As I predicted, nurses would oppose this idea. SCK argues very convincingly for the status quo, and as a very experienced nurse her opinion will carry a lot of weight with many people. This perfectly illustrates my point when I say most people will embrace the simple and vague platform solution over specific solutions. It's just so complex.
I'm not for the status quo, that's for sure. Someone has to take back the health care industry from the insurance industry. I don't claim to represent all nurses. I am only one person/nurse speaking my own simple opinion.
SCK was kind enough to cite two specific suggestions I made, so I'd like to respond to her on both and try to clarify my meaning on both my JCAHO and HIPAA comments. I'll begin with questions addressed to SCK, but invite anyone who works with a healthcare provider to respond.
When you working as a nurse, were you ever not aware of when a JCAHO site visit would take place, and did a JCAHO site visit day ever remotely resemble a typical day on your unit?
To me, it represented what it should've looked like everyday. I 
'spring cleaning' the unit and having extra staff for once! Funny how staff is found if JCAHO was coming. Funn to watch administrators come visit your unit that barely ever show any interest in your role, because of all their meetings. It was the one time when you could really tell the management had to respect the professional skills of their staff, the bedside caregivers. JCAHO could ask you age specific patient care questions and did. They even asked questions like how long our patients had to wait, and what did you tell them, and how long do you wait to tell them. They made sure that our crash cart had been checked daily, and that meds and supplies were labeled properly, disaster escape routes, things our administrators never really showed any appreciation for until JCAHO came to town.
People like to be appreciated for their unique skills and knowledge, and hard work. JCAHO at least provides you with a real number, a score, from a joint commissioned agency, comparing you to other accredited facilities. At least we got to cheer for ourselves a little.
In the hospitals where I have worked, months were spent planning and training for the JCAHO site visits. Temporary, locum tenens nurses were hired to pad the staff. Everyone worked to make things compliant for the three days JCAHO would be on site, and for those three days things were stellar. And once they were gone, administration went back to skeleton staffing and everything went back to normal... In my experience, JCAHO is all about the certification, not improving quality or guaranteeing great patient care. It's a pass fail, and astonishingly few hospitals, after paying the
enormous JCAHO fees, fail.
(They should do surprise visits.)
To illustrate my point.... Both have sharps containers
(One of us should've invented those red boxes. ;-)) mounted securely to a wall at least 4'10" off the ground...There are so many highly-paid administrators who add nothing .....I've never worked with an RN who didn't complain to me that she had to spend so much time on paper work and things that are "a waste of time" for compliance reasons that they have to delegate the actual patient care to CNA's and LPN's.
(I always want to be 'hands on' in my patient's care. I'm responsible for carrying out orders notifying the physician of any changes in a pt's condition, etc. Accurate charting is also the responsibility of the nurse. If a CNA was assigned to work with me and my group of patients, all the better, but I would still be there at the bedside, answering questions, teaching, and involving family in the patient's care. The nurse is also responsible and held accountable for the care given by the CNA according to law, so you can't just go sit at the desk and delegate, that's for sure, and a CNA can make or break your assignment, depending on expertise.)To me, it would make more sense for the most qualified person on the floor to be the one interacting with the patients and delegating the secretarial work to an administrative assistant and the scut work to CNA's. Nurses are highly trained medical professionals. RNs should be part of the medical team working with doctors to develop a treatment plan and then delegating out all aspects of that work that do not require their high degree of medical expertise. Nurses are expensive.
(That is very relative. A good one could save a hospital or office millions in the long run just by anticipating and preventing patient problems and outcomes, not to mention lives.) When you compare the per hour cost of an experienced RN (compensation + benefits) with what a doctor is paid for four 15 minute inpatient visits under the RVS fee schedule, the nurse makes about $5 to $13 more.
(Nurses make way less than MD's, and rightfully so. We normally didn't train for ~10 years either.
Curious, did you calculate $63/hour as a nurses pay or did I read that wrong below?) Perhaps it would be possible to utilize the nurses more effectively and spend nursing dollars more efficiently. Let's pretend there is a "theoretical" 8th floor women's unit that is staffed by one nurse supervisor, four R.N.'s, two LPN's and two CNA's. This what is required by JCAHO in order to be compliant. The four RN's round and look in on the patients a couple of times per shift, but spend most of their time and their computers charting and doing other paperwork. The LPNs are taking vitals, administering drugs, doing most of the hand's on care, while the CNA's are taking care of the personal needs. The LPN's and CNA's are the least professional team members and each is covering 16 patients. They are rushed, overworked, and probably not the best members of the team to deal with questions from the family, but they are the face of the hospital to most patients. Let's say someone gets the bright idea to try something different -- take the same nursing budget and have one nursing supervisor who directly oversees two administrative assistants who (at $18 vs. $63) are there to assist two RNs with the paperwork, the RNs are free to get up and oversee two LPNs and four CNAs.
