Veterans Affairs Nurses Management Scrutinized After Patient Deaths in Two States (Norman Costa)
A re-editing of an article by Tracy Weber and Charles Ornstein
ProPublica, April 30, 2012, 1:19 p.m.
After a patient died last year at a Veterans Affairs hospital in Manhattan, federal inspectors discovered nurses in his unit [Management] had a startling gap in their skills [supervision and training of nursing staff]: They [Management] didn't understand [they were responsible for the competence and training of nursing staff as to] how the monitors tracking vital signs worked.
Management - Gen. Eric Shinseki
None of the nurses [management] interviewed could accurately explain [their lapse in supervision and training of nursing staff, so that nurses could tell] what would happen if a patient became disconnected from a cardiac monitor — which allegedly occurred to the patient who died, according to an October 2011 report from the U.S. Department of Veterans Affairs' inspector general.
The incident followed two deaths in the cardiac monitoring unit at a VA hospital in Denver that raised similar questions about nurse [Management] competency.
Earlier this month, a broader review by the VA inspector general of 29 VA facilities found only half had adequately documented that their nurses had the needed skills. Some nurses "did not demonstrate competency in one or more required skills," but there was no evidence of [Management taking charge and providing the] retraining [for nursing staff], the report said.
An outside nursing [management] expert who reviewed the reports at ProPublica's request called them "troubling" and said the fact that the [management] lapses weren't caught and corrected "signified much broader [management] problems."
The inspector general's findings reveal [the management showed] "a lack of oversight and adherence to accepted clinical and regulatory standards," said Jane Hirsch, a clinical professor emeritus at the University of California, San Francisco School of Nursing, who previously oversaw nursing at U.C. San Francisco Medical Center.
The April 20 IG report also noted that previous inspections had found [lax management, poor supervision, and absence of training were responsible for] nurse competency issues in "dialysis, mental health, long-term care, spinal cord injury, endoscopy procedure areas, the operating room and the cardiac catheterization laboratory and with reusable medical equipment."
In a response to the inspector general, the VA pledged to create uniform competency standards for [management of] its 152 hospitals and to ensure that evaluations of every nurse's [manager's] skills are up-to-date. Nurses Managers, supervisors, and trainers] will not be able to work in areas in which they have not demonstrated [executive and supervisory] competency.
A VA spokeswoman declined further comment.
Nurse [Management] competency has increasingly become an issue in medicine. Hospitals and clinics [create their own procedures and tests for assessing the skills of nurses [management], but their adherence to these policies is spotty.
Outside regulators don't test individual nurses [supervisors], but simply check if a sampling of the nurses' [supervisors'] files have the appropriate paperwork certifying [supervisory]competency.
That's what VA's inspector general did for the April review. As such, officials acknowledged that they could not verify whether [management is doing what was necessary so that] nurses at those hospitals, or others, are providing competent care.
"We did not look at [management's ultimate responsibility for] actual care or actual [management] competence," Julie Watrous, director of the inspector general's combined assessment program, which inspects each VA hospital every three years, told ProPublica.
Only half the 29 facilities included in the new report had complete [management, supervisor, and] nurse skill assessment records that met the hospitals' standards, inspectors found. Of the 349 nurses whose files were examined, paperwork showed that [management was deficient in providing proper supervision and training to nursing staff. This resulted in] 58 [nurses who] lacked skills in at least one area. And for 24 in that group, there was no evidence that anything was done in response[, by hospital management].
In an interview, however, the IG official who coordinated the report said she was generally pleased with the findings. Although both the VA and its hospitals had room to improve, she said, all of the hospitals had policies in place and at least some proof of skills in each nurse's [manager's] file.
"We never found one single site or even person [manager] that didn't have at least components of competency assessment and validation," said Carol Torczon, associate director of the St. Petersburg, Fla., office of the inspector general. "Where we found the holes [in the management system] was in the paper process."
Torczon said she believed that the problems identified in Denver and New York were not reflective on the care generally provided by VA nurses in cardiac monitoring units.
Inspectors in the New York and Colorado cases said they could not definitely tie the deaths of the patients to [the failure of management and supervisors to adequately train and monitor] their nurses' care. But they noted that their [own] lack of [providing proper supervision and] training put patients at risk.
Registered nurses assigned to telemetry units typically place cardiac leads, set parameters for the monitors tracking each patient, verify heart rhythms and take appropriate actions if there is an irregularity. They also enter progress notes and inform doctors of any changes.
After the patient in New York died, inspectors quizzed nurses and a biomedical engineer about what would happen if a patient got disconnected. "According to some staff, a 'red alarm' would be triggered since a disconnected lead was considered critical," the report said, "whereas other staff told us that a disconnected lead would trigger a yellow alarm or that it would not trigger any alarm at all." [Clearly management and supervisors had a lot of work to do to improve training and competence. After all, it's their job.]
Inspectors also found no evidence that the nurses' [manager's] competence had been checked. Records showed [serious management lapse in] that one of the patient's nurses had last received training on the monitors 13 years earlier.
