TRANSPARENCY for EQUAL ACCOUNTABILITY in MEDICINE

May 20, 2008

ACGME: WAKE UP, AND DON’T RELY ON THE COFFEE!

Filed under: ACGME WAKE UP CALL — Tags: , , , , , , , — Kim Sanders-Fisher @ 1:01 am

Should ACGME demand a more proactive approach to fatigue management with safer levels of basic staffing in teaching Hospitals as a condition of accreditation?   

        It takes a complete Medical Team with fully alert practitioners to deliver safe patient care. But Deliberate Negligent Understaffing of clinical units, and a cursory adherence to providing adequate on-call arrangements to facilitate quality sleep, adversely impact the ability of American Doctors in training to cope with fatigue and avoid unnecessary Medical errors.   

         In a landmark case Whistleblower Troy Madison reported prestigious Johns Hopkins Hospital to the ACGME when he felt that his fatigue due to non-compliance with the work hours regulations had almost compromised the care of one of his patients.  Was this an isolated incident involving just one teaching facility or indicative of a far greater problem industry wide?  In a for profit healthcare system there’s a tremendous incentive to do more with less and our Doctors in training are being forced to compensate for the drastic consequences of understaffing.  If a well financed institution like Johns Hopkins Hospital was overworking their trainees how are smaller facilities coping with the financial pressure to make cuts.  The Troy Madison case certainly proved that even the most iconic Hospital in the country was prepared to push their trainees to the absolute limit of physical endurance in total denial of the reality that it might easily cause serious harm to patients.  Denial regarding the negative impact of fatigue is all too common in Medicine and we need to enforce regulatory safeguards to combat this danger.  

         Should we be pushing Doctors to the limit of exhaustion endurance?  It is far too simplistic to merely regulate how long someone in training is allowed to spend continuously on-call.  Hospitals are not proactively facilitating the opportunity for key Medical staff to obtain sufficient rest in dedicated sleeping areas while on-call.  Despite ACGME mandates, those in training frequently go without sleep for dangerously long periods of time, even while keeping strictly within the current regulations for maximum time on duty.  We are expecting these Doctors to absorb knowledge and safely treat vulnerable patients by functioning flawlessly in a state equivalent to being legally drunk!  At the end of an extensive period of stressful Medical duties no one is monitoring whether they are still fit to drive home without causing an accident! “Power Napping” in a comfortable sleeping arrangement like the EnergyPod pictured below is highly preferable to the current grossly inadequate alternatives that fail to acknowledge the importance of sleep with regard to the alertness of Medical staff. 

                         Authorized by & Created for MetroNaps to provide public information

The dirty little secret is that Residents are not expected to get quality sleep during lengthy stints on duty and are deliberately discouraged from leaving critical clinical areas like the ED.          
        
         While I agree that continuity of care is best delivered while maximizing learning opportunities in long hours of work to provide greater exposure to clinical practice, this becomes non-productive when Doctors in training are chronically fatigued.  Currently this excellent goal is all too easily manipulated to justify zero sleep.   This situation has been getting steadily worse exacerbated by the Deliberate Negligent Understaffing of clinical units to cut costs.  When assistive staff and uncommitted temps, with grossly insufficient numbers of regular Nurses, are there to back up the efforts of eager trainees, our future Doctors are increasingly exploited as a free labor source.   

           Does ACGME have the power to set required standards for teaching facilities as a condition of accreditation and what changes might they consider making?
1.        Stringent multidisciplinary minimum basic staffing requirements as proposed by the C.U.T!  Campaign Goals to CONTROL UNDERSTAFFING TODAY.
2.      Regulation of tasks to insure that Nursing and Ancillary staff take far greater responsibility for duties that are not essential for Doctors in training.
3.      Easily accessible dedicated quality sleeping arrangements to proactively facilitate adequate rest while on-call with monitoring of usage by those on-call to determine if they are obtaining safe minimum sleeping time during extended periods on duty.
                                       

               ACGME must deny accreditation to teaching facilities that do not meet standards!  

          You might well ask what qualifies someone who is not an MD to talk with any authority about fatigue?  I have come from a rather unusual background of extensive overseas travel and many years at sea.   My Medical training, such as it is, represents a second career after spending most of my adult life working aboard private sailing yachts.  While that might sound far too cushy to even justify the title of “job” let alone “career,” it was actually very challenging on occasion and surprisingly hard work.  You learn a lot about fatigue at sea, how to pace yourself, plus how to insure that all of your crew remain fit and well rested.   There are times when you are faced with a serious crisis, dealing with a life threatening emergency, but the second time allows, your solemn duty to your crew is to get quality sleep.  It is just as hard for Medical professionals to unwind following critical emergency procedures, but getting sufficient rest is a duty for them too.  

The importance of the duty to be well rested is not outweighed by the critical nature of your workload, rather it is necessitated by the skill and complex decision making involved in such tasks. The impact of sleep loss and fatigue in Residency training is well documented in Medical journals like this one in JAMA:  http://jama.ama-assn.org/cgi/content/full/288/9/1116  

         My last few years at sea I did many ocean passages sailing double handed. Dealing with fatigue when there were only two of us to take watches, steer the boat, navigate and cope with extreme conditions offshore took stamina, self-reliance and good planning.  As a yacht delivery Captain I learned to deal with serious emergencies at sea, not panic, but instead use innovative strategies to think through problems logically.  Keeping a clear head by paying attention to my own basic need for regular sleep was an essential duty of command.  It is time US Medical facilities stopped treating their Medical professionals as if they were super-human and sleep was a superfluous luxury: without rest mistakes are inevitable.  After surviving dismasting, injury, a full capsize and watching my best friend washed overboard into the freezing Southern Ocean on the Whitbread Round the World Race, I strongly maintain that most disasters at sea are the result of “Panic, Fatigue or Complacency.”  I once gave a lecture on this sponsored by West Marine; but, how many errors in our Medical facilities are caused by these exact same issues?   

How often are our Medical professionals compromising their ability to cope, diminishing the standard of their care or narrowly avoiding unnecessary errors by suspending the reality of their need for sleep?   Do they even drive home safely?          

         Following my experience on the Whitbread race I became convinced that “fatigue” was a major factor in precipitating mistakes; it was the hidden element all too often overlooked by hardened professional crew.  Ignored impediments like the cold, wet gear, damp sleeping bags, lousy nutrition, stringent water rationing and plain old lack of sleep, rendered even the world’s top sailors more prone to dangerous errors and impaired their efficiency with less than impressive racing results. I created “Team Pro-Maxi,” my own team of internationally renown women sailors, determined to pay attention to the debilitating details of fatigue in our bid to win the 93/94 Whitbread race.          

         Fate intervened when Hurricane Andrew devastated south Florida; my personal ambitions were transformed by this first experience working as a Medical Volunteer in the aftermath of a major disaster.  I made an abrupt career change seeking additional Medical training with the lofty goal of working in disaster relief.  However, when I entered a conventional Hospital setting I had great difficulty trying to adapt and learn to stifle or ignore the tell tale warning signs of fatigue among my overwhelmed coworkers in the Medical staff.  I would observe with pity as an exhausted Resident tried to doze off bolt upright in a chair behind the Nursing station, right opposite one of our “Baker Act” restrained patients whose tormented screams further intensified the general mayhem of the Surgical ER at 2:00AM on a Saturday night. The Residents call room was too far away from the ER for practical purposes so this harrowing scenario was what constituted “rest” during 36 hours of continuous duty!  How many regular human beings could cope with that? It is accepted practice, Medical professionals rarely complain, but what impact does this have on the safety of patient care?  We are naive to pretend that it doesn’t matter.   

Why do so many Hospitals knowingly create torturous conditions for their Medical staff who desperately require quality sleep? Do they really still expect them to remain alert and focused on critical live saving interventions?  

           I am not one of those who believe that it just takes intelligence and good grades to become a Doctor, it takes phenomenal stamina as well. Today’s Medical students and Residents must face the cynical comments of older Doctors who will insist that they coped so well with almost zero sleep and mounting patient care responsibilities.  However, it does not have to be this way, and besides, the exaggerated claims of having coped with an equally demanding schedule are not quite true.  There is at least one added dynamic that I am sure most Doctors in training are already aware of: the greatly increased acuity of the current typical Hospital patient.  If the patient is not half dead they are discharged; not such a bad idea considering the rise in nosocomial (Hospital acquired) infection rates.  However this leaves Medical staff to care for only the very sickest individuals with the same demanding Residency routine under which their predecessors worked so well.      

        But wait there’s more, yet another important dynamic affecting the workload of Medical Students and Residents that they might be far less aware of: the Deliberate Negligent Understaffing of clinical units.  This does not yet fall under the jurisdiction of ACGME Medical program rules or even include Doctors in training, but it does impact the overall workload and the current debilitating lack of time to rest up while on duty.  This growing problem has been getting steadily worse since the 90s and has reached epidemic proportions as money hungry Healthcare Corporations have now managed to precipitate a nationwide “Nursing Exodus” in America.   

Q:      How do Nursing and ancillary staff numbers affect Medical Students and Residents?  
A:      Simple, when fewer people are available to tackle routine tasks, those in training end up picking up the slack, often doing simple jobs that require little or no Medical experience at all.           

          When those confident Doctor mentors faced the rigors of Medical Residency there were more Nursing staff, plus the training, experience and skills of those on duty was more comprehensive while they were also far less fatigued by unreasonable work demands.  Bottom line: they had great backup!  When basic Nursing and unskilled drudgery jobs are not done they seriously disrupt the work flow, so people who should really prioritize their own need for rest during long hours on duty, do not hesitate to pitch in.            

         An ER patient has been waiting for ages just to go to X-Ray, no one is available for transport, so the compliant Resident does the brief transport detail so that another of their patients can progress though treatment. I know this sound petty, a minor detail, but all too familiar to many who have endured Residency in a busy county Hospital.  I am not suggesting that certain people are above such basic tasks, but if the real goal is training and gaining sufficient rest to function safely without causing harm to patients, we simply must prioritize with regard to who does what. It is the cumulative affect of dozens of mindless unskilled tasks like this that seriously eat into the rest-time when Medical Students and Residents should be recuperating to stay alert. These routine jobs are usually done by minimum wage assistive personnel, but when those in training shoulder the burden the Hospital can hire fewer people and that fattens their bottom line.  

Regulating this overlooked dynamic, with mandatory basic staffing requirements as a prerequisite of ACGME accreditation, would insure that the entire duty period was either spent productively, doing complex tasks that reinforced the skills and experience of Medical training, or recuperating in readiness to function safely.  

         I have witnessed three separate consultancy firms at two different Hospitals analyze the ER and OR in order to find ways to “trim the fat.” On all three occasions the answer was exactly the same: “you are top heavy, trim down on your Management positions.”  Managers control this ridiculous situation and they aren’t about to authorize their own redundancy! By ignoring the advice of Consultancy groups and eliminating jobs at the very bottom they will make the least possible difference to payroll, but time after time this is the strategy of choice.  There is a hiring freeze and positions are not filled as people leave.  The overworked staff must learn to do more with less; every day becomes another overwhelming emergency, but at teaching Hospitals part of the burden caused by understaffing is alleviated by dumping on Doctors in training.  This is all at great detriment to the safety of patient care.     

         Encouraging experienced higher paid staff to leave only to replace them with barely trained new Nurse grads and entry level assistive personnel also saves money for greedy Managers serving Corporate interests.  Medical Students and Residents unwittingly assist them in implementing this dangerous strategy by filling in for missing Nursing and ancillary staff while compromising their precious sleep. There are fewer Nurses available to monitor far sicker patients and less people to implement thorough cleaning just as Hospital bugs are becoming more virulent and resistant to antibiotics.  There is no redundancy of personnel, a glut of unfamiliar Agency staff, minimal breaks, frequent mandated overtime and excessive call among the people who are there to support a young Doctor’s work.  This is a recipe for disaster! 

         When all of the regular staff are overwhelmed and exhausted, there is a far greater potential for oversights and mistakes that more senior Medical colleagues might well be held partially or totally responsible for not preventing.   This is the completely unnecessary part of learning from your mistakes: Doctors do not need to blunder through training in a sleepy, guilt ridden haze!

         The good news is that this is not an irreversible mess.  Nurses who have left Hospital care in disgust still maintain their licenses and could be lured back. Tenured Nurses are higher paid, more experienced professionals who are therefore far less desirable to cost-cutting Management.  But, highly trained key personnel were the first to be targeted and encouraged to leave. The most senior Nurses were forced out by intolerable work demands and unsafe patient care compromises.  Their departure made room for inexperienced new Nurse Grads who should not be overstressed with inappropriate responsibility while still attempting to learn.  These new Nurses are more compliant with excessive work demands and far less likely to speak up about dangerous negligent practices.  This helps the Hospital to cut a few more corners and still make a big fat profit.

         Unfortunately these new Nurse Grads are ill equipped to teach the ancillary staff and supervise proper cleaning as they are barely able to cope with their own duties.  While they might not yet possess reliable qualities with regard to backing up the Medical team, they could easily learn if more experienced Nurses returned to the workforce to train them properly.  Unless the current unhealthy situation changes more Nurses will join the exodus as Nurse burnout is swift under such intolerable extremes.  If we do nothing, then even rawer recruits will soon take the place of the last remaining tenured staff to make the clinical areas even more marginal and unsafe for patient care.  This is disastrous for patients: unsafe care, higher infection rates, a greater potential for avoidable Medical errors and longer periods of abandonment with fewer qualified staff on duty.  

This also means receiving Medical treatment from an exhausted Doctor who is running on empty; another accident waiting to happen.             

         While exploiting Doctors in training continues to facilitate Deliberate Negligent Understaffing this dangerous trend will continue. How much do Residents benefit by becoming familiar with pushing stretchers and what can they possibly hope to learn when they are barely able to remain awake?  We are sabotaging vital elements of their training experience, while leaving them vulnerable to making serious mistakes that will torment their consciences just as they start into their new career.  Doctors do not operate in a vacuum, they need reliable backup with diligent patient monitoring, but they must also be relieved of the unskilled tasks that eliminate their only opportunity to rest while on duty.          

         Teaching Hospitals must do more than just provide the barest minimum token number of bunks in a remote on-call room relegated to an obscure section of the Hospital too far from high stress clinical areas for any practical use.  Call rooms do not have to accommodate cumbersome conventional beds and could be far better equipped with ultra comfortable recliners making more efficient use of the space.  A Company called MetroNaps  have developed a specially designed sleeping pod for “power napping” called an “EnergyPod” that would be ideally suited for use during long periods on-call.  Additional equipment could be installed to facilitate note dictation while relaxing prior to taking a nap.  Doctors could carry a pass key to enter these quiet rooms for periods of rest that could be easily monitored and recorded to ensure that they got sufficient nap time during lengthy stints on duty.   

We monitor the rest periods of long-haul Truck Drivers, to ensure that they drive safely, and Airline Pilots, insisting that they must be fit to fly, but we ignore the sleep requirements of Medical personnel at our peril as it is costing lives.           

         Other employees among the Hospital staff might also request access to the call room or be ordered by a supervisor to take a nap if they demonstrated the need for rest.  Current Medical facility policy penalizes those who attempt to sleep while at work even when they are on a scheduled unpaid break period.  We can mandate overtime and force Nurses to take a double 16hour shift, but there is no responsibility to insure that they are sufficiently rested or fit for duty, despite obvious signs of fatigue!  Following an exhausting 12-16hours on task a tired employee might need to take a brief opportunity for a nap before driving home since serious accidents have occurred due to Medical staff getting behind the wheel of a car when they were not fit to drive. However, while Medical facilities are not considered negligent for ignoring this known risk, eliminating the dangerous potential of falling asleep at the wheel is not a well established priority. Proactive efforts to combat fatigue among all Medical staff do not end with facilitating the delivery of safe patient care while on duty; we must include responsibility for ensuring that they are able to drive home safely without causing an accident.   

“Never Create a Second Victim”  is a core principal instilled in all EMS and Rescue workers. This priority to avoid placing ourselves in any unnecessary danger also requires us to pay vigilant attention to our own ability to function safely by maintaining personal fitness for duty with regard to rest, hydration, nutrition, etc.  The continuing exploitation of Medical staff represents a completely avoidable, unconscionable level of negligence that risks creating multiple victims!        

         All Medical facilities would benefit from a proactive policy that recognizes and deals with staff fatigue, but this is especially relevant for Doctors in training who are also attempting to learn at the same time.  This will reduce the likelihood of unnecessary Medical errors and ensure that key employees are ready to face a genuine emergency refreshed and alert: this is a frequently overlooked vital component of emergency preparedness with regard to Medical staff. The suggested radical change of attitude regarding rest requirements is precisely the type of proactive strategy towards fatigue that constitutes routine practice for all safety conscious Captains at sea, but it is long overdue for implementation within the healthcare industry.  On passage we cannot risk having any crew member fall asleep while on watch during a time period where we are completely reliant on their vigilance: a serious accident or collision might occur.   

At sea no one has ever needed to wake me up for my watch: I wakeup automatically.  Ashore I never use an alarm clock. I rely on these indicators to reassure myself that I am getting sufficient sleep to function safely and effectively.         

         Why are Medical staff not treated in a similar manner with due respect for their need to remain alert and focused on the safe care of their patients?  Why do Medical facilities prefer to torture their Doctors in training with endurance marathons in critical clinical areas when a nap as brief as 20 minutes within a sleeping pod like the one below would help them to recharge and recoup mid shift?

                         Authorized by & Created for MetroNaps to provide public information

 
ACGME should insist on more call rooms closer to clinical areas in addition to a proactive policy to remove the unnecessary workload created by Deliberate Negligent Understaffing. 

         Johns Hopkins Hospital was shocked to be called to account for breaking the work hour rules monitored by ACGME, after Troy Madison exposed the truth, but do these rules go far enough to ensure that Doctors in training get proper rest?  ACGME can no longer trust teaching Hospitals to provide sufficient staff to safely complement or complete their obligations with regard to the Medical team as a whole.  

         The current situation is in urgent need of change,So what can ACGME do to help turn this dangerous situation around? It is time for mandatory staffing minimums for Nurses, ancillary staff and even cleaners as proposed in the list of C.U.T! Campaign Goals.  Without meeting these minimum staffing requirements and instituting vital mandatory safeguards no facility should be able to obtain ACGME accreditation as a teaching Hospital.  

         These sanctions might sound harsh, but teaching Hospitals must take proper responsibility for genuinely facilitating the learning process and this is not accomplished on zero sleep.  Teaching facilities that fail to employ sufficient Nursing and support staff, exploit those attempting to learn, and neglect to provide necessary sleeping arrangements, do not deserve the privilege of training the next generation of American Doctors.   

A prestigious reputation for Medical excellence does not negate the obvious danger of ignoring important issues like fatigue! 

         The situation here in the UK, where I now live, might be even worse as reported in this piece that describes a widespread trend towards the elimination of on-call room in NHS Hospitals: http://www.aagbi.org/gat/gatpage/docs/2006/may06.pdf   Please leave your comments. 

                                    

                                                                  ###

 

At both of the Hospitals where I worked, first in the ER (A&E) then in Surgery, the survival instincts that had saved my life so many times at sea were immaterial to unimaginative Managers focused on cost-containment. They felt threatened by any suggestions or creative input: I was removed from my OR job by an untimely and unjustified dismissal.  So now, I Blog! 

Advertisements

January 7, 2008

THE “GOLDEN HOUR” IN TRANSIT? – PROPOSED NHS “RESTRUCTURING” TARGETS A&E AND MATERNITY CARE WITH DANGEROUS CUTS THAT WILL COST LIVES.

The Golden Hour” in Emergency Medicine refers to the critical time frame following a serious or multi-system Trauma where intensive rapid intervention through definitive care in Surgery is vital to the patient’s chances of survival.

         This critical time frame, know as the Golden Hour, has governed American EMS, (Emergence Medical Services) planning and preparedness by dominating decision making regarding their complex nation wide network of Trauma response coverage for decades. It has remained the cornerstone of all EMS training throughout the US.  NHS restructuring touting potentially improved Trauma survival statistics, endorsed by this highly successful overseas model, must acknowledge the core principals of rapid intervention on which it was based.

American EMT’s and Paramedics are taught that their portion of the “Golden Hour” should be confined to ten minutes or less at the scene prior to rapid transport!  

But, will Government “restructuring” plans for the NHS ignore the necessary logistics of rapid transport?

        The Golden Hour concept evolved from US military experience, primarily during the Vietnam War.  The catastrophic Trauma of battle; multi-system failure; damage to vital organs; massive internal bleeding; extensive areas of burned tissue; shattered or severed limbs: in such cases nothing replaced immediate Surgical intervention.  Unable to withstand the abnormal stresses imposed on vital systems by such serious defects, the body deteriorates extremely rapidly: a process called decompensation. It was preventing the onset of shock with rapid decompensation that first dictated the urgency of transporting Trauma victims to a place where definitive Surgical care was available.  As a military Surgeon the late Dr. R. Adams Cowley recognized the significance of rapid transport to definitive care, noting that the chances of survival dramatically decreased following delayed Surgical intervention.  Credited with promoting this strategy, Dr. Cowley coined the term “Golden Hour” to describe what has now become a widely accepted critical time frame for Trauma survival. 

          Dr. R. Adams Cowley went on to develop the first clinical shock Trauma unit in America. This was made possible when, in recognition of his many years of groundbreaking research, the Army awarded him a $100,000 contract to study the impact of shock. The initial two beds became four as staff were specially trained and equipment installed by 1960.  Patients referred by other Doctors were ominously close to death when they arrived and the unit gained a morbid reputation as the “Death Lab.”  Dr. Cowley and his team focused on this critical phase of treatment and proved that, with their rapid intervention and highly specialized skill in operating procedures, a few could be saved. In pioneering this concept Dr. Cowley identified a “Golden Hour” between life and death where critically injured patients demonstrated a poor prognosis for survival if treatment was delayed beyond the first hour. He believed that even when death was not immediate following delayed intervention, irreparable damage predicted the patient’s inevitable demise.

Dr. Cowley described shock as:  “A momentary pause in the act of death” 

             His goal was to reverse this seemingly irreversible process.                       

University of Maryland Medical Center – R. Adams Cowley Shock Trauma CenterFor more information Visit:       http://www.umm.edu/shocktrauma/history.htm  

  

Some still  question the validity of a rigidly defined  “Golden Hour,”  but their doubts about this specific time  frame do not  negate the  core principals of  rapid  Trauma intervention.    In reality, to imagine that any critically injured Trauma patient might benefit from a delay in treatment necessitated by a protracted road journey is patently ridiculous! 

WORLD WAR I DATA SUPPORTING THE GOLDEN HOUR IN EMS

Above data found at:    http://www.trauma.org/archive/history/resuscitation.html 

The current focus on proposed restructuring dominates vital Trauma funding for the NHS, but attempts to selectively cherry pick the information that best suits drastic Government cuts!

     Well-documented time-critical treatment considerations exist in certain cases: 

  • Stroke Patients:  A risk/benefit 3 hour window of  opportunity exists  where the  risk of  major bleeding complications  is  outweighed  by  the  benefit  of  administering  clot-busting  drugs.

  • MI  (Myocardial  Infarction)  –  Heart Attack Patients:  “Time is Muscle;”  rapid  intervention  to  define and stabilize fatal  arrhythmias can prevent  sudden Cardiac death.  Reduced  mortality is time dependant  with a direct relationship between  time-to-treatment and the success of reperfusion  (restoration  of  blood  flow  to  the  heart).

      However, it is overly simplistic for the Government to selectively cite any one aspect of emergency response because in reality Medical emergencies are extremely varied. True, life saving rapid access to defibrillation can be performed by Ambulance crews, or an even less experienced layperson using a fully automated defibrillator (AED). 

So what else can we realistically expect from our trained Paramedics? 

While Ambulance crew can administer fluids in transit, they cannot combat the massive blood loss that requires definitive care in Surgery: they must “Scoop and Run.”   

        Trauma  injuries often require immediate  Surgery and  delayed access to definitive care will severely  compromise the possibility of survival.  Perhaps the most vulnerable constituents to be impacted by proposed cuts to emergency services at NHS Hospitals are those who don’t yet support the current Government?  Their voices will remain unheard for now as they are still far too young to vote for anyone!  The fact is that children decompensate far more rapidly than adults.  Too late to wish that we had opted to salvage the local A&E when the tragic death of a toddler hits the headlines or a fragile premature infant fails to survive the ride to definitive care elsewhere after a complicated delivery inside an emergency vehicle in transit.

HOW DOES EMS RESPONSE COMPARE THROUGHOUT THE EUROPEAN UNION?   PowerPoint Presentation           Review the European Emergency Data (EED) Project – EMS Data-Based Health Surveillance:  http://ec.europa.eu/health/ph_projects/2002/monitoring/fp_monitoring_2002_a1_frep_07_en.pdf

                                                                                                              

If the Medical Emergency or Trauma patient reaches a critical “Tipping Point” in their Medical crisis while still in transit the highly experienced team at a remote “Center of Excellence” Hospital will be too late to compensate for the damage!   

SO WHY IS THE NHS CONSIDERING  A&E  AND MATERNITY DEPARTMENT CLOSURES?

I fail to understand how this could possibly be in the best interests of tax payers served by the Hospitals where these drastic closures are scheduled to take place, especially in the light of important new research evidence.   

DIRE WARNINGS FROM A NEW REPORT:   Sheffield  University  Researchers  found that the longer the Ambulance journey took the more likely seriously ill patients would die.  

        Researchers  assessed an increase in the  risk of death in  relation to  distance traveled to  receive care:  for every 10km it rose by 1%.  In a study of rural, urban and mixed areas in England made between 1997 and 2001 over 10,000 life-threatening calls to four Ambulance services were reviewed.  People with breathing problems had a 13% chance of dying if the distance to Hospital was between 10km and 20km, but this increased to 20% if the distance was 20km or more.  Because a longer journey time to Hospital appeared to result in an increased risk of mortality for certain patients with life-threatening emergencies, researchers argued that closing local A&Es might increase the number of deaths among this small cohort of patients. The conclusions drawn from the Sheffield University Study were published in the Emergency Medicine Journal, calling into question Government proposals to close community Emergency Departments in favor of fewer, more specialized centers.                 For Links to access this report GO TO:

                                                   http://emj.bmj.com/cgi/content/abstract/24/9/665 

        Dealing with a chronic life-threatening condition in a youngster who might have needed to make frequent trips to local A&Es in the past is a constant emotional drain for already overwhelmed families.  Parents who have suffered the anguish of seeing their child struggling for breath during rapid emergency runs to the nearby Hospital cannot imagine the justification of risking any child’s life by prolonging this torturous journey to accommodate Government cuts!  They often become very familiar with the staff and feel confident in the care delivered locally.  They harbor justifiable concerns over whether axing vital services at community Hospitals will seriously endanger their child’s chance of surviving a future incident.  With all the money being expended on our  NHS  these dutiful parents do not deserve any additional anxiety and  understandably they  want their  children  treated  close to  home to  facilitate regular visits  without  extended travel.     I sincerely doubt that the Government has bothered to consider how families will manage to visit loved ones who are sent to Hospitals many miles away from where they live.

CONFLICTING INFORMATION MIGHT AT FIRST APPEAR TO BOLSTER THE GOVERNMENT’S CASE…                      The National Confidential Enquiry into Patient Outcome and Death, (NCEPOD),                      Just released a scathing report criticizing the standard of Trauma care in the UK.

To download this report Go To:         http://www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdf 

       “We found that the  organisation of  pre-hospital care,  the trauma team response,  seniority of  staff involved and immediate in-hospital care was deficient in the majority of cases,”                                                                           said NCEPOD Clinical Coordinator, Dr.George Findlay.                                     The number of patients seen has a direct bearing on the experience and ability of clinicians to manage challenging cases,”   he added.

       Findlay  suggested new  protocols  allowing  Ambulances to  bypass the  nearest  Hospital  seeking more specialized treatment elsewhere; however this provision existed back in 1963 when following my mother’s car crash a severely injured fellow passenger was rushed to East Grinstead under police escort. I doubt Findley intended to endorse the wholesale downgrading of so many regional A&Es across the country. The enquiry found that NHS Medical staff often failed to appreciate the severity of illness, displayed little urgency in caring for patients, or made incorrect clinical decisions; this clearly demonstrates the need for significant improvement through additional investment in training. 

        In US  Trauma Centers like  Ryder at  Jackson Memorial,  a teaching  Hospital in Miami, besides the Medical Director and a select core of veteran Trauma specialists, most of the  Doctors leading Trauma teams are completing their Trauma rotation, not necessarily with years of experience handling hundreds of complex cases. A Trauma fellowship candidate spends a longer period working within a teaching facility like Ryder in preparation for a career elsewhere in the country leading the team at another Level One facility.   A consistent standard  of Trauma preparedness is sustained among the regular Nursing staff and Techs who must all maintain at least ACLS (Advanced Cardiac Life Support) and often PALS, the Pediatric equivalent, as do a reasonable percentage of all ER staff.  Short certification courses, like ACLS, PALS or PHTLS, (Pre-Hospital Trauma Life Support), taken on a regular basis, are certainly a vital, affordable training option that must receive sufficient funding.  The proposed centralization of Trauma receiving units in the UK might well attempt to deny the need for this essential  training regimen or cruciaL disaster preparedness among staff at downgraded local facilities.

 

This current Government is setting the stage for disaster by creating an extremely dangerous situation where it will be logistically impossible to contend with a serious Mass Casualty situation with so few trained personnel at only a very limited number of selective locations. 

          I question  why we  should  accept  that  what is  often the last  remaining  Hospital in a  sizable town with a  rapidly expanding population cannot have an experienced Trauma team on call with the necessary organization and support structures, especially where they already exist today.  Despite numerous local Hospital closures to achieve centralization of care, the Government is seriously contemplating diminishing access even further, rather than responding appropriately to the demand for more training among personnel. Commenting on the report Dr. Jonathan Fielden, Chairman of the BMA (British Medical Association) Consultants’ Committee, confirmed that it demonstrated how Consultant expansion was vital to improvements necessary to reach the “Gold Standard” for Trauma. The BMA endorsed NCEPOD recommendations for Consultant led teams in the management of Trauma patients to achieve the best survival statistics.  Lack of sufficiently qualified Consultants within the NHS to provide coverage for local Hospitals and insufficient experience dealing with the complex injuries sustained in a major road accident were cited as the main reasons for substandard performance.

This is difficult to reconcile after witnessing our eager young Doctors marching in protest over lack of placement opportunities in this country!  Why aren’t we targeting fulfilling this need for more trained Consultants in Emergency Medicine rather than closing existing A&Es?

         British  survival  statistics  do not  stack up well  compared  to  other  industrialized  nations   like  the  US, but does this justify the concept of Trauma specialty centers funded by closing A&Es?  This is misguided; it requires a lot more thought before we rush to judgment regarding how to revamp EMS throughout England. Analyzing both practices and survival statistics in the US makes sense as we work towards achieving that “Gold Standard” for Trauma.  America has a network of dedicated Level One Trauma Centers, some of them highly sophisticated stand-alone Trauma facilities, plus Emergency Departments at most local Hospitals.     

        Major logistical differences that have dictated how this system was organized in the US should not be ignored.  There are vast distances to be taken into consideration in the US as they try to provide a safety net that does not exclude communities in sparsely inhabited remote rural areas of the country.  However, even relatively small towns in rural America still have a Hospital with an Emergency Department, and that isn’t solely because it’s the only resource for the uninsured.  With more guns in circulation, there is a much higher incidence of violent crime and penetrating Trauma in the US, but we are starting to see more of these types of injuries in the UK and we should prepare staff to handle such cases.  Americans insist on the independence of vehicle ownership, in some remote areas it’s a real necessity, but many people still drive their car well beyond the point where they are capable of driving safely.  America also has an alarmingly high rate of heart disease so rapid access to definitive Cardiac care is a big priority in EMS funding.       

       Undisputedly the dynamics are quite different, but the US has not achieved their success by closing Emergency Departments in an “either/or” fashion as is being suggested in the UK.  Improved results for Cardiac Arrest have not been accomplished by reducing the number of specialist treatment  facilities.  Seattle, Washington  achieved an  impressive record by establishing the “Chain of Survival” with a combination of ACLS trained Hospital staff; excellent Paramedic manned Ambulance fleets; a comprehensive Air Ambulance service for rapid transport from rural areas; Automatic Defibrillators (AEDs) in shopping and community areas; plus public sector awareness and training.  AEDs can enable relatively inexperienced citizens to provide early, life saving, intervention even before an Ambulance crew arrives on the scene, but that doesn’t mean critical patients should then endure an unnecessarily protracted road journey.  

So how will the NHS improve Emergency Services to stack up against this US model? 

  • Will there be more ACLS trained Hospital staff or will funding such training focus on “Super Centers” alone?  
  • Will the Government fund more highly trained Paramedics in greater numbers for local Ambulances?  
  • Will the Government take over the funding of Air Ambulances for rapid transport to Centers of Excellence?  
  • Will private businesses and public spaces provide AEDs for use in Cardiac Emergencies?
  • Will there be greater emphasis on funding awareness and training of ordinary citizens in the community?

Establishing so called “Centers of Excellence” does not justify any significant cuts on the local level or a drastic reduction in funding for EMS personnel at most local Hospitals, as proposed by the Government, since all of the above points are necessary to achieve genuine success.  

         In the US the majority of standard emergency cases are still directed towards regular ERs even in urban areas where several ERs and possibly more than one Trauma Center serve a dense inner city population.  Severe Trauma cases benefit from rapid transit by Ambulance if they are within close proximity of the Hospital, but for greater distances they are flown by Air Ambulance to the nearest Trauma facility.  The use of helicopters in the US is dictated by the vast distances that must be covered, not by the absence of trained emergency personnel in all but the largest of towns and cities across the country!

                                                                                           

The Government is choosing to endorse successful aspects of the American Emergency Management system while ignoring inconvenient logistical details like the additional cost of using Air Ambulances for rapid transport or suffering the consequences of serious delays on the road.   Taking the “rapid” out of “rapid transit” will ultimately cost lives!

        Rapid transport is the key to remaining within the Golden Hour that has dominated the emergency response system in the US for decades.  American Level One Trauma Centers would not have such excellent statistics on saving lives if the precious time critical to the survival of patients with catastrophic injuries from a car wreck was squandered just getting to the facility!

Will NHS restructuring just create a logistical nightmare with regard to patient transport?

       The shift in focus from locally managed Trauma coverage to centralized treatment in heavily touted “Super Centers” will require more Ambulances, with additional trained personnel, to cover longer journeys by road. It will also increase the burden on Air Ambulances with more frequent use of rapid transit from areas where the current A&Es are scheduled to close.  Helicopters are prohibitively expensive to operate, but is the grater reliance on air lifting patients to Super Centers even being taken into account? In the UK Air Ambulance services are managed differently depending on regional funding. In England and Wales they are funded by various local charities targeting the specific coverage needs within each region; in Scotland the national parliament agreed to state funding. Will charities be expected to somehow cope with the increased demand for their services or will Government funding take over paying for the growing need?  

         While America’s minor rural Hospitals still maintain an ER and Maternity services, this Labor Government is proposing to means test sizable towns throughout England to selectively close existing A&E, Maternity Departments, or both, based on current population density that marginalizes the impact of immigrants.  When I was a child there were four Hospitals in my home town of Hastings with an A&E, plus a choice of two local Maternity units and a separate Hospital in Rye. Despite the campaigning efforts of Sir Paul McCartney, Rye Hospital closed.  Only the Conquest Hospital remains, now ravaged by threats to close our last local A&E and limit Maternity care.  Meanwhile the population has mushroomed with a huge influx of refugees and eastern European immigrants, but this downgraded access is disgracefully portrayed as improving the standard of local services.

                                                                                                                                                                                                                                                             

Please visit Hastings “Hands of the Conquest” Campaign:  http://www.handsofftheconquest.org.uk/                                   For a list of Links to NHS Hospitals threatened with closures GO TO:   http://www.savethedgh.org.uk/   

        Our  Government is still  trying to ascertain  the exact number of people  entering the UK and  their estimates remain way off the mark.  Citizens worry about the impact that uncontrolled mass immigration is having on the delivery of local services like Medical facilities. Towns with widely underestimated numbers of undocumented migrants are judged to have insufficient population density to warrant keeping their local A&E.  The authorities that feel the most overwhelmed by recent waves of immigration are still obliged to provide public services no matter how they feel about the question of whether migrant workers benefit the economy.  For most UK residents it is not the arrival of people from overseas that concerns them it is the harmful impact when critical services like Medical care become overwhelmed.  

         This is hardly the time to start  inappropriately downgrading critical aspects of the infrastructure like our Emergency Departments, while we still have no real control on how many more people will arrive from overseas.  We should instead respond to the growing demand on local services by investing in insuring that adequate E&A and Maternity provisions are put in place at local Hospitals in anticipation of increased population growth as we continue to reap the benefits of the boost foreigners bring to our economy. 

 IS THIS ABOUT PROMOTING THOSE IMPRESSIVE “CENTERS OF EXCELLENSE?”

NO:  IT IS ALL ABOUT COVERING THE SHORTFALL IN MISMANAGED NHS FUNDING!

         While the unhealthy emphasis on “quotas” and the demand for religious monitoring of waiting times continues to divert precious resources towards redundant paperwork, an excessive number of pen pushers and unnecessary administration costs, Hospital patients will repeatedly suffer the consequences of depleted care.  What I refer to as “Deliberate Negligent Understaffing” of Hospital units is now no longer confined to greedy Corporate Healthcare giants in the US, it is a UK problem too.  With the huge increase in funding that has been pumped into the NHS, British tax payers deserve significant improvements in services not a dangerous reduction in local access to care. 

        Closing an Emergency Department has a knock-on affect that heralds further problems with sustaining other clinical units.  Surgical patients who normally enter via the A&E are treated elsewhere, so the Surgical Department is then downsized; other clinical areas are impacted and suffer a similar fate, threatening the viability of the Hospital.  When it becomes too late to reverse the damage of closing the ED, what will our Government tell us if those precious “Centers of Excellence” do not fill the void?  What excuse will they give when Super Centers fail to receive the necessary Government funding or become too overwhelmed to function as well as expected.  Will they too be stymied by cost cutting, crippled by understaffing or buried in the redundant paperwork of painstakingly nitpicking the details in typical NHS fashion?

                                                                                                     

The potential logistical complications and the  inevitable  consequences could be devastating.   We need to think very carefully and proceed with great caution before removing existing services at regional Medical facilities as we could pay a high price in human suffering and it will be extremely costly to undo the damage.

                                                                              

                                    ###                                   

Text in Blue: Concise definitions and data obtained from Wikipedia or other sources included in the cited Links.

WHAT QUALIFIES ME TO VENTURE AN OPINION ON THIS SUBJECT?

         Despite frustrating complications that have blocked my transition into an equivalent job role working within the NHS, on the subject of Emergency care and the rapid treatment of Trauma victims I feel more than qualified to render an informed opinion regarding the A&E “restructuring” proposals for the UK. I speak from years of experience working within the American EMS (Emergency Medical Services.)

         I was originally trained as a Wilderness and US National Registry EMT, (Emergency Medical Tech).  I spent three years working at the second busiest ER (A&E) in the America, Jackson Memorial Medical Center in Miami.  On weekend night shifts I joined the Trauma Resuscitation Team at Ryder Trauma, Jackson’s stand-alone Trauma Centre, a second generation state-of-the-art Trauma receiving facility in Florida that accepted critically injured patients from Miami, the Florida Keys, the Bahamas and the entire Caribbean.  I also trained as a Disaster Response Volunteer with the South Florida D-MAT (Diisaster Medical Assistance) Team, a reservist multi-disciplinary response unit, “Federalized” for deployment to provide Emergency Medical Services following a major national disaster like Katrina.

         After training as a Surgical Technologist I moved to Baltimore, Maryland where I worked at Johns Hopkins, another Level One Trauma Center.  My second specialty area of training encompassed providing care to Trauma victims in a city with an average homicide rate of over 300 a year!  During my five years in the OR (Theatre) I dealt with the devastating consequences of urban violence as Hopkins was the principal receiving facility for “Penetrating Trauma” (gun shot and stabbing victims).  My regular assignment working busy weekend nights during my last two years at Hopkins dictated my main Surgical specialty: Trauma and Transplant.

       I worked as a Disaster Relief Medical Volunteer after Hurricane Andrew in the US and for six months in Aceh, Indonesia after a massive tsunami devastated Asia.  In addition to assisting in Surgery at Cut Nyak Dhien Meulaboh Hospital, at the request of top functionaries at WHO and UNDP, I wrote the comprehensive report:  “Capacity Development of Emergency Preparedness Planning for Meulaboh.”  Because of my ongoing interest in Disaster Relief I have familiarized myself with every aspect of emergency response from the sophisticated network of rapid response in the US to the necessary practical compromises of a field Hospital after a major natural disaster.  

November 2, 2007

SLAYING THE NHS SUPERBUGS – Mind the Dif!

         It is very alarming to hear about the problems NHS Hospitals are experiencing in dealing with “Superbugs;” this is very worrying on top of all the threats of curtailed local A&E and Maternity services.  These two problems might not at first appear related in any way, but in reality they both stem from the inappropriate squandering of Government funding.  Through this Internet Blog I have been very outspoken with regard to exposing factors that have exacerbated similar problems in US Hospitals, notably  what I call the “Deliberate Negligent Understaffing”  of Medical facilities that prompted me to create the “C.U.T!” Campaign to “CONTROL UNDERSTAFFING TODAY.” 

        Both my family and I have always received an impeccable level of service and exemplary care from the NHS.  It is hard for me to talk with any real authority about the inner workings of the British system as I do not work in the NHS, but from what I have been told a disturbingly similar pattern has emerged here in the UK.  I have several close family members and friends working within the NHS at various UK Hospitals and it certainly appears that the NHS is eagerly following the disastrous US model for bloated top heavy Management and understaffing of basic care providers, Nursing and cleaning staff.  Ultimately the NHS is hemorrhaging money on those high wage earners in Management, but instead of addressing the real problem the Government orders a restructuring of essential services to reduce local access to care.   We all know that even if this crazy strategy was clinically justifiable those infamous “Super Centers” would still be ham-strung with the same budgetary constraints caused by top heavy Management.

Fact:    in Healthcare you cannot do more with less! 

        It is simply ludicrous to try and pretend that Government targets don’t impact the NHS Trust’s ability to deliver quality care. All initiatives that generate paperwork require additional administrative staff to handle the paperwork; this is an unfortunate fact of life. “Targets” might look good on paper, but the issue is that there is far too much paper and the burden of managing that excessive quantity of paperwork is sinking the ship.  The consequences have a powerful impact on the staffing budget within the NHS, as financial resources must be diverted to cover the cost of those administrative personnel often at the expense of Nursing and cleaning staff.  You just cannot do more with less.  Fewer Nurses mean less bedside care and less stringent supervision of assistive personnel; fewer cleaning staff mean lower levels of sanitation that allow Superbugs to thrive on unclean surfaces.

           The use of contract cleaners might at first appear to save money, but this has introduced an entire workforce of minimum wage earners who are not in the least bit invested in maintaining safe, hygienic patient care and are not trained in medical grade cleaning. Meanwhile money is squandered on unnecessary contract commission fees.  Staffing constraints have been eroding the quality of Nursing too with the ratio of Agency temps steadily on the rise.  Although the Agency Nurses are often highly qualified they will always be at a disadvantage in the workplace.  They may not know where essential items are kept plus they are unfamiliar with their coworkers and the hierarchy of responsibility among other staff. It is unreasonable to expect stringent supervision of unfamiliar assistive personnel from an Agency Nurse hired by the shift!  This is one reason that cleaning standards have seriously deteriorated.  Bring back Matron! The NHS has recently made a commitment to increase the number of Matrons, a very wise decision.  Any money paid to outside contractors or Nursing Agencies reduces the cash available to pay directly to staff and reduces both the number of staff and the quality of their commitment to their job. 

      From an employment perspective Hospitals require 24/7 staff coverage so the necessity for flexible working hours already exists; this is ideal with regard to additional obligations, study or internal training. Entry level jobs in Healthcare offer a unique opportunity for unqualified school leavers and unskilled Job Seekers to obtain employment that can lead to potential on-the-job training. This investment in internal training schemes should become a new NHS priority as it creates a powerful incentive to do quality work to be considered for further training and job advancement.  This will promote a genuine pride and commitment from employees that outstrips the miniscule savings of cheap high turnover contract laborers. 

       While New Labor proudly touts the money that has been pumped into the NHS, far too much has been squandered on bloated administration costs, increasingly top heavy Management and expensive consultancy or commission fees.  What really outrages the public is when an obscene payout is obtained by a departing Manager who has been removed or forced to resign due to a public outcry over their gross incompetence! Departure bonuses are adding insult to injury, especially at Hospitals like the Conquest in Hastings that was threatened with closure of the A&E and reduced Maternity services just as a former head Manager left with a huge payout.   

     

HOSPITAL ACQUIRED (NOSOCOMIAL) INFECTIONS

Nosocomial Infections can Result from the following Causes

BREACHES OF INFECTION CONTROL PRACTICES:                         e.g.   Improper hand washing or a reluctance to use gloves on all occasions.

BREACHES IN STERILE PROCEDURES:                                        e.g.   Improper donning of sterile gloves for minor procedures like the insertion of a Foley Catheter.

INADEQUATE CLEANING OF ALL ENVIRONMENTAL SURFACES:     e.g.   Less obvious targets may get ignored in the rush; this often includes Computer keyboards and phones.

IMPROPER STERILIZATION OR INSTRUMENTS AND EQUIPMENT:   e.g.   Autoclave sterilization of Instruments provides for stricter controls than Bronchoscopes or larger items of equipment like an operative microscope or a C-Arm.

HOSPITAL STAFF WHO COME TO WORK WHEN THEY ARE SICK:   e.g.   Unfortunately, this is alarmingly common in the US where staff are actually penalized for calling in sick! I do not know if this disastrous tactic has been implemented or even considered yet by the NHS, but it is a very bad policy.

      It is overly simplistic and insulting to blame the current sharp rise in the infection rates on lazy, careless Nursing staff, improper hand washing or a reluctance to use gloves on all occasions.  Medical staff need enough time to ensure that simple routine practices do not get ignored in the rush, while cleaning staff need training, supervision, and motivation as well as adequate time to do a thorough job.  Management have become so focused on doing more with less that the overstretched regular staff have no opportunity to do their job diligently and this has resulted in the increased infection rates and a higher incidence of unnecessary Medical errors.

        One disingenuous initiative required staff to wear special buttons with the words: “Ask me if I have washed my Hands?”  Nurses resent these top down campaigns, and rightly so, because they consistently ignore the single most important issue: lack of time due to understaffing.  In reality it would be more appropriate for the buttons to say: “Ask me if I had time to wash my Hands?”   While Deliberate Negligent Understaffing is ignored Nurses remain so overstretched and overworked they barely have the time to run to the toilet, so how are they expected to prioritize routine infection control practices?         

        One example of sterility botched in the rush, is the fairly common procedure for donning sterile gloves prior to Foley Catheter insertion.  Inadvertent contamination is only avoided be strict adherence to Sterile procedure in order to prevent Urinary Tract Infections, UTIs.  There is far more likelihood of contamination when Nurses are in a tearing hurry or distracted by a multitude of other duties that demand attention.  This has resulted in an increase in the number of Urinary Tract Infections among Hospital patients; an unnecessary consequence of inattention to sterile procedure. In the US the ongoing expenses related to avoidable infections that are caused by procedural errors or acquired during treatment, including UTIs, are on a list of targeted billing charges that will no longer be covered my Medicare. Time is an important factor in reducing these unnecessary infections, but Management are still putting the squeeze on Nurses and disciplining them for the inevitable lapses that result from overwork.  Patients left in soiled bedding for hours on end or not turned to reduce the chance of bedsores; all these oversights are unfairly blamed on “lazy Nurses” who have no say over the chronic understaffing of clinical areas.

          Although there are still a few stubborn old-timers who insist they cannot start an IV while wearing gloves, on the whole compliance with universal precautions is getting much better.  However, the real danger is when gloves worn during a procedure are not promptly removed as soon as the patient contact is finished.  It is pointless telling staff they shouldn’t do this if the reality of severe time constraints and their excessive workload make such lapses inevitable.  Computer keyboards and phones have become the unconscious magnate for bacteria because overworked Medical staff will frequently go directly from the patient to the documentation point or phone without removing contaminated gloves.  This carries bacteria from the patient to a place that is generally ignored by cleaning staff.  Contract cleaners or untrained entry level cleaning staff tend to focus on just the visible dirt if they are not specifically taught about the transmission of bacteria on work surfaces.  These staff need more comprehensive training, so that they fully understand the significance of what they are asked to do and how they are expected to do their job. 

         A Nursing assistant cleaning the OR (Operating Theatre) might not understand the infection risk presented by a fly within the Sterile Core.  But, something as miniscule as a fly can still transport bacteria from Fido’s last poop to the sterile instruments in Surgery!  Untrained cleaning staff might not understand why infected material must be removed promptly from the OR (Theatre) or why containers for hazardous waste must be confined to the Hopper Room.  They may think that this stipulation is just a petty Hospital rule, but it is the responsibility of the Hospital to train cleaning staff properly and supervise their work.  When these staff do not make the connection between the full to overflowing dumpster left in the hall way alongside a piece of equipment like a C-Arm that will go into Surgery we risk life and limb.  That C-Arm could be used during a case where the insertion of an orthopedic implant would make the patient highly vulnerable to a very serious risk of infection.  Ignorance, inadequate supervision and poor Management is no excuse for the unnecessary infection or potential amputation that could result from a seemingly unrelated oversight like this. 

        Agency Nurses who do identify problems with compliance in the facilities they are assigned to on a purely temporary basis might not know who is responsible for assistive staff or getting clean up taken care of.  Agency staff are only working because too few regular staff are on duty, so who is responsible?  Agency staff unwittingly provide a convenient scapegoat; when things go wrong it is easy to divert the blame away from regular employees or Managerial incompetence. While oversight remains minimal, genuine accountability is in jeopardy.  All too often potentially serious infection control incidents are overlooked in the hectic pace of shift work, but this situation is exacerbated by reducing the number of regular, full time staff.  All Medical facility cleaning staff need proper supervision to insure they are doing a proper, thorough job and providing Hospital standard levels of sanitation, however expecting overstretched Nursing staff or Agency temps to keep an eye on them during their frenetic working day is expecting the impossible.  Ultimately, Management is responsible for making sure that there are enough regular trained staff on duty in their clinical area for every shift.  When they understaff an area for financial reasons they risk the disastrous consequences of unnecessary infections and serious Medical errors.

      The above examples refer to incidents observed in US Hospitals, but they could just as easily occur in NHS facilities. In the US the drive to cut costs with Deliberate Negligent Understaffing of clinical areas has seriously backfired with the increase of Hospital acquired (Nosocomial) infections that often require prolonged Hospitalization and cancel out any savings benefit.  Another disastrous strategy was to penalize staff for calling in sick.  Each time someone calls in sick it is considered a separate “Occurrence,” but more than three such “Occurrences” in the same calendar year place an employee in the disciplinary process requiring counseling by a Nurse Manager.   The “Occurrence” policy was introduced to discourage unnecessary absenteeism, but has resulted in sick staff treating very sick vulnerable patients and placing those patients at increased risk.  A serious outbreak of a virulent new strain of virus could gain a serious stranglehold on the US Healthcare industry before inoculation ever really got underway, because sick  Hospital workers would still feel compelled to come to work. In America this deeply flawed policy has created yet another weakness in a society with a myopic focus on money.

        Can a Nurse with a raging migraine headache really cope with a dozen screaming newborns as the American TV advert for one medication suggests?  Does this disastrous policy provide safe patient care or just larger profit margins by reducing sick pay?  Someone with a really bad cold should not be working in Surgery, especially treating cancer patients who have lowered immunity.  Despite violating well established protocol guidelines for managing infection risk among those who scrub into Surgery, US Hospitals adhere to a dangerous policy that forces sick staff to show up for work in the OR.  Worse still when Surgical staff all cram into an overcrowded locker room to change into scrubs they pass their germs on to multiple other coworkers. Management still think that treating illness as an unnaceptable conduct offence to be disciplined, rather than an infection risk to be avoided, is a great way to lower absenteeism and save money! 

     I do not know if similar warped sickness call in policies are used within the NHS, but it seems that whenever US Healthcare comes up with a disastrous idea, Britain rushes to emulate their mistake.  The 21 points that I identified in the list of priorities to CONTROL UNDERSTAFFING TODAY certainly include all of these issues that affect our ability to fight infection in Medical facilities.  I can only hope that if this set of priorities becomes part of US legislation, the NHS will be just as eager to rapidly take these issues seriously.  I would like to encourage British readers familiar with the NHS to comment here on the points I have made.  I would welcome a more informed contribution from someone more familiar with working here within the NHS.

September 25, 2007

UNJUST “AT WILL” FIRING LAWS

ABOLISH UNJUST “AT WILL FIRING” EMPLOYMENT LAWS:  AN IGNORED CONSTITUENTS OPINION ALMOST EXACTLY AS IT WAS SENT TO MARYLAND REPRESENTATIVES IN 2001.

A COPY OF THIS CONSTITUENT OPINION WAS SENT TO BOTH OF THE MARYLAND SENATORS AND TO CONGRESSMAN CUMMINGS BACK IN MID 2001. DESPITE FOLLOW UP CALLS TO THESE REPRESENTATIVES THERE HAS BEEN VERY LITTLE INFORMATION REGARDING THEIR CONSIDERATION OR ANY PROGRESS ON THIS IMPORTANT LEGISLATIVE CHANGE. SENATOR SARBANES OFFICE WAS RECONTACTED TO INQUIRE IF THIS CONSTITUENT’S OPINION HAD HAD AND BEARING ON “SOX” ACT, RE WHISTLEBLOWER PROTECTIONS PUT FORWARD BY SARBANES, BUT THEIR MAIN EMPHASIS WAS FINANCE AND GOVERNMENT EMPLOYEE PROTECTION. HOSPITAL STAFF STILL DESPERATLY NEED REAL PROTECTION

CONSTITUENT OPINION                                                                             pg.1. Constituent: Kim L. Sanders-Fisher
ISSUE: ABOLISH UNJUST, “AT WILL FIRING,” EMPLOYMENT LAWS.

New  Labor Laws are urgently required to provide basic standards of protection for both Union and non-Union employees. Businesses, especially the large corporations, will continue to take full advantage of the gapping holes in Maryland’s current system until stricter laws are enacted.

At Will Firing” Practices Severely Harm and Endanger Maryland Constituents.      

Maryland Companies are free to intimidate, coerce or finally remove anyone from the workforce for making a legitimate complaint: from vital public safety issues to gross negligence, fraud, or blatantly illegal practices. A hospital worker might ignore unconscionable patient endangerment, a secretary might turn a blind eye to shady dealings that defraud the public, a mechanic might never complain about substandard auto parts, a dishwasher may fail to contact the Health Department about a filthy, infested kitchen. The consequences impact all of us: a neglected patient dies; people loose their life’s savings; a bus crash kills innocent school children; an epidemic of food poisoning plagues the patrons of a run-down restaurant. All of these situations are potentially preventable when our ordinary citizens step forward to report a problem; however, the vast majority of workers genuinely fear persecution and the dire consequences of America’s flawed firing practices as applied here in the State of Maryland.

Whistle-Blowers are Effectively Silenced by Unjust,“Business Friendly,” Employment LawsFinancial Incentives Encourage “At Will Firing”  Practices in Maryland Businesses.

Unscrupulous Companies are further rewarded because here in Maryland they are legally entitled to just “write off” a percentage, or even the entirety, of accumulated vacation hours and other standard benefits, like health care or the vesture earned by tenured employees. I am sure that, on at least some occasions, this alone is sufficient financial incentive and a significant motivation for targeting diligent workers for removal or firing an employee without cause. The worker who accumulated vacation hours in preparation for a lengthy, well deserved, holiday suddenly looses her job; the diagnosis of a medical condition has to be abandoned after the, now less desirable, worker is fired; a staff member is falsely accused of “unsatisfactory job performance” just a few weeks short of becoming vested. This culling of the work force is only possible because in Maryland we do not require a person to be fired for cause.

At Will Firing”  Practices Negatively Impact the Entire Community in Maryland.

Maryland business Owners are also permitted to sabotage their former employee’s ability to find an alternative job or receive any unemployment. Keeping unemployment insurance low is an incentive for companies to block unemployment compensation after a termination. They can, and do, routinely delay desperately needed benefit funds even on occasions when they are subsequently unable to show any valid cause for the termination. By the time an employee is judged eligible for benefits the most disadvantaged of former workers have grabbed the first menial job available out of sheer desperation.

For the unfortunate victims of wrongful termination who might try to hold out for a suitable position with equivalent pay and benefits the simple phrase “Not Eligible for Rehire” is often sufficient to sabotage their prospects: they are thus penalized once again. The cruel stigma and ultimate degradation of being falsely accused is crippling, further impairing their ability to move on. They may be forced to abandon valuable scholastic and career goals thus becoming totally disillusioned by their powerless status in the work force to which they belonged. America’s “at will” firing laws have driven people into depression, addiction and criminal behavior; in rare cases these laws have led to suicide or a violent desire to exact revenge.

Ordinary citizens pay to support this corporate indifference while the entire community must share the burden of its dire consequences: we are all debilitated by these archaic employment laws

CONSTITUENT OPINION                                                                      pg.2. Constituent:  Kim L. Sanders-Fisher  

Condoning Laws that Permit Corporate Profiteering at the Expense of Workers is Morally Bankrupt and does not Promote Business or Stimulate Economic Growth.

The recent Enron debacle serves as a lesson to us all. Countless employees lost their retirement funds because those who knew Company stock prices were plummeting were too spineless to admit the truth. The corporate power mongers prohibited most regular workers from withdrawing their savings in time. Enron’s wealthy executives profited at the expense of ordinary staff members who, devoid of any basic rights, were powerless to prevent their inevitable demise: the majority of states in the US are no better!

Under Current Maryland Employment Laws that Support Businesses by Depleting the Rights of All Workers, Union Contacts Afford Minimal Additional Protections.

The majority of employees believe that their Union contract will protect them from unjust business tactics or Management persecution, but this is a false sense of security. In many cases Unions have allowed a reduction in termination pay to be inserted into their contract not fully realizing that they are increasing the incentive to fire Union workers for little or no cause. The language used to describe grounds for disciplinary action or termination is so vague and all encompassing that no effort is required to create what, on the surface, appears to be just cause. However there’s generally no necessity to elaborate on these vague one-liners so they are wide open to manipulation and gross misinterpretation. The action to remove an employee from the workforce is often immediate, requiring no investigation of the facts or presentation of evidence to support termination. Following a dismissal it is impossible to return to the work place, speak with co-workers or obtain any evidence at all.  One is barred access to ones own personnel file and any potential evidence, including letters of allegation. Pay records can be suppressed to ensure that pay discrepancies are never uncovered or raised. Unions can, and do, attempt to obtain evidence and information on ones behalf but this can become a torturous and often fruitless project.

  • 1.)       It took my Union eight months and pressure from the Labor Board to obtain copies of three letters, initially described as “Letters of Outrage,” one of which was then found to be at least partially supportive to my case.

  • 2.)    My Union has still not managed to obtain copies of my Pay Records that have been suppressed for at least fifteen months because they contain evidence that I was forced to take time off without pay.

  • 3.)    The charges against me remain unspecified, never quantified: to this day there are just two vague phrases “Verbally Abusive” and “Disruptive Behavior in the Workplace.”  At each confrontation the  false allegations against me change and have escalated significantly to the level of criminal acts!

So called Grievance Hearings with Management, Labor Relations and the Union are delayed as much as possible in the hope a former employee will just give up and look elsewhere for a job. When they are finally held no evidence is required from Management to prove that they had real cause to fire the employee and anything the worker brings to the hearing is completely ignored: this rubber-stamps the grossly unfair, one-sided process. Recourse after the inevitable denial is minimal and may stretch out for more than one year. The Maryland Commission on Human Relations and EEOC are in place to investigate some abuses, but their mandate of protection under the law is so narrowly defined that in many cases it is worthless. Internal regulatory bodies are available at some companies, but it does not take long to realize that their main objective is to protect the Employer and white-wash over problems.

The Union contacts the National Labor Board and the Wage and Hour Board for Union Employees. Congressman, Senators, Representatives, the ACLU, Legal Aid, Lawyers, the State’s Attorneys Office, the Federal and District Court House, the Public Defenders Office: all appeals in all directions are completely useless because in Maryland, as in so many other States, we have no fair Labor Laws!  I have actually contacted every single one of the above mentioned officials and agencies with no result. My missing pay checks may total as much as $1500 if I include pay for Forced Time Off. However I was told by my Union that when we go to Arbitration, I cannot even mention missing pay or the clear agenda to force me out of my job in retaliation for bringing a legitimate complaint against a Manager. If this is how protracted and difficult the process of seeking justice is for a “protected” Union Worker you can imagine how hopeless and abysmally unfair it must be for those who are not Union Members.

CONSTITUENT OPINION                                                                        pg.3. Constituent: Kim L. Sanders-Fisher

Industrial Progress is Impaired when the Input and Ideas of Innovative Workers is Thwarted by Insecure Managers who Label these Subordinates “Troublemakers.” 

An innovative employee is traditionally seen as a threat by less imaginative supervisors; these are the people most often targeted for removal from the workplace. Positive input and opinions are viewed as disruptive to the status quo; all regular employees are strongly encouraged not to “rock the boat.”   Even when a suggested change might save money and improve conditions, the implementation of any new ideas will generally require extra effort, especially by Managers, and additional expenditures by the company. There are incentive bonuses compelling most Management personal to cut costs to reduce their own workload; few look beyond their own immediate goals to consider “the big picture.”

