Title: Cutting-edge discussions of management, policy, and program issues in emergency care
Abstract: Effective staffing levels have become a topic of concern as a result of evidence that they are linked to quality patient outcomes, the expanding health care worker shortage, and the general public's awareness of patient safety issues. JCAHO defines staffing effectiveness as the number, competency, and skill mix of staff as related to the provision of needed services. It has a matrix approach (versus a single indicator) of both human resource (administrative) and clinical (service) indicators. The analysis of these indicators must be done at the level most effective for planning staffing needs within the organization (eg, for the department versus just one shift). Health care organizations will need to select a total of 4 screening indicators: 2 from human resource and 2 from clinical/service. One for each category must be from JCAHO's list of identified screening indicators (Table 1). The other 2 (1 for each category) can be the organization's own indicators. However, all must give data and information that is meaningful and relevant to that service area. For instance, considering the incidence of pressure ulcers might be appropriate for a medical-surgical unit but not an emergency department.Table 1Staffing effectiveness screening indicatorsHuman resourceClinical/service• Overtime•Patient falls• Staff vacancy rate•Adverse drug events• Staff satisfaction•Injuries to patients• Staff injuries•Skin breakdown• Staff turnover rate•Pneumonia• Sick time•Patient complaints• Nursing care hours per patient day•Family complaints• On call or per diem use•Length of stay•Postoperative infections•Shock/cardiac arrest•Gastrointestinal bleeding•Urinary tract infectionsBased on JCAHO criteria. Open table in a new tab Based on JCAHO criteria. Lawrenz Consulting has found the following checklist helpful for organizations to use in identifying potential problem areas in staffing effectiveness:•Is your core staffing meeting 85% of your schedule needs?•Does the core staff feel confident in the quality and performance of agency/traveler nurse the hospital uses?•Does the hospital have performance goals for nursing units or the nursing division as a whole?•Are the hospital's core nurses exhibiting flat or declining performance?•Is nursing turnover greater than 10%?•Are the hospital's nurses in the habit of expecting an annual merit raise regardless of the performance?•Are nurse managers too overworked to make an organized effort to identify and retain top-performing staff?•Does the hospital have sufficient ways to reward and recognize top performing nurses?1 —Carol Ann Cavouras, MS, RN, Principal, Lawrenz Consulting—Healthcare Management Solutions, Phoenix, Ariz; E-mail:[email protected]; www.lawrenzconsult.com Reference 1. Lawrenz Consulting. Staffing effectiveness. Perspectives on staffing & scheduling. 2002;21(1):1-2. For human resource indicators, I monitor staff hours per statistic, overtime use, staff vacancy rate, and the department staffing plan. I use computer software to collect some data. Patient volume (number of visits) has been a traditional indicator for staffing in many emergency departments and correlating the set staff hours per visit to volume would meet the JCAHO human resource indicator requirement. However, an acuity aspect is more informative for an emergency department, and patient acuity rating scales are one common option. I believe a more effective way is to include analysis of the percent of the total ED patient population being admitted. There are many outside agencies approving or reviewing the criteria for any admission, and it becomes a reliable, valid indicator of patient acuity. I have developed a simple equation formula that allows the staff hours to increase as the percentage of admissions increases.1 I have also created and have used an adjusted outpatient census formula to modify staffing to justify staffing for patients who are held in the department for more than 6 hours (waiting for an available inpatient bed).2 I believe ED staff skill mix can be a nebulous indicator for the purpose of the JCAHO survey. There are inconsistencies between facilities for training/qualifications, how employees are counted, or the distribution between the shifts. For instance, environmental, but not registration, personnel are figured in the staffing numbers for our department. However, I still consider this indicator in managing my staff. I use approximately 70% licensed staff (eg, RNs only) and 30% technical/support staff (even if they have a certification, such as EMT-P). Licensed practical nurses (LPNs) are included in the technical description at our facility. Besides length of stay, the other clinical/service indicators I monitor are patient and family complaints, staff satisfaction, and sentinel events. Lewis-Gale Medical Center uses both a standardized national survey and a hospital-based survey to measure satisfaction. Although the JCAHO list places staff satisfaction as a human resource indicator, my experience is that it is more reflective of clinical quality because I have found that staff will stay only if they feel they are able to provide adequate care. I believe it is important that these new JCAHO requirements not be viewed as a burden, but as another tool to ensure adequate staffing for improved patient outcomes.