Two years earlier at a VA hospital in Denver, inspectors looked into the deaths of two patients on cardiac monitors. After the first death, the hospital gave nurses a basic test of their ability to interpret monitor readings: only one of 28 passed, according to a January 2010 report. The nurse in charge when both patients died had never received specialized training in cardiac monitors. [This was a clear demonstration of a failure of management and supervisors to train, improve, and monitor staff competence.]
Even after the second patient died in 2009, inspectors found "it was unclear [if management understood] who was responsible for telemetry training, and [that management had no clue that] staff were not aware that policies had been updated."
Both facilities vowed extensive reforms [in management and supervisory practices] in responses that were included in the IG reports.
Experts say up-to-date competency evaluations are important because they ensure that nurses [management and supervisors], who provide [staff training for] the bulk of the frontline care in hospitals, have the skills for their position.
"It would appear that the old adage 'inspect what you expect' has most certainly not been taken very seriously [by mangement] in these environments," said Hirsch, who was chief nursing officer at UCSF Medical Center for nine years.
After reading the New York and Denver reports, Hirsch said her concern wasn't the incidents themselves as much as that the competency of [management in the supervision and training of] the nurses hadn't been documented or evaluated in a long time.
Had she been in charge, the findings would have caused her "to be really nervous and want to jump on [management's asses and have them fix] it immediately," she said.
My reading of the original article suggests that it was spot on, didn't really need substitution of 'management' for all the 'nursing' references. It's a systemic as well as nurse training and competency issue, in my opinion. Imagine having a nurse who is unaware of how the telemetry monitoring system in the CCU works and doesn't know why a lead is improperly placed. Would you like to have her monitor you when you are recovering in hospital from a cardiac event?
Posted by: Sujatha | May 04, 2012 at 05:55 AM
Sujatha,
Thanks for taking the time to read and comment.
My intent, here, is the same as when I write about the ultimate responsibility of officers for the soldiers in their command. The VA Eastern Colorado Hospital has an executive in charge of Education and Training. Assuming she was there when the substandard competencies were uncovered, I wonder why she still has a job in that facility. Nurse training and competence is not a nurse issue, it's a management issue. Nursing student ignorance is not a student issue, it is a faculty problem. Having nurses in my family, having known nursing faculty over the years, and my own experience, it is virtually axiomatic that nurses are the first ones to get thrown under the bus when the tort monster rears its ugly head.
You and I read the original article, and we both both understand that there is a lapse in the management system, as well as in nursing competence. I would go so far as to say that most readers of AB have no problem in reaching the same understanding. However, Tracy Weber and Charles Ornstein did not write about the scrutiny of management. They wrote about the scrutiny of nurses. They did not write about the incompetence and poor skills of management. They wrote about incompetence and poor skills of nurses.
Another way of looking at it is to pose the question of how you arrive at a long lasting solution for providing excellent nursing care. Do you fire the nurses and hire new ones? Or, do you fire the supervisors and managers and hire new ones who will take responsibility for the competence and performance of the nurses in their charge? The philosophy of supervisory management can be summed up very nicely. It is doing everything possible to make sure that the people in your charge are successful in their jobs.
Posted by: Norman Costa | May 04, 2012 at 10:55 AM
Norm has the better argument here. The authors focus on the link between patient and nurse, eliding the link up the hierarchy to administration. There's a vague reference to the IG's finding of "lack of oversight." Bureaucracy parcels out the division of responsibility, hence the inspectors' entirely appropriate review of samples of files, rather than their stepping in for management to do their work. (What do they do all day, after all?)
Posted by: Dean C. Rowan | May 04, 2012 at 01:33 PM
The departmental investigations linked to in the original, this, for instance show a slow but careful inquiry into the sequence of events leading to demises of patients. That does focus on both the systemic problems (inadequate or improper protocols) as well as nurse competence.
The ProPublica article comes from a couple of writers (Ornstein and Weber) whose 2010 article on abuse perpetrated by rogue nurses brought them a Pulitzer nomination, so it's possible that it would have colored their current article and made them weight it towards 'Blame the nurse'. (Kind of like, school administrators who 'Blame the teacher, not the student' for students failing to learn from a teacher who is battling uphill with trying to impart education to a child who has little home support and reinforcement.)
Axes to grind, anybody?
Posted by: Sujatha | May 04, 2012 at 03:26 PM
Sujatha,
That was exactly what I was thinking before I did my re-edit. However, I didn't want to make a point of it. I wanted the nurse v. manager criticism to stand on it's own. I sent my re-edit parody and this link to Weber and Ornstein. I hope they might weigh-in on the discussion.
Posted by: Norman Costa | May 04, 2012 at 03:33 PM
Considering that the management would have also consisted of several who were regular nurses before moving up the career ladder, I guess that using the generic 'nurses' instead of 'management' may not have been totally off the mark.
Posted by: Sujatha | May 04, 2012 at 03:41 PM