Keep your hiring standards high, or risk adverse patient outcomes

Florida nurse was disciplined twice before case in which patient died

Hiring practices of same-day surgery providers are coming under scrutiny in the wake of five deaths this year following cosmetic surgery in Florida. A nurse involved in one of the cases had state disciplinary complaints filed against her at two previous jobs, including another incident in which a patient died.

In the most recent case, the registered nurse worked on a per-diem basis for a surgeon at a surgery center. (For more information on hiring contract nurses, see Same-Day Surgery, October 2002, p. 121.) The nurse "was highly recommended to us by a nurse who worked with her" at a hospital, said a surgeon who ran the center. Also, she possessed an active and clear license, and the managers were unaware of any previous problems, according to that surgeon.

The nurse handled anesthesia, at least initially, during the most recent operation in which the patient died, according to an adverse incident report the surgeon filed with the state. The surgeon’s report stated that another nurse relieved her, but provided few other details. No action by the state has been reported against the nurse; however, at press time, the surgeon’s license had been suspended.

In June 1997, the Florida Board of Nursing accused the nurse of falsifying records while working as a surgical recovery room nurse at a hospital. Although she failed to take a patient’s vital signs, she indicated in the medical chart that she had, according to records. When the nurse did check the patient, the patient had no vital signs, according to the state complaint. The patient was pronounced dead in the recovery room. The nurse paid a $250 fine, was reprimanded, was required to complete a course on medical documentation, and paid $567 to reimburse the state for its investigation.

In March 2002, the nursing board accused the nurse of improper handling of medication, including Demerol, while employed at a surgery center between June 18, 2001, and June 29, 2001. The state complaint said the nurse’s medication records contained numerous errors, including "withdrawal of medication for a patient who was never admitted, improper corroboration of waste and excess, administration of medication without a physician’s order, and nonadministration of medication that a physician did order." That case is pending before the nursing board.

The most recent incidents follow a 90-day moratorium on certain office-based surgery procedures in 2000 by the Florida Board of Medicine, which led to enactment of some of the nation’s toughest office surgery standards. (For more information, see SDS, November 2000, p. 133 and p. 137.)

In the scramble to find nurses and other staff in the midst of a nursing shortage, there are steps that same-day surgery providers can take to ensure they hire and maintain competent staff. "It’s a tough thing; nurses are in a shortage," says Jerry Henderson, executive director of the SurgiCenter of Baltimore in Owings Mill, MD. "But sometimes a warm body is not good enough. You have to have people who are qualified."

Consider these suggestions:

Conduct a thorough interview. Dawn Q. McLane, RN, MSA, CNOR, executive director of Allied Physicians Surgery Center in South Bend, IN, says that in addition to education, your interview should cover these areas:

Employment history. "I like the candidates to tell me about their work history — why they have chosen the path they have taken in the past," McLane says. "I look at longevity at previous employers and like to ask if the candidates mind sharing why they left previous employers, including why they are currently seeking a change."

Personality. "I ask the candidates to tell me what they believe their three greatest strengths and three weaknesses are with respect to the job they are applying for," McLane says. "This can be very telling."

Ability to cope with change. "I ask the candidates to tell me how they feel about change in the workplace and how they cope with change," McLane says.

Involvement. "I ask what types of committees the candidates would like to be a part of in this workplace, assuming they are familiar enough to answer this," McLane says.

Conflict. "I ask the candidates to tell me about a time when they had to deal with anger, or disagreed with their boss, or were forced’ to do something they didn’t want to do, and how they reacted to it," McLane says. "The answers to these and similar questions tell me a lot about the employee that I can’t get from a resume." Consider having two staff — one of whom is a manager — present at second interviews, McLane suggests. "I have found that including a second person often affords a different perspective of the candidates," she says.

You can "bounce" impressions off of the second person, McLane says. "If two candidates are clinically or technically equal, it is the professionalism, personality, team spirit, etc., that will make the difference.

Check out their experience. During the interviews, McLane asks for specific names of supervisors with whom she might speak about the applicant.

Don’t accept a reference letter and simply stick it in a file, Henderson warns. "Letters in and of themselves mean nothing until you go back and check them," she says. Call their references, she advises.

Professional references, not simply personal references, are essential, McLane says. "One of the most useful sources of information available is talking with my current employees about their own experience with a potential candidate, provided this nurse has previously worked in the professional community," she says.

