed that was blameless because allocating blame and adjudicating it was fundamental in our society. In closing, he said the association was excited about the opportunity to participate in any way it could.
Vice Chairman McClain closed the hearing on A.C.R. 7; however, no vote was taken as a quorum was not present. Ms. McClain returned the gavel to Chairman Koivisto.
Following a brief recess, Chairman Koivisto then opened the hearing on A.J.R. 10.
Assembly Joint Resolution 10: Urges Congress to amend Social Security Act to modify certain reductions in social security benefits that are required for spouses and surviving spouses who are also receiving certain federal, state or local government pensions. (BDR R-1484)
Assemblyman John Carpenter, District 33, explained that women working for the county and the convention center had brought the issue to his attention. In the early 1980s Congress enacted a provision that removed benefits from people who worked for local government, which created an inequity for those people; actually 70 percent of whom were women. Mr. Carpenter noted that Senator Reid had also sponsored similar legislation for some time, and Mr. Carpenter hoped that the current resolution would result in Congress taking action to rectify the situation.
Chairman Koivisto commented that her husband was a local government employee who was affected by the inequity of the present situation, having worked for many years under the Social Security System.
Vice Chairman McClain recalled she was working for a school district when Congress enacted the provision and there had been a huge push to grab the pension money that was in local government pensions. At that time not many people considered the repercussions of the provision and it was detrimental, especially to those who had worked their entire career in public service. She wished something stronger could be done, but commended Mr. Carpenter for bringing the resolution. Mr. Carpenter remarked that one of the committee members might have some influence on a certain Congressman. The committee laughed, knowingly. Mrs. Gibbons smiled.
Bobbie Gang, Nevada Women’s Lobby (NWL), complimented Assemblyman Carpenter for bringing the bill forward and wanted it on record that the NWL strongly supported the measure. She hoped someone would indeed have influence with the Congressman.
Chairman Koivisto asked the committee’s wishes regarding the resolution.
ASSEMBLYWOMAN LESLIE MOVED TO DO PASS A.J. R. 10.
ASSEMBLYWOMAN GIBBONS SECONDED THE MOTION.
THE MOTION PASSED UNANIMOUSLY BY THOSE PRESENT.
Vice Chairman McClain noted that a quorum was present and therefore asked if a motion would be in order on a previous resolution.
ASSEMBLYMAN MANENDO MOVED TO DO ADOPT A.C.R. 7.
ASSEMBLYWOMAN LESLIE SECONDED THE MOTION.
THE MOTION PASSED UNANIMOUSLY BY THOSE PRESENT.
Chairman Koivisto noted there was nothing further before the committee and accordingly adjourned the meeting at 3:04 p.m.
RESPECTFULLY SUBMITTED:
Darlene Rubin
Committee Secretary
APPROVED BY:
Assemblywoman Ellen Koivisto, Chairman
DATE: