Transcription:
Vote No on Question 1

Melanie Cole (Host): Question One is shaping up to be the most expensive and closely watched ballot measure this year in Massachusetts. My guest to tell us about this is Nancy Gaden, she’s the Senior Vice President and Chief Nursing Officer at Boston Medical Center. Nancy tell us a little bit about Question One. What is this question on the ballot? How did it come about? And what will it do?

Nancy Gaden, DNP, RN (Guest): It turns out that in Massachusetts and about half the states in the country you can make a law through a ballot question. So, of course, typically, laws are made by the legislatures after a lot of deliberation and sort of thoughtful consideration of different components. But in the case of a ballot question; anybody can propose a ballot question and they write it and the voters vote on it and if it passes; it becomes law as written. With ballot Question Number One, it was actually proposed by the Massachusetts Nurses Association which is a nurses’ union here in Massachusetts that has about 25% of the nurses in the state in it. And so, what Question One does is it effects acute care hospitals, acute rehab hospitals and acute psychiatric hospitals and it imposes very rigid nurse to patient ratios at all time, regardless of the hospital size, the location or unique patient needs. Everyone in acute care including every unit, medical surgical units, labor and delivery, the emergency departments, psychiatric beds would all be affected, and would all have these ratios sort of imposed on them.

The way the ballot question is written, which is the way it would become law; there is only one exception to these ratios and it would be in case of a public health emergency and the definition of a public health emergency is very specific. The last one we had in Massachusetts was in 2014 and that was for the opioid crisis actually. But for example, the marathon bombing was not a public health emergency, the fires north of Boston a month ago or so would not be considered a public health emergency, hurricanes. So, basically this law would be in place all the time, 100% of the time. And if it passes, on November 6^th, the law would go into effect on – says right in the law – it would go into effect on January 1^st, 2019. So, hospitals would literally have about 38 or something like that business days to meet the ratios as mandated in the law.

Melanie: Wow. It seems that voters might be confused about this ballot question and Nancy they are seeing ads that say nurses are yes on Number One, nurses at no on Number One, 86% of nurses support Question One; how do they know what to trust?

Nancy: Yeah, that is a great question. A few years ago, in Massachusetts we had a ballot question on charter schools and the first thing I did was go to find a teacher to say what do you think because of course, I don’t know anything about charter schools. And I think in the same way, that the public will really look for nurses and for people who work in healthcare to give them insight on Question One. So, I will start with your – the 86%, so this statistic is extremely misleading. It is based on a poll that was done several months ago of 305 nurses. Now there are 125,000 nurses in Massachusetts so to poll 305 of them and then put out an ad that says 86% of the nurses voting yes on Question One is just absolutely patently false. There are thousands of nurses in Massachusetts who are voting no on One because they are worried about the unintended consequences. I think one of the most important things for people to know is no on One? Every single hospital is no on One. Every physician group in Massachusetts, every professional nursing organization in Massachusetts who has taken a position, like the Emergency Nurses Association and the Academy of Med-Surg nurses are all no on One. And every healthcare organization that serves patients including so many, I’ll just list a few like the Homecare Alliance of Massachusetts, Massachusetts Assisted Living, Community Health Centers, the VNA, the Ambulance Association, Hospice and Palliative Care; every single group with the voice of the patient is no on One. And so I think people – voters need to think about this and make their own decision but I think understanding who is against Question One and why is really important.

Melanie: Certainly, is and as some people are proponents of Question One, they claim these ratios are necessary for safe staffing and to improve patient care. Will Question One improve patient care? What are some of the consequences for patients?

Nancy: So, it does sound like the right thing, more nurses equals better care. It does sound intuitively like it’s the right thing, but absolutely Question One would not improve patient care. Patient safety is a huge priority for every hospital. We report quality metrics, nurses and physicians work together to manage all kinds of patients and honestly, Massachusetts has some of the best healthcare in the country. Here at BMC, we staff very thoughtfully according to patient acuity and experience and volume and we look at every single area and make sure that we have the resources that we need. Staffing is extremely important. I mean I just want to reiterate like resources – having the right resources for the patients, for the nurses, for the families is the most important thing. And I’ve personally been committed to nurses and staffing my whole career. There’s nothing more important. But, the reality is, that the way Question One is written, if it becomes law; it will be implemented just the way it is written and there are extremely serious, unintended consequences, negative consequences for our patients and for every hospital and mental health facility. We have all gone through the analysis of the ballot question and figured out what the impact would be, and it is absolutely bad for patients.

Melanie: Well speak about some of those consequences and as well as consequences for the staff and for centers like BMC. You mentioned that they would only have 38 days to be compliant. So, what does that mean?

Nancy: Yeah. So, well first of all, we know how much it would cost in Massachusetts if the ballot question passes, it will cost almost a billion dollars according to the health policy commission and they did not even include the emergency department in that, so we know it’s more than that. It would cost Boston Medical Center 28 million dollars, if we could find the nurses to implement these rigid ratios and that money would have to some from somewhere and hospitals are talking about being forced into making very difficult decisions and difficult choices about what they will do if they have to comply with this law; what programs would be at risk and some hospitals have even said their whole future is at risk. Every hospital has said they would have to look at limiting and closing services. But, to be absolutely honest with you, I have not really been focused much on the cost because I don’t think that we will be – well I know we won’t be able to hire that many nurses by January 1^st. It’s absolutely impossible. We already have a vacancy rate in Massachusetts of 5% and so this bill apparently would cause the state to need between three and five thousand more nurses and here at BMC my numbers line up with that. Our piece of that is hundreds of nurses. So, what would happen on January 1^st, if this ballot question passed and we had to comply with those ratios; is we at BMC and other hospitals also, would have to limit access to patient care. So, why is that? Well, we – as you know, we are a busy trauma hospital. We serve vulnerable patients. Our patients need all kinds of services, but we – when we think about this ballot question; we realized what we would have to do to our services. We did the actual calculations to figure out the impact and I’ll just give you a couple of examples.

