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Slice and Dice:4 5/29/09 12:34 AM Page 15 years ago, for example, Kaiser Fremont's urgent care clinic was open until 9 p.m. and accepted walk-ins. Today, it closes at 7:30. Under the proposed plan, the clinic will officially close at 5 p.m. and only patients whom doctors deem over the phone are sick enough to see in person will be able to come in after hours. Kaiser at many area facilities is also closing or reducing hours for walk-in care at its minor injury clinics and at some pediatric clinics. The UCLA home health RN also reports that UCLA has likewise closed its wound clinic. "I wouldn't be surprised if more clinics closed," she said. "Respiratory, physical therapy, internal medicine." Kaiser RNs are livid over these service reductions. They say that not only do the changes hurt working people who are often unable to take time off during the workday for medical appointments, but they are also encouraging the practice of bad medicine by making it harder and harder for a patient to be physically seen by a healthcare provider. "Looking at somebody tells you a thousand things in a minute, just by eyeballing them," said Corinne Johnson, an RN working in heart failure care management at Kaiser in Hayward. "You can't get that over the phone." RN Susan Latour, who works at the Kaiser Fremont clinic on Sundays, reports that the Kaiser call center representatives are no longer allowed to book real face-to-face appointments at her facility, that only clinic staff or doctors can schedule those. Instead, patients are being told they can have a telephone appointment with a doctor. "Patients are just getting all these roadblocks," said Latour. "I think it's a total mistake. You need to touch the patient. You need to look at the patient. I'm just appalled as a Kaiser patient to see what's happening. Some of the doctors aren't comfortable with this either." As Kaiser cuts off access to lower levels of care, the result, say RNs, is that patients will be forced to seek help through the emergency room, usually at much higher copayments and with longer waits. In anticipation of being overwhelmed, many Kaiser ERs have already implemented a "fast track" system where lower acuity patients who are not really having a medical emergency are sent. Yet patients still pay the higher ER copay, a much greater amount than they would pay if they were able to see their own doctor or go to the clinic. Some Kaiser members have ER copays of up to $250, say RNs. "More and more people put off seeking care because they don't want to pay the high copays," said Michelle Gutierrez-Vo, an RN in the Kaiser Fremont medicine clinic. "They are really gambling with their lives." She points out also that if the after-hours clinic is allowed to close, the ER has no place to refer patients who really don't belong in the emergency department and will instead be forced to treat them there, increasing already long wait times for everyone. "Adding more people after hours to the ER is just craziness," agreed Johnson, who before her current position worked for seven years as an ER nurse at Kaiser Hayward. Kaiser RNs say they are determined to fiercely fight these clinic cuts and will enlist their coworkers, members, the public, and the media to reveal how patients are being denied access to care. On the inpatient side, RNs report that hospitals are trying to merge or mingle units to squeak by with less staffing. Kaiser is one of the leaders of the pack here again. At many of its facilities, Kaiser has wanted to put telemetry patients on medical-surgical floors, even though they require better ratios and it becomes difficult to adhere to the ratio law as the mix of patients changes. RNs at Kaiser in Vallejo, Calif. also report that management earlier M AY 2 0 0 9 this winter was trying to subtly subvert the ratio law by asking night shift RNs to take additional patients in the final hours of their shifts. "They would cap the floors on the night shift and then a couple hours before the day shift started say we needed to open up beds and taken another patient," said Victoria Rondez, a surgical-orthopedic RN at Kaiser Vallejo and chief nurse representative. "We said, 'Why are you making us take these extra patients and break ratios?' And they said, 'Oh, just do the bare minimum, take their vitals. Just keep an eye on them.'" Rondez and her coworkers fought this unsafe practice by waging an assignment despite objection (ADO) campaign and won. The hospital has since stopped trying to violate ratios on the night shift. "They were messing with us and trying to create that environment of intimidation and hoping that everyone would feel like we just have to take it because you're supposed to feel lucky to even have a job," said Rondez. Besides making patient care cuts, hospitals have also targeted nursing positions to cut labor costs. At California Pacific Medical Center in San Francisco, which is a Sutter Health hospital, RNs report that the hospital has suspended a policy they won in 2007 limiting daily cancellations, citing the economic situation. It has also announced layoffs of ancillary staff, a wage freeze, a hiring freeze, and elimination of the employer contribution to their 403(b) retirement plans for the year. At Kaiser, RNs report that management is aggressively disciplining coworkers for relatively minor infractions, is trying to enforce unknown rules, and is using the privacy provisions of the Health Insurance Portability and Accountability Act (HIPAA) to fire RNs. A number of Kaiser facilities have this spring implemented computerized charting, and Robert Marth believes management is using the program's tracking abilities to go after RNs who are innocently or in good faith checking up on patients because they want to monitor their progress. "In just one three-week period, we've had 19 investigations of RNs for alleged HIPAA violations related to technology," said Marth. "This is very highly unusual and sends a tone throughout the hospital, 'We're watching you.'" Rondez said that she's noticed discipline get "hyped up" and "very heavy handed," particularly for senior RNs who tend to make the highest salaries. Another tactic managers are using to keep tabs on expenses and intimidate nurses, says Johnson, is to scrutinize overtime and timecards. Johnson said that, recently, she incurred two instances of legitimate overtime treating very sick elderly patients, but her supervisor acts like "any overtime is a cardinal sin. They are nitpicking 10 minutes of overtime and pushing everything to the minute." She, like many other RNs, has been pressured by managers to chart the next day or chart off the clock, but she refuses to and advises her colleagues to reject such ideas. She suggests fighting back with ADOs, a petition, or other collective action. The bottom line, said RNs, is that nurses must not sit back and let hospital management undermine patient care. Nurses, particularly those who enjoy the protections and resources of union representation, have an obligation to change circumstances that they know hurt patients. "Kaiser loves to throw around the word 'thrive,'" said Marth, referring to the corporation's popular advertising campaign, "but now we're talking about just staying alive." ■ Lucia Hwang is editor of Registered Nurse. W W W. C A L N U R S E S . O R G REGISTERED NURSE 15