—Camilla “Cami” Jones, RN, Director of Emergency and Transfer Services, Columbia Lewis-Gale Medical Center, Salem, Virginia, E-mail:[email protected] References 1. Jones C. Justifying nurse staffing. In: Zimmermann PG, editor. Managers forum. J Emerg Nurs 2002;28:340-341. 2. Jones, C. Adjusted outpatient census formula. In: Zimmermann PG, editor. Managers forum. J Emerg Nurs 2002;28:60-1.DOI CROSSREF JCAHO modified their standards regarding staffing effectiveness as part of their mission“…to continuously improve the safety and quality of care provided to the public….” Through research there is evidence that inadequate staffing and negative outcomes go hand in hand. However, we also know it is not only about numbers or ratios alone. It is not only the right number and type of staff, but staff competencies and ongoing learning that enable nurses to “rescue” deteriorating patients before they are in trouble. Staff behavior and communication are just as important as staff numbers. Therefore, staffing effectiveness is integrated in the human resource standards (HR.2; HR.2.1), performance improvement standards (PI.3.1.1; PI.4.3), and leadership standards (LD 3.4.1, LD.4.2; LD.4.3). What the surveyor is looking for is a common thread and process in all these standards throughout the organization. Data and process analysis should be driving our decisions for the best, safest patient care. It is not enough to collect data; using data to improve our outcomes is part of this expectation. Human resource data should be correlated with outcomes. How do you know that these staffing numbers (for all departments, not just nursing) were adequate? For instance, did your medication errors increase when your FTE vacancy increased? What did you do about that? Two indicators must be selected from the JCAHO lists—one from the human resources column and one from the clinical/service column (Table 1). A second indicator set should be specifically appropriate based on the patient population served. For instance, collecting data on skin breakdown or postoperative infections would not be as appropriate for an emergency department as patient complaints or wait times might be. What is new under the leadership standard is the requirement to have selected appropriate indicators from the provided list for both the hospital and the individual units. These indicators must be promulgated from the top leadership, have evidence of a holistic alignment throughout the organization, and include involvement of staff. If a staff nurse is asked, will he or she be able to relate what and how the unit is doing with a chosen indicator? Some of the tools that can help an organization think critically about implementating of these standards include established staffing standards, the Malcolm Baldrige Criteria for Healthcare, the ANA Report Card, professional association standards, or outcome measures appropriate for your discipline and patient population. They include many of the exact same staffing effectiveness screening indicators as the JCAHO. At times there are complaints that these standards seem burdensome. It is important to remember that the reason for this whole issue is our concern for patient safety. —Rhonda Anderson, MPA, RN, CNAA, FAAN, Chief Operating Officer, Desert Samaritan Medical Center, Mesa, Ariz; E-mail:[email protected]; JCAHO Commissioner on the JCAHO Board, Accreditation Committee, and Measurement Committee A sentinel event is defined as “an unexpected occurrence involving death or serious physical or physiological injury, or the risk thereof.” In the past, JCAHO had posted 26 sentinel event alerts. Those alerts are still pertinent, but 6 available on their Web site www.jcaho.org bear careful scrutiny. At the time this piece was written, these alerts were:•Patient identification•Communication•High-alert medications•Wrong site surgery•Potassium chloride (KCl)•Infusion pumps Integrate these alerts and related recommendations in your organizational measurements and practice evaluations. When a sentinel event or even a “near miss” occurs, it is important to perform a root cause analysis of what happened to establish accountability (not blame). The JCAHO surveyor will want to know what processes were involved and what was done to prevent that type of event from happening again.