New York City Council Hearing: Safe Staffing Ratios in Hospitals

Mitchell Katz, M.D., President and Chief Executive Officer
NYC HEALTH + HOSPITALS
Monday, June 24, 2019

Good afternoon Chairperson Rivera and members of the Committee on Hospitals. I am Mitch Katz, M.D., President and Chief Executive Officer of the New York City Health + Hospitals (“Health + Hospitals”). I am joined by Natalia Cineas, DNP, RN, MS, a respected nurse leader and care provider, who recently joined our management team as Senior Vice President and Chief Nurse Executive. Thank you for the opportunity to testify before you today on safe staffing ratios in hospitals.

At Health + Hospitals nurses are at the heart of our mission to deliver high quality, compassionate care for all New Yorkers. From our emergency departments to our skilled nursing facilities to the neonatal ICU, nurses are essential caregivers for all of our patients. They not only offer top quality clinical care but they help patients navigate a complex health care system and support them during some of most trying times in their lives.

In my first year and a half back in New York I’ve listened and learned a lot from our nurses. I’ve learned about the amazing work they do for our patients, often under very difficult circumstances. I’ve learned it took far too long to recruit and hire nurses at Health + Hospitals. I’ve learned we do an amazing job training new nurses and that we have incredibly dedicated career nurses, but that we often lose early career nurses to private health systems. I’ve learned that we are one of the only systems I’ve come across that doesn’t pay nurses higher salaries for more specialized tasks. And I learned that in some of our units we needed more nurses.

In the past year and a half we have taken some great steps to address these challenges. We have hired 340 net new nurses across our system. Some are still in training and orientation but the new staffing is being felt across the system.

Historically, we have not had standard nurse staffing plans, but now we do in almost all units. The staffing plans allow us to hire nurses in the units where our patients need them the most, and help us react quickly if staffing levels get too low on any one unit. We took steps to hire and train nurses more quickly and effectively. We have made our training and orientation more efficient. We reduced unnecessary paperwork. Now, whenever possible, we start to train a new nurse before a departing nurse officially leaves so there’s no gap in staff coverage. And we launched a series of very successful recruiting campaigns like Nurses4NYC.

Our contract renewal negotiations with NYSNA began earlier this month. We have a terrific relationship with NYSNA and I think those negotiations will help us make great progress. I know we both want to focus on retaining the great nurses we have and boosting staffing in areas we have the hardest time hiring.

We love to hire new nurses and we are proud to train the next generation of nurses.

We’re currently looking at our business model because when we hire nurses directly out of nursing school and train them – after one to two years they become very marketable and they leave the public hospital system for the private sector. So, we’ve paid for their training, but do not gain the benefit. If we can retain more nurses through those early years we know they’ll fall in love with our system and we’ll have more stability in our staff. That is better for our patients and for our care teams.

Another key area we are working on together is improving our ability to hire in specialty nursing care. Nurses all across our system do amazing work but it does take special training and experience to be an ER nurse or to work in an ICU or neonatal ICU. Other health systems in this city, and both public and private systems around the country, pay differentials for nurses who are certified to work in certain specialized settings. That change would help improve our staffing in key areas.

I know as a related issue to nurse staffing, members are concerned about wait times in the emergency department (ED). First, it’s important to note that if you have a very serious injury there is no wait time in the ED – the most urgent patients are always triaged and they don’t wait. For less urgent visits, a sprained ankle, a bad cold – there can be a wait if the ED is busy. While nurse staffing is one factor in wait times, patient demand and the historical difficulty in getting primary care or express care services at Health + Hospitals are very important. With new hiring, better workflows, and investments in express care and primary care, we’ve made great progress in reducing wait times and improving the flow of our EDs. There is much more to do and our nurses will play a critical role.

There are more than 9,600 full and part time nurses in Health + Hospitals and they are essential to our efforts to deliver safe, high quality care to our patients. My elderly parents, my husband and I receive care at Health + Hospitals, and my daughter will, once she arrives in July. I would not have my family receive care if I did not believe it is safe. I believe in safe staffing and I will not operate facilities that are not safe.

Improving quality and safety requires the right staff but also the right tools and processes and teamwork across disciplines. I want to hear from our nurses if we can improve the care we deliver on any of our units. Those open lines of communication and the strong relationship we have built with our nurses will be critical to making our system even better in the years ahead.

Thank you for the opportunity to testify before you today, and I look forward to answering your questions.