( Administrative assts., you mean like the unit secretary, they can't chart anything on the nurse's notes. They usually do their job which is to answer the phone and flag MD orders, answer the call bell, etc. So you're saying, we get rid of JCAHO and their staffing requirements to save a few dollars by instead cutting down 5 nurses total as opposed to 7 nurses total. In the long run, I don't think it would pay because of the RN's and LPN's being too few and far between. CNA's are grayt, esp a seasoned CNA,and can make or break a nursing assignment, but still usually can't replace an RN or LPN, nor can an admin. asst., just because of the various job duties and legal requirements. It's nice that you are thinking about alternatives but the answer is not in cutting back on nurses. BTW, I never knew any RN to make $63/hour even with benefits. Try a little over a third to half of that quote, and that's with 20 years experience.) It might result in better patient care, better patient outcomes, but no one can ever try it to see if it would work because they have to staff as JCAHO directs. There is no innovation, no incentive to invest in technology to unchain nurses from their computers, no hospital culture of thinking outside the box.
(Some hospitals now have computers in the hallways by the patients room or even in patient rooms. I think the public is going to have to ultimately be the ones to demand better healthcare and fewer mistakes caused by understaffing,and/or the lack of experienced bedside caregivers, and also by taking away insurance companies' monopoly on the hospital and heathcare industry, forcing hospitals in to constant cut backs.) In every hospital I've ever worked with the attitude has been, "If it ain't broke, don't fix it." And if the measuring stick you use to determine if it's broken is JCAHO, then the more queen bees pulling down $60,000 a year to run around and check what's in the red bags and what's in the regular garbage the better.
IMHO, there is a lot broken in the hospital systems. I've had to either personally walk over to the unit or send a member of my staff over a couple of times a day for patients...I've seen patients left to lie in their own urine for more than an hour -- sometimes because it was almost shift change, sometimes to punish them for not holding it until the CNA could get there even though they told three nurses they needed to go to the bathroom.
(That was mean and 'not right'. It sounds like a lack of staff though. Why would a professional do that to punish a patient? I just want to have more faith than that in nursing. That is very sad and humiliating and can be a real blow to a person's dignity to be made to eliminate on themselves. I will agree though there are uncaring people everywhere who are worried about doing too much work.) I've had a woman fly half way across the country for an 8 hour surgery that required the lower part of her abdomen to be harvested and microsurgically attached to the place where her breast used to be call me at home in the middle of the night in a panic because her breast flap was cold and no one would listen to her ...(
Sounds like she could've used more frequent vascular checks, some private duty nursing or a family member who knew what to look for by her bedside from the minute she got out of the recovery room.) These flaps are fed through two tiny arteries, and if a blood clot develops at the suture site where the arteries were attached, the flap will die within an hour or two. ...The CNA told me privately that she'd told the RN twice that she needed to look, but she never came to the room.
(Was she not aware of an order to do q 15 or 30 min. site checks, I wonder? Wonder why if the CNA knew the flap was endangered, and the RN was tied up she didn't page your doc for the nurse, instead of waiting, for the flap to die and then saying to you I told her. 
What's up with that passive aggressive behavior?
The hospital refused to fire or even discipline the nurse because 1) flap death was one of the complications listed on the liability waiver and they didn't want to give cause for litigation and 2) there was a
nursing shortage and they couldn't remain compliant with JCAHO if they fired nurses for this sort of thing.
(Sounds like a case of either too few RN's on the floor and/or just lack of experience.)Because the doctors I worked for were highly aware that they were building a national reputation for themselves based on information women were exchanging on a breast cancer message board, they took a very different approach. The first rule in healthcare is to never do anything following a complication for free because it can be construed as admitting fault.
(It is? I would think that could get some people upset (and most likely a lawsuit) if the complication was the cause of someone else's mistake. As a consumer, I would sure expect to be taken care of if it was some one else's mistake but not so if I was told it could be a complication and no one was negligent.) My doctors took her back to surgery, did a much more complicated gluteal flap which harvested tissue from the rear, and then spent hours doing body contouring and liposuction. ..They did this for free. ...The cool doctor told the CEO of the hospital, who refused to comp the surgery
(There's that first rule in action.), to send him the bill for the second part of her stay, but to "print it on soft paper, because I plan to use it to wipe my @$$."
(That was nice of your docs to take care of their patient for free after all.)
Our group realized that a group of people talking about their personal experiences was a much more powerful incentive to provide a high quality service than JCAHO. ......