—Rhonda Anderson, MPA, RN, CNAA, FAAN, Chief Operating Officer, Desert Samaritan Medical Center, Mesa, Ariz; E-mail:[email protected]; JCAHO Commissioner on the JCAHO Board, Accreditation Committee, and Measurement Committee I worked in a small hospital that does not have any local commercial pharmacies open after 9 PM. We handle this situation by having the hospital pharmacy make and label packets of the drugs that our department most commonly uses for this purpose, such as antibiotics or analgesics. Physicians are allowed to dispense drugs in our state. Thus the process we use is that the nurse obtains the drug packet and gives it to the ED physician. The ED physician then checks the label, initials it, and hands it to the patient.—LyRae Sullivan, RN, CCRN, ED Staff Nurse, SUNY Upstate Medical University, Syracuse, NY; E-mail:[email protected] We provide some “meds to go,” especially if a patient needs to contact a social worker or someone else to make arrangements to have a prescription filled. Pharmacy supplies the department with empty bottles and labels. Nursing removes the medication from the automatic dispensing machine (eg, PYXIS). The physician checks the medication and fills out the label (name, age, drug, dose, and directions). The physician then gives it to the patient when discussing the discharge. We try to limit how often we provide these “to go” medications because it can be difficult to obtain insurance reimbursement.—Virginia Hebda, RN, CEN, Staff Nurse, Emergency Department, Rochester General Hospital, Rochester, NY; E-mail:[email protected] We use a similar process, with the physician writing out the label. Even though the nurse may physically hand the medication to the patient, it is essentially considered and documented in the chart as “dispensed and labeled by Dr X.” We only dispense 2 doses for any patient because that is all the insurance companies will allow for reimbursement. —Susan Horvath, RN, CEN, Nurse Supervisor, Heritage Valley Health Systems (The Medical Center), Beaver, Pa; E-mail:[email protected] According to JCAHO standard R1.1.2.2: “Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes.” The description of the intent indicates that the “responsible licensed independent practitioner or his/her designee clearly explains the outcome…whenever those outcomes differ significantly from the anticipated outcomes.” A licensed independent practitioner is defined by JCAHO as any individual permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the individual's license and consistent with individually granted clinical privileges. It is not beyond the realm of possibility that nurses could be considered the designee, even though they are not licensed independent practitioners. However, informing patients seems to run contrary to the advice given by many malpractice lawyers. It is important to focus on the word “outcome.” This standard does not mean that you have to disclose every time something does not go per plan, such as medication being 2 hours late. Disclosing is necessary only when there was a medication delay and an unanticipated outcome. I recommend, with caution, the document Perspective on Disclosure of Unanticipated Outcome Information. It is published by The American Society for Healthcare Risk Management of the American Hospital Association and is available on its Web site, www.ashrm.org . Overall, its recommendations are sound, but the authors quickly move to having a nurse be the one to inform the patient and/or family. The document notes that “unanticipated outcomes” are often issues that constitute reviewable sentinel events. However, it also suggests that these outcomes “may actually be a known remote risk that could have been discussed in the consent process.” Then, they assert, it is a risk potential and no longer an unexpected outcome. The other question raised is how this new standard will be surveyed. Surveyors are looking for a functioning process for handling such incidents. It is expected that they will ask the hospital leadership about what they do to inform patients of unanticipated outcomes. Their answers will be verified by interviewing caregivers, including physicians, about the policies and handling of these matters.1—Ann Kobs, MS, RN, President &CEO, Type 1 Solutions, Cape Coral, Fla; E-mail:[email protected]; www.TYPE1SOLUTIONS.com Reference 1. Kobs A. A patient's right to know…everything! CurtinCalls 2001;3(9):8-9. The scenario is easy to picture. Mr Jones is having an acute allergic reaction to a bee sting. The ED physician orders 0.3 mL of subcutaneous epinephrine. After you give the injection, you realize you just gave 0.6 mL of the drug instead. What should you do? We have all been in a situation where an inadvertent error has occurred, such as inappropriate dosing, contraindicated medication, or wrong drug administration. Did you admit the mistake? If so, did you and/or the physician inform the patient and/or family? Or did you hold your breath and