  
Industry as a whole is debilitated by this stifling of ideas. Many companies run inefficiently, incurring unnecessary expenses, with workers hopelessly frustrated and dissatisfied in their jobs; any respect for Management or corporate bosses, is abysmally low.  Companies squander thousands on an expensive consulting firm, but choose to disregard unpleasant conclusions like, “Your business is top heavy.”   Ignoring consultancy advice, rather than trimming the glut of management positions, they lay off large numbers of minimum wage earners or force them to reduce their hours, take pay cuts or sacrifice their benefits.  The burden always falls on those at the very bottom of the job market, regular workers who have no rights! I have seen this futile process three times, in two separate hospitals; the lesson is never learned. These huge layoffs swell the ranks of unemployed, a consequence which impacts all of us.  

Forward-thinking American Companies who have independently decided on implementing basic fair employment practices foster a positive work environment, and are generally rewarded with increased productivity as job satisfaction is optimized. Regular employees from every level of their business feel valued and free to submit their input without recrimination or fear of retaliation. Companies benefit from this multidisciplinary, internal review of their standards and practices, expensive consulting firms are unnecessary and new avenues of business are opened up.

Capitalizing on the innovative ideas and knowledge of the rank and file, regular employees who are already familiar with your particular type of enterprise, makes good sound business sense. However, this bold strategy will not be implemented across the board by all businesses without government intervention to ban America’s unjust “At Will firing” practices that continue to intimidate potentially brilliant employees from helping their company to attain higher goals.

 Abolition of the “At Will Firing” Laws will dispel the pervasive atmosphere of distrust for Management by the majority of regular employees in the workforce, thereby motivating, inspiring and boosting productivity among despondent, disillusioned US workers. This bold positive change to restore confidence among all US workers must ultimately stimulate economic growth. 

W.H.E.N? WHISTLEBLOWERS in HEALTHCARE EXPOSE NEGLIGENCE 

http://www.thepetitionsite.com/takeaction/938995258

A CITIZEN’S FIRST AMENDMENT RIGHTS CANNOT BE JUST SUSPENDED IN THE WORKPLACE 

Obscure, unwarranted subjective feelings, vague, unspecified, uncorroborated accusations manipulated to deliberately misinterpret the rules cannot, or should not become grounds for dismissal. No employee should be able to swear at, harass or intimidate their coworkers without being disciplined, but these events must be documented in full and in writing with the unsolicited corroboration of other employees before a worker is fired.  If an employer cannot provide an accused employee with a detailed account of the circumstances or actions that justified their dismissal then their motivation for firing must be regarded with a high degree of suspicion.  Employers using such deceitful tactics certainly do not deserve public accolades and awards for “Honesty, Integrity and Transparency!”

An employee should feel free to defend their own integrity by denying false charges without the very denial itself becoming a cause for further discipline. An appeal for acceptable, fair and even handed treatment is not “Berating;” phone calls to request reasonable consideration are not “Harassing phone calls;” telling a supervisor that they are being “Unnecessarily Inflexible” is not “Verbal abuse;” and those who claim to feel “Threatened and Intimidated” but cannot identify why, should not be believed.  If those same employees did not feel sufficiently threatened to call Security they probably didn’t really feel threatened at all, besides worrying that their own jobs were under threat if they did not provide a solicited letter of accusation.  No one should loose their entire livelihood because a coworker felt threatened or intimidated by behavior as innocuous as having ones arms folded or standing with hands on hips!  

If something a coworker thought that they might have heard you muttering to yourself under your breath is sufficient grounds for dismissal then workers have suspended all first amendment rights while on the job! When even Union employees cannot ask simple questions of a potential witness or obtain evidence to support their innocence, without incurring additional disciplinary action or being fired, then businesses are encouraged to coerce, torment and persecute their workers with impunity.

                                                                     

All of the above circumstances and false accusations pertain to my own wrongful termination case.

THIS SAME LAW PROBABLY APPLIES IN YOUR STATE AND RESTRICTS YOUR RIGHT TO PROTECT PATIENTS FROM HARM DUE TO FEAR OF RETALIATION AND WRONGFUL TERMINATION. WE NEED NEW LEGISLATION TO PROVIDE BETTER PROTECTIONS FOR ALL WHISTLEBLOWERS, BUT ESPECIALLY NURSES AND OTHER HOSPITAL STAFF.   IF YOU HAVE BEEN NEGATIVELY IMPACTED BY THIS ISSUE PLEASE COMMENT.

September 17, 2007

A WHISTLEBLOWER’S EXPERIENCE: ADVERSITY TO INSPIRATION

http://www.thepetitionsite.com/takeaction/938995258


KIM SANDERS-FISHER - PROOF OF NO CAUSE FOR DISMISSAL AS DETERMINED BY MARYLAND UNEMPLOYMENT COMPENSATION (Recreation taken from Original)

August 22, 2007

COMPLIANCE LINE ACCOUNTABILITY and COMPLIANCE OBLIGATIONS

          Compliance Lines were created back in the late 90s in response to Sarbanes/Oxley otherwise know as the “SOX” legislation to combat fraud.  They were intended to encourage safe reporting of fraudulent activity and dangers towards the public from within an organization, followed by a proactive approach towards internal self-policing.  Companies and organization who established a Compliance Hotline were rewarded in that, if wrongdoing was uncovered, they would face lesser fines than if there was no internal efforts to prevent corruption.  Most Medical facilities already had a “Risk Management” Department to alert them to dangers towards patients, but Compliance went beyond this mandate to examine billing and financial aspects as well.

         These well intentioned efforts at identifying fraud, negligent and dangerous practices to swiftly deal with such issues internally without involving outside agencies were very noble in principal.  However, market forces soon insured that these quasi independent departments were hijacked to protect and serve Corporate financial interests!  Since “Risk Management” has been in place far longer, more numerous examples of their corruption have surfaced in independent reporting. There are certainly enough widespread examples of deficient protection towards those who report to “Risk Management” that mandatory regulation of their code of practice is not only warranted but long overdue.   

         Unfortunately, the wanton manipulation of Risk Management just provided the model for setting up sham Compliance Lines who’s sole purpose was to protect institutions from external scrutiny.  This began with selecting the right candidate to create a Compliance Line led by a Chief Compliance Officer who was a loyal internal appointee; someone who could be trusted to protect Corporate interests with a view to further advancement of their own career.   While this might sound incredibly cynical there are clear examples that this is exactly what has taken place in some instances, with an internally appointed Chief Compliance Officer already rewarded by significant promotion within the same Healthcare conglomerate.   This cannot be dismissed as mere coincidence and must be examined for conflict of interest due to the sensitive nature of their task in establishing and monitoring Compliance.

        Regulations are urgently needed to reign in this abuse of Compliance monitoring as blatantly self serving corruption now leaves the general public with fewer protections than before the inception of Compliance Hotlines. The main object of such regulation would be to insure that Compliance Lines were genuinely independent and unbiased when they conducted thorough impartial investigations that in future must be subject to more rigid external scrutiny. In addition the rules governing reporting must facilitate that frequently touted objective that remains so illusive today; they must offer legitimate tangible protection from retaliation to all employees reporting negligence, fraud and abuse of power by Management. The current system allows retaliatory protection to be stalled indefinitely by the disciplinary process and abandoned after an employee is removed under suspicious circumstances.

       Zero protection for Whistleblowers promotes negligence, corruption, bullying and abuse of power in the workplace.  It negates any benefits that might have been possible through establishing a Compliance Hotline to encourage internal reporting.  Employees have already become very wary of reporting anything up the “Chain of Command” to Management, they no longer trust Risk Management and now the dirty little secret about corrupt Compliance Hotlines is starting get out.  The seemingly unequivocal protection offered in their literature and on the internet is bound by impossible limitations and restrictions that in reality render no retaliatory or Whistleblower protections what-so-ever.  Unfortunately employees do not discover this until they have fallen into the trap of believing that they will be protected from retaliation, only to be betrayed. 

THE FOLLOWING MANDATORY REGULATORY CHANGES ARE URGENTLY NEEDED TO PROTECT THE PUBLIC FROM NEGLIGENCE AND CORRUPTION, PLUS PROTECT THOSE WHO ATTEMPT TO BLOW THE WHISTLE:        

1. Compliance Lines are duty bound to investigate all allegations of dangerous, negligent or fraudulent practice without delay or any regard for the status, current situation or alleged lack of credibility of the person reporting. Reprimand or dismissal must never be sited as legitimate grounds for ignoring a report of potentially dangerous, negligent or fraudulent practices.

Without this stipulation a facility or organization guilty of violations can use protracted delays and stalling tactics to postpone an investigation indefinitely.  In addition they can unjustly manipulate the disciplinary process to exclude Compliance intervention. While reprimand or wrongful termination is permitted to negate the credibility of an informant this tactic will encourage retaliatory intimidation to silence or remove an outspoken employee.

2. Employees should be able to report to Compliance Lines without going through a “Chain of Command” in their workplace first as they may genuinely fear Managerial retaliation.

 If reporting up through the “Chain of Command” is a prerequisite before contacting Compliance it becomes impossible to report the abuse, negligence or fraud perpetrated by a Manager and it leaves the employee vulnerable to a tangible fear of retaliation or dismissal.

3. There must be no postponement or delay before a Compliance Line agrees to investigate and very strictly monitor the dismissal of any employee who reports being targeted by Management.  Waiting until after the Grievance process, Arbitration and all other avenues of recourse have been exhausted, cannot possibly offer adequate retaliatory protection to a vulnerable targeted employee in the interim.

 If an employee contacts their Compliance line to report retaliation or wrongful termination, but the proceedings are not vetted for legitimacy and monitored for fairness then abuse of power and manipulation of the disciplinary system is encouraged.  Special attention must be paid to any evidence of irregularities or prejudicial behavior that precipitated a suspicious firing,

 4.  Compliance Lines must not be allowed to review allegations or charges concerning the conduct of an employee where written detailed documentation does not exist or the employee has never been permitted to review all of this documentation and therefore cannot respond to or refute its validity in any way. Employees must never be denied full access to their own personnel files or pay records even after dismissal.

A general category of event that might satisfy the basic reason given for dismissal is not valid without a detailed written documentation of exactly what occurred as, without such documentation and without the accused being allowed full access to it, the details can be changed and the seriousness escalated after the fact to secure permanent removal. If an employee does not know exactly what they were accused of doing they cannot possibly mount any defense at all against such nonspecific charges.  There is no legitimate reason to deny an employee full access to their own personnel file or pay records.

5. A Compliance Line must document or provide the employee’s documented written response to all allegations or charges made against them giving that employee’s response statement equal attention and credence.

An accused employee who is prevented from submitting documentation of their response to allegations is unfairly denied the right to prove their innocence and defend their reputation.  No requirement for equal representation encourages false accusations that erroneously appear to go unchallenged by the accused: no charge is valid without a response or at the very least a signed refusal to respond.

6. No employee should be discredited or removed with charges that are not documented in full and in writing in documents that are made fully and promptly available to the accused prior to the date of their discipline. A timeline of all included paperwork with submission dates must accompany this. No additional charges or embellishments added after a dismissal should be considered relevant or credible evidence of misconduct by the fired employee.

Charges or allegations against an employee that are not presented prior to an employee’s removal are simply not valid. The legitimacy of charges can only be verified by an accurate timeline of events leading up to the employee’s removal. Without this stipulation employers can conduct a “Witch Hunt” where the targeted employee’s file can easily become a revolving door of late submissions and backdated entries accumulating unnoticed by the accused for many months after they are fired without cause.

7. Compliance Lines must remain totally impartial without demonstrating bias towards protecting the facility or the organization’s best interests at the expense of an employee, This is especially important with regard to the potential for inequality in disproportionately ignoring the equal accountability and necessity for discipline of Management found guilty of dangerous, negligent or fraudulent practices.

When an employee is dismissed on the basis of a technicality or an inconsequential minor infraction used to silence their protest, but the negligence or corruption they report is virtually ignored and no one is disciplined for actions that present a serious risk to people’s lives then the system is seriously biased.

8. A Compliance Line should not be Managed or staffed by internal appointees with a vested interest in protecting the best interests of the facility or organization.

A serious conflict of interest exists when Compliance Line staff are recruited from internal departments: they may anticipate another more lucrative transfer in future, if they protect the best interest of the facility or organization they are supposed to be monitoring in a fair and unbiased way.

 9. When approached by an external agency a Compliance Line must demonstrate in detail the evidence on which their findings, even a finding of no cause for concern, plus their decisions regarding corrective measures and proportionate discipline following an investigation, are based.

 If a Compliance Line knows that their findings will be accepted without a presentation of the facts then they are under no pressure to really investigate at all.  This will encourage meaningless cursory internal investigations to placate external Agencies and evade external scrutiny.