(Maybe the pulic, the people, our government, like JCAHO does now, would demand more RN's per patient. Maybe hospitals would care more about retaining experienced RN's and pay them what their worth, rather than readily replacing them with younger and less expensive models. Nurses leave nursing all the time because they are burnt out, tired of the working short staffed, with new young administrators who are not really understanding their RNs' responsibilities, accountability, and liability to our patients by stretching us to thin. )
As an example,
http://www.healthgrades.com/directo...Fowler-MD-74F81839.cfm?tabphysprofile=pat_exp
let's look at HealthGrades.com....Today, most doctors have no idea how long people have had to wait because the nurses usually don't tell them, and the patients rarely complain to the doctor...
But I have to say, my main problem with JCAHO is that they do not factor billing into their "quality" equations at all. There is all this stuff about the size of the bolts used to attach the glove dispenser to the wall, but nothing about being able to tell a patient how much their planned course of treatment will cost beforehand, or the circumstances under which a patient will receive a bill for charges denied by the insurance company, or when it is proper to turn a patient over to collections.... He billed $513 for that service.
(These are grayt questions.)
JCAHO accreditation and compliance is incredibly expensive, and while
many of it's requirements are good and practical, a great many are silly and wasteful. A well organized hospital with a healthy fear of litigation and an awareness that patients had easy access to data about their outcomes, quality issues, incidence of complications, and rate of MRSA infection run by doctors and people with training in public health and one or two good MBA's would, IMHO, have far superior quality to one run by a bunch of MHA's who memorized the JCAHO rule book in grad school, but don't have a great understanding of reasons behind the rules.
Regarding HIPAA, do you know of any person or institution who has ever been prosecuted under the privacy or security provisions of the HIPAA?
After the law came into effect, yes, it was rumored some hospital staff were fired after accessing charts of folks they had no business accessing.
I don't believe there has ever been an attempt to enforce these provisions, nor so much as a fine imposed. I know a few nurses must still gossip about patients. I think most hospitals have long had policies
(It's a moral,ethical and professional code of conduct for nurses and doctors, and now, illegal. I'm glad since the other 3 don't seem to matter to some people.) in place forbid the kind of behavior you describe -- the nurse who looked at her enemies' medical records. I am sure if you had reported her, she would have been disciplined or fired
(Actually, she practically runs the place . 
I'm only laughin' here to keep from cryin' and 
. 
)-- which seems to me a much fairer penalty than forcing the hospital to pay a $40,000 fine. In fairness, I have no problem with the provision that requires that hospitals have a P&P in place to limit the number of people who have access to PHI.
My problem is with the provision that requires the hospital to purchase and use an electronic system that can limit the amount of information an employee can access on a need to know basis.
(I would not want every administrator, plant op, unit or billing clerk with a computer to have full access to my medical records. Do you?...esp. if you happen to work there too.)The end result of this is that almost everyone in the hospital has access to pretty much the whole file. The nurse you mentioned above would still have access to patient medical records, and it would still be her professional obligation to respect every patient's privacy and confidentiality. She probably wouldn't have access to the billing screens.
(Funny though, once it carried the big fine, the hospital supposedly started firing snoopers. They held 'HIPPA' meetings for staff. Word spread fast. The IT dept. even had policing capabilities and could tell who accessed what, she at least, quit advertising the fact that she was snooping on her supposed 'crazy' ex-coworker.) Trust me, though, the high school graduate making $10 an hour in the billing department has access to everything, though. She may have no license to lose, no problem finding another low wage, soul-eating job, but she has access to every social security number, date of birth, address, cpt code, patient hx, everything. So, in short, I don't believe that privacy is protected by this provision -- but the hospital has to have a software program customized to take every level of employee and block some bit of information here and there within the system. That kind of customization is expensive, inefficient, and unnecessary.
(It is absolutely necessary, otherwise everyone in the hospital on the computer could get in your chart. Thank goodness different positions within the hospital have different security clearance and access capability. As a nurse, I didn't have access to the billing screen, and didn't want it. I had enough to deal with. I also didn't want the maintenance dept. in my biopsy screens, etc., and I'm sure vice versa.)
HIPAA was a law passed in 1996 to make health coverage portable when a person lost or left a job. It is the law that created COBRA. The insurance companies had long wanted to digitize and automate much of the claim processing, but were having a difficult time persuading doctors...but a nurse must go to her desk to get her work done for fear of not being HIPAA compliant.
(Actually, HIPPA never really slowed me down. Computers near the bedside are becoming more common too.)
There is a great explanation of HIPAA here...
http://en.wikipedia.org/wiki/Health_Insurance_Portability_and_Accountability_Act
Be sure to scroll down to the discussion of impact and costs at the bottom.
Nurses are in a constant battle trying to improve standards of care and increase the nurse to patient ratio, not cut staff. Then people have the nerve to complain when medical mistakes are made but won't stand up for proper staffing. 
I had to cut parts. 
Thanks for asking your questions. 