Ask very blunt questions regarding what kind of experience they’ve had after training, advises David Shapiro, MD, president of the San Diego-based American Association of Ambulatory Surgery Centers. "As everyone knows, most of medical training is based on experience after school has ended," he says. "They may have a freshly earned certificate in their hand, but they may not have had experience to handle an emergency situation as best as they could."

Credential your staff. It is imperative that administrators hire staff responsibly, McLane says. "Just like credentialing of our physicians, we must ensure that the staff we hire are competent to perform the job functions and roles that are assigned to them."

Henderson’s facility credentials nurses in a process similar to one they follow for physicians, she says. The person who is delegated the responsibility, usually the administrator, takes the following steps, she says: He or she checks the person’s license to be sure it is current. He or she contacts the state (it can be done on-line in Maryland) to be sure there hasn’t been any action on that nurse’s license. He or she also checks the Office of Inspector General (OIG) Exclusion List to ensure that the person hasn’t been excluded from participating in any government-funded programs such as Medicare. You can check the OIG Exclusion List on-line at http://exclusions.oig.hhs.gov/search.html. Also, your Medicare Fiscal Intermediary should publish a list of licensed staff excluded from or reinstated to Medicare.

"If you have anyone working for you on that list, and you have Medicare and Medicaid patients, you risk being excluded from that program," Henderson says. Every staff applicant providing patient care should be credentialed, she maintains. "It’s a matter of scale," Henderson says. For example, because many nursing schools are no longer open, it is difficult to do primary source verification for nurses, she says. "But you certainly can make sure, at least, that the license is valid," Henderson says. "Anyone can doctor’ a copy of a license."

Meet Joint Commission requirements. Approximately 11% of ambulatory care facilities and 35% of hospitals received type 1 recommendations in 2001 from the Joint Commission on Accreditation of Healthcare Organizations for Human Resources standard 5 (HR5). Those standards are assessing staff abilities to fulfill job expectations (ambulatory care) and assessing, maintaining, and improving staff competency (hospitals).

The problems are twofold, says Lucille Skuteris, RN, MS, associate director of the Standards Interpretation Group at the Joint Commission. One area concerns the lack of age-specific competencies, she says. In the other area, "People aren’t meeting [their] own expectations for frequency [that] they are to be evaluating staff members," she says. For example, facilities may say in their policies and procedures that they’re going to evaluate staff on an annual basis, but they’re two or three weeks late.

The Joint Commission doesn’t specify that the evaluations have to be done annually, Skuteris points out. "Timeliness would be important, relative to the fact that you want to be able to identify any outstanding issues related to competency," she says. HR3 requires ongoing competence assessment in ambulatory care facilities and hospitals, Skuteris says.

Competency testing should include an ongoing annual re-appraisal of competency with high-risk, low-volume, or problem-prone cases, McLane advises.

Ensure staff are adequately trained. Provide a detailed, comprehensive orientation program, McLane advises. "The nurse should complete a thorough orientation program, and these competencies must be tested prior to the nurse taking solo responsibilities in these areas," she says.

Staff who lack experience need to be proctored until they can "fly on their own," Henderson says. Ensure that an ongoing education program is in place, "and that remedial education is available whenever needed," McLane suggests.

Once qualified staff are in place, be certain that nurses aren’t asked to handle tasks for which they’re not adequately prepared, Shapiro advises. "To keep their jobs, they may agree to do something they’re not trained to handle," he says. Same-day surgery managers may go a lifetime without anything problematic happening in their facilities, Shapiro says. "But in an emergency situation, the lack of training shows up to the patient’s detriment," he says.

Sources

For more information, contact:

Dawn Q. McLane, RN, MSA, CNOR, Executive Director, Allied Physicians Surgery Center, 53990 Carmichael Drive, Suite 100, South Bend, IN 46635. Telephone: (574) 247-3377. Fax: (574) 247-3300. E-mail: Daquay@aol.com.

Jerry Henderson, Executive Director, SurgiCenter of Baltimore, 23 Crossings Drive, Suite 100, Owings Mill, MD 21117. Telephone: (410) 356-0300. E-mail: jerryh@surgicenterofbalt.com.

David Shapiro, MD, Surgis, 30 Burton Hills Blvd., Suite 450, Nashville, TN 37215. Telephone: (615) 665-3012. Fax: (615) 665-3028.

Standards Interpretation Group, Joint Com-mission on Accreditation of Healthcare Organizations, One Renaissance Place, Oakbrook Terrace, IL 60181. Telephone: (630) 792-5900. Web: www.jcaho.org.