10. A basic report of Compliance Line findings, even a finding of no cause for concern, plus decisions regarding corrective measures and discipline following an investigation should be made available to the person reporting in order to provide assurance that the situation has been handled appropriately by internal Compliance.

When an employee reports abuse, negligence or fraud they may have considerable worry over the consequences of inaction and they have a right to know that genuine corrective measures were taken, that people were held accountable and that they do not need to report the matter to any external Agencies due to inappropriate Compliance Line inaction.

 11. Compliance Lines are duty bound to investigate all allegations of retaliation and wrongful dismissal, despite any rulings against the employee, even after the employee has been permanently removed from the workforce and even if an employee has felt compelled or bullied into writing a solicited letter of resignation or accepting a financial settlement.

If a Compliance Line can simply write off the need to investigate a case of retaliation or wrongful dismissal because retaliatory practices have succeeded in totally removing an employee or bullying them into writing a solicited letter of resignation to end all further abuse then this only encourages more aggressive, corrupt and relentless tactics.

12. Compliance Lines must be subject to external scrutiny by Public Agencies and Government Regulatory Bodies. This is especially important when an employee removed under suspicious circumstances, reports strong suspicions of an inappropriately dismissive or purely cursory investigation with the complete refusal to pursue any charges against serious offenders without explanation, or valid evidence of an internal cover-up.

When a facility or organization knows that Public Agencies and Government Regulatory Bodies are powerless to subject them to external scrutiny, that they must accept the findings or corrective strategies of a cursory internal investigation conducted by their Compliance Line without question, the manipulation and corruption of Compliance Lines is fostered and condoned. There is a very strong incentive for facilities or organizations to create an internal Compliance Line for the express purpose of avoiding external scrutiny and highlighting any outspoken “troublemakers” for swift removal from the workforce. This is the diametric opposite of the concept that inspired the creation of these Compliance Lines in the first place and the general public is left with fewer safeguards and protections than existed before their inception.

                                                                                                                                                            

WHERE IS THE EVIDENCE TO SUPPORT THE NEED FOR DRASTIC REFORM

      The main purpose of demanding that the Compliance Line at my former Hospital must investigate my particular case is to expose the gross inadequacies in the Compliance process itself.  I believe that this Compliance Line is still legally obligated to investigate my allegations of retaliation even after the Hospital’s retaliatory efforts succeeded in my permanent removal. This ongoing claim is based on the well established premise of “Truth in Advertising” which would require the Compliance Line to adhere to their own written assurances as published on the Website.  The Compliance Line cannot guarantee retaliatory protection in print and on the Internet, while there is never any intention to protect Whistleblowers and retaliatory protection is repeatedly denied after an employee places all of their trust in that commitment. 

      Despite their compelling written assurances I was extremely alarmed to discover the impossibly restrictive limitations: the Hospital’s Compliance Line claimed that it was standard policy for them to maintain a strictly hands off approach throughout the entire disciplinary process. This extending way beyond my initial wrongful dismissal to Grevance hearings, Mediation, Arbitration and all efforts related to my attempts for reinstatement, a process that took several years!  During this time, and for no legitimate reason, the Compliance Line adamantly refused to monitor what became an increasingly blatant and thoroughly corrupt process that included among other things a documented finding of “Unfair Labor Practices” by the Labor Board. 

       Bear in mind that this followed a wrongful discharge for which the Hospital had been unable to demonstrate to unemployment compensation that they had a legitimate cause for my dismissal.  The only reason the Hospital was able to win an Arbitration ruling was by submitting additional rule violations that were backdated and entered into my file months after I was removed: I saw them for the first time 15months after being fired. Top Managers were able to continue lying under oath with impunity; there seemed no end to their relentless pursuit of my removal at all costs.  The Director of Surgical Nursing herself concocting a harrowing new tale of my threatening her life, an incident that supposedly she had never mentioned to other Managers for over 15 months?  If such an incident had occurred I would have been dismissed on the spot, but no one ever questioned why there wasn’t a single report to Hospital Security regarding a “threatening” employee.  This deliberate pattern of deception simply would not have been possible with vigilant monitoring of my paperwork by Compliance and intervention to prevent Managers from constantly reinventing their cause for dismissal.   

       After I insisted that there could be no delay in investigating the very serious danger towards patients that I had documented and submitted in a written report, a cursory investigation of my allegations was conducted. I say cursory because there was no interview scheduled to go over the details of my report or examine any evidence.  When an employee places their job on the line to expose negligence and they are left to suffer serious retaliation consequences simplistic reassurances that the situation has been dealt with are understandably regarded with a high degree of suspicion.  When I enquired I was told casually over the phone that the investigation had discovered that there was “some truth” to my charges, but the Compliance Line had decided to “just keep an eye on things.”   Knowing that no specific corrective measures would be taken and no one would be held accountable or disciplined for ongoing negligence that had risked the safety of multiple OR patients for a period of several years was really quite shocking.  

        This commitment to inaction makes a total mockery of the Hospital Compliance Line’s mission and reveals the true purpose of creating the Hotline: to obscure financially beneficial negligent practices and facilitate the targeting of “troublemakers” who attempt to expose the truth.  Their complacency and refusal to intervene was an especially cruel blow at a time when, despite the Labor Board finding, the perpetrators were permitted to continue doctoring my employee file and restricting my access to false accusations.  In stark contrast to the very serious patient safety problems I had reported, these inconsequential, rather vague, behavioral issues had absolutely no bearing on my competence with regard to my job; none of this ever placed a single OR patient in danger at any time. 

      Under circumstances where my credibility and my entire career were in jeopardy, there was still no access to desperately needed retaliatory protection from the Compliance Line; I was outraged!  This represents grossly disproportionate punitive measures taken against those who dare to report negligence while those who perpetuate deliberate negligent understaffing, frequently risking the lives of multiple patients over an extended period of time, remain unchallenged because their negligent policies protect Corporate financial interests.

       The Compliance Line had assured me that if all other avenues of recourse failed they would investigate my allegations of retaliation.  The policy that compels a Compliance Line to postpone retaliatory protection until after the worst abuses of an unmonitored disciplinary process have succeeded in their targeted objective is simply ludicrous.  However, the offer of any recourse to delayed justice was just a calculated lie to fob me off and stall for time, because the Compliance Line had no intention of ever investigating my case. When I called them to say that Arbitration had ruled against me, following a hearing where Managers had lied under oath to secure my permanent removal, I was told that since I was no longer an employee they had no obligation to investigate!

        By ignoring nearly three years of relentless retaliatory tactics the Compliance Line knew that the Hospital was bound to prevail.  This corrupt policy encourages retaliation and serious abuse of power.   They have now refused the previously assured recourse to an investigation due to the success of Managerial retaliation!  The excuse that now Management had succeeded in securing my removal, the continuous reports of their relentless retaliation were irrelevant, the Compliance Line were determined to accept the result without challenge.

 According to the standard policy of the Compliance Line at my former Hospital there was no point at which I was ever entitled to retaliatory protection or an investigation into my wrongful termination, despite reporting serious negligent practices that were confirmed as true, but virtually ignored

  

       The independent objectivity of my former Hospital’s Compliance Hotline is confidently touted on their Website however, the Chief Compliance Officer that I dealt with was indeed an internal appointee.  He was also later promoted to a top level position at another Hospital within their Corporate network, hence the implication that this conflict of interest made him heavily biased towards protecting the Hospital’s best interests at the expense of conducting a thorough internal investigation and offering retaliatory protection to a clearly targeted Whistleblower.  This course of career advancement might not seem inappropriate if the conduct of the Chief Compliance Officer concerned had not remained so heavily biased, disproportionate and dismissive concerning the negligence issues I had reported.  To read about the Chief Compliance Officer and the job track that I personally believe smacks of conflict of interest, please visit this link: 

                 http://www.hopkinsmedicine.org/Press_releases/2003/12_24_03.html 

      In hindsight it is simply inconceivable for me to ever believe that a Compliance Line set up in this way, and deliberately restricting access to vital retaliatory protections, can possibly be intent on focusing on the identification and elimination of negligence, safety violations, fraud and corruption.  Under such biased and consciously deceptive standards of oversight one might easily consider this type of operation borderline criminally motivated, due to a valid potential for obscuring ongoing negligence and fraud.  Bear in mind that the very existence of a Compliance Line will reduce the impact of punitive fines and distance an organization from more stringent external scrutiny.  We have no way of knowing how many other reports of serious negligence, safety violations or fraud have been covered up using this deeply flawed process.  I do not know how pervasive this Compliance Line corruption is at other Medical facilities, but if it only represents the deliberate deception of Public Agencies and Government Regulatory Bodies at this one Hospital, it is one Hospital too many! 

      I would welcome a full public inquiry into the functioning of this and other Compliance Lines with a view to implementing vital safeguards to restore the integrity of such programs, with a strong mandate to protect Whistleblowers.  There is no legitimate reason for the Compliance industry to reject regulation that would demand a consistent policy towards vital retaliatory protections.  Until there is a public inquiry and I have an opportunity to testify under oath regarding the corrupt handling of my case, the most I can do is warn patients and employees via this Blog.  Be warned: Compliance is not always Compliant, and may protect non-Compliance!  Employees need to know that if a Compliance line refuses, or attempts to postpone, retaliatory protection you must act swiftly to bypass the hotline and report directly to external Public Agencies and Government Regulatory Bodies.  The Investigation into my case will merely demonstrate that the current dangerous situation warrants an urgent public inquiry into all Compliance Lines.  To demand the investigation into my case, go to: 

                   http://www.thepetitionsite.com/takeaction/938995258

August 12, 2007

SIGN A PETITION

Filed under: Uncategorized — Kim Sanders-Fisher @ 11:58 pm

http://www.thepetitionsite.com/takeaction/938995258

August 11, 2007

INSURANCE: COVERING MEDICAL RISK

Filed under: Uncategorized — Kim Sanders-Fisher @ 1:30 pm

IS THE UNHEALTHY EMPHASIS ON TARGETING MEDICAL PROFESSIONALS WITH MALPRACTICE DIVERTING OUR ATTENTION AWAY FROM FIXING SERIOUS SYSTEMIC PROBLEMS IN HEALTHCARE, BUT PROVIDING NO FINANCIAL RECOURSE FOR THOSE WHO SUFFER A ‘BAD OUTCOME?  

         In the area of Medical, beyond the basic Insurance plans to cover treatment and care, I would like to see an additional completely different Insurance with a new emphasis based on Medical risk to compensate patients who suffer a “bad outcome.” Such Insurance would entail a major divergence away from the punitive concept of Malpractice and recent attempts to cap payouts for damages.  When a patient’s treatment does not go according to plan, or not as well as expected, what they really need is a swift payout to cover real necessities and the expense of ongoing Medical treatment or long term care.  Fault is immaterial to this immediate need, however the protracted legal efforts to assess willful negligence often postpone any relief that might be offered by insurance.  These attempts to demonize well intentioned Medical professionals have radically changed attitudes towards practice as they encourage negative trends like “Defensive Medicine.”  Theft insurance does not demand that we prosecute the thief; why must an insurance payout be so dependant on blame when Medical treatment simply fails?

         I see no reason why Insurers are not focusing more heavily on providing coverage for a “bad outcome” with regard to Medical care.  Money is squandered on Lawyers fighting acrimonious battles over who was at fault when a Medical error occurred or a patient did not do well in response to even the most sophisticated treatment, during a critical period when readily available cash to cover urgent expenses is a far greater priority.  At such times there is a genuine need for the security of an insurance payment that is not reliant on anything more than the cost associated with a poor response to treatment or bad surgical outcome.  On some occasions the fault lies with a non-compliant patient, but far more often Medical errors and bad outcomes are the result of multiple factors including systemic problems that are never addressed by Medical facilities because the current Malpractice system provides little incentive for them to do so.  This system diverts attention away from the route cause of problems that could be fixed to instead target Medical staff with full accountability in situations where they are helpless to improve conditions.

         Medical staff are human too and errors will occur; in reality few other professionals are ever held to the same zero tolerance standard of accountability with regard to their work.  The Medical profession does have a well established system of self monitoring referred to as M&Ms, (Morbidity and Mortality).  This process is extremely rigorous in reviewing all bad outcomes regardless of liability.  Doctors participate regularly in M&Ms to target any mistakes made and draw positive conclusions about possible lessons to be learned for improving the standard of care. 