So, in labor and delivery here at BMC, if we couldn’t hire the experienced nurses we need, and we have remember, two months to do it; we are training people all the time and hiring all kinds of nurses, but we could never get the additional nurses needed to comply with these ratios. We would have to decrease the number of women that could give birth here.  But for us at BMC, it would mean 800 fewer mothers able to deliver here, 800 women that want to come to BMC to get their care, would not be able to deliver here. For us to staff not according to the professional guidelines like we use today, but according to these mandated ratios in the ballot question; we would have to decrease 800 births a year.

So, in our emergency department, as another example, the implementation of these ratios, these rigid numbers that are identified in the ballot question would mean that once a nurse has the number of patients that are listed in the ballot question; she could not take another patient. Like no matter, even if in her clinical judgement, it was appropriate, she would want to bring a patient in from the waiting room, the physician and she work together to figure out the right care for that patient; she could not take another patient without breaking the law. If we can’t hire the huge number of experienced emergency department nurses that are called for in this bill; the result here at BMC would be that 100 patients a day would not be able to come inside of the ED. Remember that the nurses’ association, the emergency room nurses’ association is opposed to the Question One and the reason is because of these unintended access issues. The unintended consequences of restricting access because of the rigid ratios that are listed. And one of the things I’m the most upset about is what I know will be terrible moral distress for those nurses. They will see patients in the waiting room. They will want to bring them into the care area, but if they do that; they would be breaking the law. So, at BMC, it’s just these huge access issues for us.

And the medical surgical floors, if we had to comply with these rigid ratios the way they are written; the result would be we would have to close 62 beds, that is almost a third of our total medical and surgical beds. It’s literally catastrophic to our patients and access to our services.

Melanie: Nancy as far as these devastating impacts to BMC specifically, and really around the state; has this been tried elsewhere and where do local elected officials stand on the measure?

Nancy: So, let me answer the first piece first. It has been tried only once in California. There is a broad ratio bill in California that passed about 14 years ago there. And we have all been able to watch it. The whole country has watched, and we know from that experience that there has been no improvements in patient outcomes that are related to ratios. The California experience is different than Massachusetts. The ratios are different. They are more loose if you want to call it that. California had five years to implement their ratios and still at the end of five years; they had a great number of nurses coming from outside the state and outside the country, but I think the most important thing is that quality did not improve. Massachusetts out performs California in every meaningful quality care metric. So, I would say California is not a state to point towards. The whole country has watched. No other state has imposed legislated ratios and even though they watched California do it and the reason is, because it’s not the right thing to do.

So, the second half of your question about the public officials. I would say the response of public officials has been mixed, but I think the most important sort of statement that was made in the last few days was from Governor Baker. He stated that he will be voting no on One and he pointed towards the cost that the health policy commission calculated which was almost a billion dollars.

Melanie: Nancy as a wrap up and I really appreciate you coming on and hearing your passion and speaking about things like nurses moral stress and patient care and the waiting times and that sort of thing because it really does take away the ability of nurses and physicians to use their best judgement which is what you are all trained to do to help patients be their own best health advocates. Wrap it up for us, why this is so important for voters to know about Question One and what BMC’s take on this initiative is.

Nancy: So, we don’t want the government legislating what should be squarely in the hands of professional nurses and physicians around patient care. This law if it passed, would deprive hospitals and doctors and nurses of the flexibility that they need even in the event of a sudden influx of patients due to any emergency like the Boston Bombings or anything, this law would restrict people’s ability to care for patients the way they want to care for them. We are worried about the effect the law would have on community hospitals, community health centers, behavioral health.

This law would hit them really hard, many of them saying that they fear they would have to close if it passes. Massachusetts Behavioral Health Association has estimated that 1000 beds in Massachusetts would close if Question One passes. It’s the ripple effect. We are worried it would draw nurses from community health centers and nursing homes and schools and other non-acute settings. We have worked so hard to provide access for patients in their communities to the services that they need. This would completely reverse that, put a spotlight back on acute care and pull nurses from other settings into the acute hospitals to meet the ratios.

There are reasons why every hospital and every group that’s involved in direct patient care is no on One. It would cost a billion dollars. It would not improve quality of care. It will restrict access and cause critical programs and services to be threatened. It is bad for patients. It’s especially scary for those hospitals like Boston Medical Center who are caring for the state’s most vulnerable patients. We really – I really encourage voters to think about it for themselves. Learn more about Question One. Go to Protectpatientsafety.com. Visit Boston medical Center’s home page, Facebook page.

We are trying to really let people know how worried we are for our communities, for our patients. I think my final comment is that I have worked with hundreds and hundreds of amazing staff nurses over my career and I have never felt so acutely that their practice was threatened as I do with Question One. I promise you, being against Question One does not mean you are against nurses. Nurses across Massachusetts are no on One. They believe in safe and appropriate staffing, but they know that this ballot question is not the answer. Please join Boston Medical Center and vote no on One.

Melanie: Thank you so much Nancy for coming on and explaining what Question One is and the impact, the devastating impact that it would have on the medical community, nurses and patient care in the Massachusetts area. Thank you again and it’s vote no on One. This is Boston MedTalks with Boston Medical Center. For more information you can go to www.bmc.org, that’s www.bmc.org. This is Melanie Cole. Thanks so much for listening.