hope there was no untoward reaction before deciding to ‘fess up’? No harm, no foul! If a complication developed, did you blame it on the disease process or underlying clinical condition? This issue is not easy to face. We certainly do not want the potential ramifications of malpractice litigation. However, we are still bound by our professional oaths and moral obligations. The simple answer, although not easy, is that we have a responsibility to be truthful to our patients and their families. A delay in notification of a medical mistake may further jeopardize the outcome. A failure to admit the mistake, when discovered, will only disrupt the nurse-patient relationship (and you know it eventually will be discovered). Finally, what about yourself? Do you want to live with this emotionally hidden knowledge and the responsibility of knowing you lied to patients who put their trust in you? This decision is not easy. However, you will have to look at yourself in the mirror in the morning.—Bernard Heilicser, DO, MS, FACEP, Medical Director, South Cook County EMS System, Director, Medical Ethics Program, Ingalls Hospital, Harvey, Ill We had a similar experience with our new emergency department. I learned that adjustment problems are a common phenomenon when moving into a newly remodeled facility. A department can typically experience 25% staff turnover during this type of major transition. For us, it was a culture shock after we enlarged from 17,000 square feet to 38,000 square feet. In part, the staff had to adjust to no longer “feeling” the teamwork that is more apparent when you are working in closer physical proximity with your colleagues. It took a full year to resolve the “rough edges” as a result of the changes from our new physical design and processes. However, only 2 staff members (out of 68 FTEs) left during this time. I credit our successful transition to a number of factors:•ED staff was involved in the design process from the beginning plans through the implementation. They had ownership for the design.•We began using as many of the new processes, such as individual supply carts, beforehand to minimize the adjustments to the new facility.•A transitional team was formed to deal with the change-related concerns. Solutions are piloted and then readjusted until we have what works best for our new situation. For instance, staffing teams were changed 4 times until all felt they were properly distributed for our larger area. Be prepared for and respond rapidly to the emotional “trauma” that these major changes create. Having the best of plans minimizes, but not eliminates, the problems of the transition.—Paula Hafeman, RN, MSN, Emergency/Trauma Services Director, St Vincent Hospital, Green Bay, Wis; E-mail:[email protected] We treat prisoners from 2 maximum-security prisons. The prisoners remain shackled at all times with 2 guards present. One guard is armed and the other is not. The unarmed guard remains at the bedside with the nurse at all times; the armed guard remains within 6 ft of the prisoner. —Sue Smith, Staff Nurse, Emergency Department, JCBlair Hospital, Huntington, Pa; E-mail:[email protected] Our hospital handles the various types of situations differently. Long-term prisoners are brought in with shackles on all extremities. They are accompanied by 2 unarmed guards, per both the prison and hospital policy. We see many state prison inmates and have never had anything even close to an incident during this type of scenario. However, police officers remain armed if the prisoner was just arrested and was now brought for a medical complaint. This category of prisoner patients can be volatile, and we have had several incidents of uncontrolled behavior requiring intervention. The police officers are obviously trained in prevention of a prisoner capturing their weapon. One reason for the distinction is that we believe the long-term prisoner would be more likely to attempt an escape by grabbing an officer's weapon.—Gordon Rogers, RN, CEN, Clinical Supervisor, Emergency Department, University of Missouri Hospital, Columbia, Mo; E-mail:[email protected] A peace officer guarding a prisoner is allowed to retain his weapon in the emergency department. If you disarm the officer, who is providing security in the case of a planned escape by the prisoner or his or her friends? As a former peace officer, I would never relinquish my weapon unless I was entering a secured facility, such as a jail. The exceptions are (1) when an officer is a patient and his or her personal condition would result in not being fully capable of physically and/or mentally performing or (2) if another officer is present to provide security for the unarmed officer.