National Nurses United

and out-of-pocket costs low enough that healthcare is truly affordable to everyone, let alone affordable to a degree that it is in every other developed country." A reminder of that reality comes from a recent Kaiser Family Foundation survey that nearly 30 million Americans remain uninsured, large- ly because of the cost (though many also because of the botched rollout Brill describes of an absurdly complicated law.) Brill concludes not by recommending the single-payer or national healthcare solution adopted by most of those other developed countries, but by a fix that would make many nurses gasp—regional-based integrat- ed care networks of hospitals and insurance companies acting as oligopolies or monopo- lies regulated as public utilities led by doctor-CEOs who will align the incentives "in the right way." One model he cites is the Cleveland Clin- ic, led by heart surgeon Dr. Toby Cosgrove. Brill may not realize this hospital system also demonstrates that having an Ivory Tower medical center in one's backyard does little to improve the health of a community. Within the three miles surrounding the Cleveland Clinic area, infant mortality exceeds some Third World countries. The system is frequently under attack for failing to meet their charity care obligations and shifting the burden of caring for uninsured and underinsured to the lone public safety net hospital. Meanwhile, the system is grossing $11.63 billion and posted over $900 million in profits in 2013 alone. The Cleveland Clinic has also been cited by the Centers for Medicare and Medicaid Services for violating Medicare rules more than three dozen times since 2010. In 2013 alone, the system was cited for 23 health and safety issues. Nurses may question whether regulation and lower executive salaries, as Brill proposes, would correct all that. He argues that his system would make healthcare a public good out of the free market, but when he talks about aligning incentives, he gives short shrift to hands-on care and resourcing the provision of care by highly skilled clinicians exercising their professional judgment. Phrases such as safe, therapeutic care or a single standard of care not based on ability to pay don't enter the lexicon of the regulated "integrated healthcare oligopolists" led by rightly aligned beneficent doctors who are allowed reasonable profits. Compared to saving money through a truly universal system of guaranteed health- care, cost controls through global budgets for hospitals that cover actual annual expenses for patient care, regulated prices and bulk purchasing of prescription drugs, and negotiated fees for providers, Brills' approach is inadequate. Rather than dis - missing single-payer, he could investigate how to pull the levers of power and over- come the industry he cogently criticizes. Brill's own experiences as a patient feature prominently in his conclusions and nurses may wish that the patient's under- standing of the system led to more insight about how to change it. —Michael Lighty and Charles Idelson. Michelle Mahon contributed to this review J A N U A R Y | F E B R U A R Y 2 0 1 5 W W W . N A T I O N A L N U R S E S U N I T E D . O R G N A T I O N A L N U R S E 9 MINNESOTA M innesota nurses fought for and won a study by the state health department to correlate registered nurse staffing with patient outcomes, but hospitals refused to provide the required information. The Minnesota Hospital Association opposed the study through aggressive lobbying, but Gov. Mark Dayton signed the study into law in 2013. A workgroup of nurses, hospital administrators, and other key stakeholders then worked out details of the study. As a compromise, Minnesota hospitals agreed some acute-care facilities would provide data to the state health department in order to minimize the reporting burden for hospitals. In spite of these accommodations, the Minnesota Department of Health researchers reported that the hospital association instructed members to not cooperate with the study, and only one hospital bothered to respond with any data—and even that data was incomplete. Despite the egregious disregard for Minnesota law, the public health depart- ment went ahead with the study in the form of a comprehensive literature review. According to the Department, "[Our] review of the extensive literature found strong evidence linking lower nurse staffing levels to higher rates of patient mortality, failure to rescue, and falls in the hospital. There is also strong evidence that other care process outcomes such as drug administration errors, missed nursing care, and patient length of stay are linked to lower nurse staffing levels." Nurse staffing in Minnesota hospitals is getting worse, in spite of decades of robust research associating ideal nurse staffing with optimum patient outcomes and care. Minnesota Nurses Association members self-report unsafe nurse staffing through an MNA Concern for Safe Staffing Form, which members fill out after notify- ing first-line supervisors. The form is also used to track patterns of unsafe staffing and monitor trends to discuss with management. In 2014, Minnesota nurses documented 2,148 instances of unsafe staffing with the potential to substantively impact patient care. Even one such instance would be concerning, but even scarier is that the reported rate of unsafe staffing has doubled over the past three years. As the evidence indicates, and as the hospitals evidently don't want Minnesotans to know, safe staffing ratios will result in better quality care, better patient outcomes, lowered patient mortali- ty, and fewer never events. In the long run, a limit on the number of patients a nurse can care for at one time will even save hospitals money: there will be lower read- mission penalties and less non-reimbursed care for hospital-acquired infections. Minnesota Nurses Association contin- ues to fight for safe staffing through a Safe Patient Standard law that provides for a minimum number of nurses on duty in each unit to care for a safe number of patients to ensure they get the quality care they deserve. —Barb Brady Minnesota hospitals defy lawmakers Refuse to provide staffing data for state study

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