        However, the current emphasis on blame in Medical Malpractice is extremely detrimental to the process of genuine honest analysis of bad outcomes.  Malpractice seeks to target a specific individual or group of individuals who might or might not be at fault. This punitive approach often leads to extraordinary efforts to try and obscure mistakes by hiding important data and facts so that the reputations of the Medical professionals involved are not irrevocably destroyed.  Generally several of the staff involved with a case will share responsibility for a mistake, but the most heavily insured will always represent the best target for a considerable Malpractice settlement.   Taking into account the prohibitive cost and significant personal commitment involved in acquiring Medical qualifications it is understandable that Doctors are reluctant to allow an isolated incident, a bad judgment call or the mistake of a subordinate to sabotage their entire career.  Inevitably, Doctors will start to avoid high risk procedures where they are at serious risk of being sued if treatment does not go well; obstetrics is a prime example where patients will suffer. 

       There are some very clear cut cases of obvious negligence or inappropriate conduct that defiantly warrant punitive action, but this should be handled via dedicated Medical tribunals and medically trained professional investigators.  Frequently the cause of a bad outcome is not an incompetent Doctor of an uncaring Nurse it is far more complicated than that and often involves a multitude of minor oversights for which no one individual is responsible. For the most part Doctors and Nurses endeavor to provide the very best standard of care in a working environment that is becoming increasingly unforgiving.

           While Malpractice remains distracted by finding “the culprit” Medical facilities are not encouraged to eliminate any of those contributing factors that lead to Medical errors. Unnecessary fatigue, stress and exhaustion are exacerbated by the drive to force Medical professionals to deliver more complex care with fewer and fewer staff.  Not only are we trying to cope with a cohort of far sicker patients than ever before, we are attempting to manage in the face of what I call “Deliberate Negligent Understaffing” of all our US Medical facilities.  Overstretched, Medical staff working torturous continuous hours of duty without relief will make mistakes, but this toxic work environment is totally unnecessary and driven only by greed.  Sadly this factor is rarely identified as the principal component in a bad outcome.  

         While the “Agency Nurse” is targeted as incompetent for overlooking a vital detail, the real issue was the chronic lack of experienced Nurses on duty.  The vast majority of Agency Nurses are highly experienced, but they are at a disadvantage when dumped into an unfamiliar work setting to plug the gaps in coverage.  When things go wrong the Agency Nurse becomes a convenient scapegoat allowing Hospitals to distance themselves from responsibility.  In most US facilities the ratio of temporary staff to permanent employees has become ridiculously high, while the experience level of those regular staff is being kept at bare minimum to meet the demand for cheap labor.  While we know that Nurse to patient ratios have a direct affect on the prognosis of those receiving care, few states have set mandatory standards.  Studies have quantified the increased risk when Nurses are forced to monitor too many patients at once, but, when errors occur, the “uncaring Nurse,” often an Agency temp is blamed or Malpractice climbs the feeding chain for a bigger payout at the top.  

        Ruthless cost containment policies for increasing Corporate profits at the expense of safe care are responsible for the huge increase in Medical errors.  Malpractice targeting beleaguered Medical staff is not alleviating this dangerous situation it is making it far worse. If the focus of Medical insurance was on outcome and providing financial relief for those who suffered a bad outcome then all of the players would be invested in making sure that the statistics were excellent at their facility and Hospitals could not continue dodging accountability at the expense of either temporary Nurses or their own Medical staff.  These for profit facilities would be forced to correct systemic problems or face the consequences of increased insurance premiums where their performance track record was the single most important factor in assessing the cost of coverage.    

        Only strong financial incentives will persuade people to take realistic responsibility for their own care.  Patients must also bear a certain level of responsibility for their own standard of compliance with a drug regimen or a rehab program and this component of risk cannot be ignored within Medical risk insurance.  Patients will feel really invested in monitoring their own compliance with treatment if their record of past compliance becomes a factor in gaining affordable Medical risk coverage.  Often it is the habitually noncompliant patient who requires more frequent Medical attention, due to a tendency to ignore well recognized lifestyle risk factors and minimal attention to their own physical wellbeing.  Medical risk insurance would stimulate a greater vigilance in the monitoring of patient compliance. This would lead to swifter, generally more reliable, assessments regarding the efficacy of new treatment strategies or newly introduced drug regimens by minimizing unmonitored variables.  

       There would also be far more emphasis on analyzing the risk/benefit of undergoing certain types of radical treatment, with a realistic assessment of the potential for bad outcome taken very seriously by the patient based on the cost of insurance.  The cursory attention paid before signing consent forms negates any real understanding of risk.  We need to move away from the premise that “if anything goes wrong we can find someone to blame.”  The patients who have the best prognosis for recovery are those who are proactively participating in every aspect of their own care and have realistic expectations based on a thorough assessment of genuine risk; we need to encourage this type of positive approach to treatment.

        I believe that a new type of Medical risk Insurance should involve joint payment assessed according to the track record of the Medical facility, the experience of the Medical team selected, the past compliance of the patient and a financial evaluation of the risk/benefit of the treatment based on the potential for an adverse outcome. Such insurance would be designed to cover the true expense of dealing with the realities that a bad outcome would entail. A comprehensive benefit package might cover more than just the basics of any ongoing expenses incurred, but the cost of such insurance would be higher.  The protracted court proceedings to seek massive damages for pain and suffering would be negated by the prior determination of a “bad outcome” payout based on the extent of coverage chosen.  This would stimulate a more transparent and thorough evaluation of poor results, leaving any genuine Malpractice charges to specialized Medically trained investigators and a dedicated Medical tribunal. 

        There would be powerful incentives for Hospitals to insure that there were safe levels of Nursing coverage to provide diligent bedside care and enough thoroughly trained cleaning staff to provide high standards of sanitation to achieve lower infection rates. It would make sure that all patients took their role in compliance with treatment very seriously and maintained a realistic approach towards achieving the best possible prognosis.  However, it would provide faster access to financial relief if an insurance payout was not delayed by the lengthy legal process of assessing blame. This is the missing link in current Medical Insurance strategies: the complete lack of incentive for patients to remain diligent in their compliance, with Doctors resorting to defensive Medicine, while the total lack of accountability enjoyed by Medical facilities condones negligent cost containment strategies.  

        Only when the financial cost associated with errors penalizes institutions for the consequences of incompetence will they realize the importance of qualified staff, ongoing training and the value of many years of experience. The current trend towards minimally trained aids and new Nurse graduates replacing higher paid tenured staff has depleted a valuable training resource for short term gains.  Managers in clinical areas of our Hospitals need to focus on reducing the risk to patients instead of perpetuating a system of Deliberate Negligent Understaffing to cut costs.   Strict control of staffing levels needs to be imposed industry wide, with Nurses required to document every incident of unsafe coverage in an incident report.  This will finally hold Managers accountable by removing the incentive of a fatter bonus check for those who exploit their staff or try to cull the ranks of higher paid tenured Nurses.  This policy has already failed financially since so many Hospitals are now squandering their HR budget on paying huge Agency commissions to bring back highly experienced Nurses who were once part of their regular staff!

        A major change in direction on Medical Insurance policies might just shift the emphasis away from inept “Top Heavy” Management and towards the safe delivery of care with appropriate Nurse to patient ratios and a concerted effort to eliminate the unnecessary fatigue responsible for errors.   Reducing the glut of Managers would also liberate funds needed for properly trained ancillary staff with a rigid agenda for Hospital grade cleaning to lower infection rates.  Please review other sections of this T.E.A.M., TRANSPARENCY for EQUAL ACCOUNTABILITY in MEDICINE site to read more about the C.U.T! Campaign to CONTROL UNDERSTAFFING TODAY. 

C.U.T! Campaign Banner CONTROL UNDERSTAFFING TODAY

August 10, 2007

DEADLY EUPHEMISMS IN HEALTHCARE

Filed under: THE DEADLY EUPHEMISMS IN HEALTHCARE — Kim Sanders-Fisher @ 11:08 am

                                   T.E.A.M./C.U.T! Campaign Header with background Picture of Kim

Greedy Profiteering in the Healthcare Industry has Reached Biblical Proportions.  

Doctors and Nurses are increasingly being forced to work longer hours of continuous duty caring for greater numbers of sicker patients with fewer staff and zero backup or relief. Exhausted Medical staff are used as the convenient scapegoat when mistakes are made, while in fact it is the Deliberate Negligent Understaffing of Healthcare facilities that has led to dangerous care.

At a time when we face the possibility of terrorism, sabotage or a global pandemic the US Healthcare system is being disabled and dismantled to drain every last dollar of profit for greedy Corporate giants. Meanwhile, to accomplish this goal, the powerful forces in the Healthcare industry are busy perpetrating a whole slew of deliberately deceptive PR lies to trick vulnerable Medical staff into remaining silent while the general public is defrauded out of safe access to Medical care.  Sure there are genuine initiatives, but in numerous cases noble intentions are easily hijacked by profiteers.  Read the alternative definitions in italics below.

These Repugnant Healthcare Euphemisms will Prove as Deadly as US “Peacekeepers!”

1. “Managed Care” 

Definition:  Too much Top Heavy Management providing far too little and increasingly more dangerous Medical Care.

2. “Patient Safety Initiatives”   

Definition:  Impressive PR Campaigns that use media spin to help obscure the sordid facts about unsafe practices like Deliberate Negligent Understaffing.

3. “Risk Management” 

Definition:   Department dedicated to reducing the Risk to Management from outspoken Patient Advocates.

4. “Compliance Hot Line”  

Definition:  Early warning system to alert or assist Management in the prompt removal of outspoken Patient Advocates.  A useful tool to avoid rigorous external scrutiny by conning Government Accreditation Agencies and Patient Advocacy Groups into confident reliance on fake internal policing.

5. “Patient Centered Care”  

Definition:  Patients now forced to “Center” on their own Care due to chronic abandonment caused by the dangerous policies of Deliberate Negligent Understaffing.

6. “Patient Abandonment”  

Definition:  The threat of legal sanctions used to force Nurses to work mandatory overtime, double shifts and unsafe hours of continuous duty without a break in order to support Deliberate Negligent Understaffing policies.

7. “ Medical Error”   

Definition:   Avoidable Mistake made by overworked, overstressed, exhausted and habitually abused Medical staff.

8. “Nursing Shortage” or “Nursing Crisis”   

Definition:  Healthcare Corporation’s deliberately engineered “NURSING EXODUS” resulting from the creation of a toxic work environment of torturous schedule demands, exhausting hours of overwork, with no breaks and numerous unsafe compromises in Patient Care driven by profiteering cut-backs and used to falsely justify a further dangerous escalation of Deliberate Negligent Understaffing. 

9. “Downsizing”   

Definition:  Forcing all of the people delivering direct Patient Care to endure the dangerously unworkable staff cut-backs of Deliberate Negligent Understaffing to support bloated Top Heavy Management and Corporate profiteering greed.

10. “Trim the Fat”   

Definition: Removal of basic benefits while increasing unrealistic schedule demands for regular Healthcare workers with Deliberate Negligent Understaffing.  Often used as an incentive to force all of the more highly paid experienced tenured staff out of Nursing stimulating a “NURSING EXODUS,” to increase the glut of money available as a reward bonus for abusive Managers and Corporate profiteers.

11. “Mandatory Overtime”    

Definition: A State sanctioned dangerous work overload forcing exhausted staff to risk charges of abandonment or compromise Patient Care by working intolerably long hours as a regular staffing coverage policy.

12. “Medicare Prescription Drug Benefit”   

Definition: Drug Company extortion campaign endorsed and implemented by the Government to reward political support with an uncontrolled pharmaceutical pricing policy designed to forcibly drive Medicare into Bankruptcy.

13. “Tort Reform”   

Definition:  Adjustments to make the deadly human cost of all of the above unethical compromises less financially devastating with zero accountability for facilities whose greedy profiteering results in ongoing unsafe practices, Deliberate Negligent Understaffing and increasingly dangerous Patient Care.

Unlucky 13 for Consumers receiving Unsafe Medical Care; Money making Bonanza for Corporate Healthcare Profiteers. Medical Professionals and the general public must demand an immediate end to this lunacy; we also really need Media help.

C.U.T!  CONTROL UNDERSTAFFING TODAY  Campaign Banner

July 21, 2007

TEAM CAPTAIN: ABOUT KIM SANDERS-FISHER

kim-sanders-fisher-12-hours-continuously-scrubed-into-surgery-without-a-break

Reasons Kim created these Patient Safety Campaigns

http://www.thepetitionsite.com/takeaction/938995258

Kim in Surgery at Cut Nyak Dhien

Pictures of Yachtswoman KimPistures of Yachting Professional KimPictures of Kim in Professional Yachting

Kim's Professional Career at Sea

http://www.care2.com/c2c/share/detail/91853

http://www.thepetitionsite.com/takeaction/938995258

Older Posts »

Blog at WordPress.com.