Additional information for written testimony:

To assist in our nurse recruitment and retention efforts, we’ve launched Nurses4NYC, are participating in the first City-led nurse residency program. We also encourage our nurses to participate in loan forgiveness and scholarship programs sponsored by the system:

• NURSES4NYC: During the recent National Nurses Week, we officially unveiled our system’s first official nurse recruitment campaign, NURSES4NYC, to recruit the next generation of dedicated and committed men and women who will care for our patients. This recruitment effort will help Health + Hospitals fill nurse positions and expand access to communitybased primary care across the five boroughs. The NURSES4NYC campaign focuses on four high need specialty areas where nurses are needed the most:
  Emergency Room/Trauma; Ambulatory Care; Home Care; and Correctional Health Services/Behavioral Health. Our transformation as a health system demands that we invest in nurses and doctors to meet the future needs of our primary care focus. Nurses4NYC is a vibrant campaign that will attract those drawn to our mission of caring for one and all.
• Nurse Residency Program: Last fall, the Mayor announced the launch of the nation’s first City-led nurse residency program in 24 participating local hospitals – including all of our 11 acute care facilities at Health + Hospitals. During the first year of the program, called the Citywide Nurse Residency program, 500 newly-hired nurses will be provided with specialized training and mentorship to promote job retention. Estimates show that losing one nurse can cost up to $100,000 and retention of newly-graduated nurses is a challenge. While residencies are a recognized best practice for retaining nurses, New York City’s public and safety net hospitals have not had the capacity and resources to launch these programs. We are excited to offer our nurses this opportunity to thrive in our hospitals and help us deliver quality health care to so many New Yorkers.
• Nurse Corps: For accepted applicants, Nurse Corps pays for 60 percent of unpaid nursing education debt over two years, with an option to extend to a third year for an additional 25 percent of the original balance. In exchange, applicants commit to two years at an eligible facility experiencing a critical shortage of nurses.
• National Health Services Corp (for Nurse Practitioners): The National Health Service Corps (NHSC) Loan Repayment Program (LRP) offers primary care medical, dental, and mental and behavioral health care providers (including Nurse Practitioners) the opportunity to have their student loans repaid in exchange for providing health care in eligible facilities with limited access to care.
• Public Service Loan Forgiveness Program (PSLF): The federal government provides student loan forgiveness through its Public Service Loan Forgiveness Program (PSLF) to all qualifying public service employees. Your employment at NYC Health + Hospitals may allow you to take advantage of this program if you meet the program’s requirements.

Health + Hospitals has implemented the below initiatives to address overcrowding and wait times in our EDs.

• NYC Care: We will launch NYC Care throughout New York City by the end of 2020, starting with the Bronx on August 1. One of the primary goals of the program is to increase access to primary and specialty care for 300,000 New Yorkers who are ineligible for insurance or cannot afford it, which will decrease reliance on emergency rooms.
• Providing appropriate levels of care: We are providing access to other appropriate levels of care to prevent people from showing up in the EDs in the first place when they don’t need to be there through expansion of primary and specialty care, and having them self-select our express care clinics. We are also implementing targeted interventions for conditions where we see high rates of potentially preventable ED visits by expanding care to the home, as well as participating in a program that would allow 911 ambulances to treat in place and transfer patients to alternate destinations (e.g. urgent care, clinics, behavioral health centers).
• ExpressCare: This new care setting will provide an alternative for patients seeking fast, reliable and non-emergent care. We do community outreach to encourage patients with non-life threatening conditions to avoid the ED and directly walk in to the clinic. In addition, patients who go directly to ExpressCare and who are experiencing health emergencies requiring more acute care will be quickly transported from ExpressCare to the emergency department. We currently have ExpressCare clinics at Elmhurst, and Lincoln, and expect to have a clinic at Jacobi by the beginning of 2020.
• Potentially Preventable ED Visits: Under OneCity Health and DSRIP, we have seen a 12.5% decrease in our preventable ED visits in the OneCity Health PPS population over the first three measurement years of the program. We are also doing targeted interventions for conditions where we see high rates of potentially preventable ED visits by expanding care to the home. For example, we are connecting patients with asthma to community based organizations’ community health workers who work with the care team to engage patients in an asthma action plan and go into the home to address environmental triggers. We’ve seen a 20% reduction in potentially preventable admissions for pediatric patients with asthma in the performing provider system’s population since the program started and are expanding to adults this year.
• Emergency Triage, Treat, and Transport (ET3) Model: In the fall the federal Center for Medicare & Medicaid Services (CMS) will issue a request for proposal, which would allow providers to apply to participate in the ET3 payment model. Under the model, CMS will pay ambulance suppliers and providers to transport an individual to an ED, an urgent care clinic or primary care doctors office, or treat in place with a qualified health care practitioner. The ET3 model will allow individuals to access the most appropriate emergency services at the right time and place, and reduce costs by reducing avoidable transports to the ED, and unnecessary hospitalizations. Health + Hospitals is in discussions with the Fire Department of the City of New York (FDNY) on participating in this program.
• Improving ED Throughput: When patient do show up in our EDs, we have developed processes to quickly move them through our EDs and get them to right to type of care that they need, whether it’s putting them in observation status, utilizing providers in triage to get the definitive evaluation and treatment initiated right away. We are also working on improving efficiency by reducing our lab and radiology turnaround time, and moving our discharge times to earlier in the day.