—Darrell Donaldson, RN, Associate Manager, Emergency Department, Baylor Medical Center of Garland, Garland, Texas; E-mail:[email protected] Our inner-city level I trauma center receives prison, customs, and immigration prisoners, including body packers or “mules” (patients with drugs in plastic bags hidden in body cavities). Officers remain armed. One important point is that any law enforcement officer in an identifiable uniform (even if it is only a jacket) needs to carry his or her weapon to avoid becoming a target him or herself. Imagine the easy mark they would become if it was known that these officers do not carry weapons inside a hospital. In addition, the visual presence of a weapon is a deterrent in and of itself. A weapon is part of the equipment of the law enforcement profession, just as a stethoscope is nursing's tool of the trade. Besides, who else is better trained in how to keep the weapon secure?—Sharon S. Cohen, RN, MSN, CEN, CCRN, Trauma Clinical Nurse Specialist, North Broward Hospital District, Ft Lauderdale, Fla; E-mail:[email protected] I do not recommend having police officers secure their firearms with hospital security for several reasons:•The police officer can be recognized as such, and thus become a target, even if he or she is in plain clothes.•Placing a firearm in a locked box with unarmed security officers is not, in my opinion, “adequately secured.”•Disarming police officers inhibits them from being able to completely fulfill their police role functions. Therefore this action places the liability on the hospital security department to provide protection within the hospital at the same level as the police would. Does everyone honestly believe their hospital security can meet that standard? Our department's policy is for officers to remain armed whenever they are on duty except within secure prison facilities. We even carry arms onboard aircraft if we are escorting a prisoner or will be taking custody of one immediately upon landing at our destination. In the end, a hospital cannot regulate corrections officers specifically or law enforcement generally. I do not know of any state that does not allow corrections officers to carry a weapon in the performance of their duties. —Sergeant David Adler #100, EMT-P Police Department, City of Philadelphia Housing Authority, Tactical Medic-SWAT, Philadelphia, Pa; E-mail:[email protected] The ENA position statement on telephone advice was revised in December 2001. It states, in part, that “sophisticated telephone triage programs provide quality health care assessment opportunities…It is deemed essential that these established programs utilize:•Experienced professional registered nurses with specialized education in triage, telephone assessment, communication, and documentation skills.•Mandatory continuing education requirement for all telephone advice staff.” In the statement of the problem, it is noted that some consumers may instead call the emergency department (rather than an established telephone triage program). The ENA position statement continues, “…Nurses must complete an educational program in telephone assessment prior to performing in the role. Programs must be established with specific policies, protocols, education, documentation, and quality improvement programs.” “For nurses who perform this function without an established telephone triage program and without appropriate education in the specialty area, the consequences can be devastating….” A complete copy of the position statement can be obtained from the ENA Web site at www.ena.org/services/posistate/data/teladv. — Sherri-Lynne Almeida, RN, MSN, MEd, DrPH, CEN, EMT-P, President, ENA; Chief Operating Officer, Team Health Southwest, Houston, Texas; E-mail:[email protected] We have a typed note by the phone in the emergency department. Anyone can read it to a caller seeking medical advice, including the unit clerk. The sign states: “We understand that you are concerned about ____ (your husband, self, etc). However, it is not safe, nor is it in your best interest, for us to give you advice over the phone. You do have some options. If this is an emergency, hang up and dial 911. You can call your physician or whoever is on call for them. Or you can go to your closest emergency department.” To further support this policy, I also tell patients when I discharge them to return for the reasons listed. I indicate that we cannot give advice over the phone. The greatest benefit from having this statement is that the unit clerks can read it without having to obtain a nurse. The callers' usual reaction is to say “Oh, I figured you would say that but I wanted to call anyway” or “thanks anyway,” or they just hang up. The most important aspect of this procedure is that every staff member is doing the same thing even if it does not appease every single caller. All it takes is for one person to give some advice to diminish all the efforts of the other staff's compliance, as well as to open up the hospital for legal ramifications.—Shelley Cohen, RN, BS, CEN, Health Resources Unlimited; E-mail:[email protected]; www.hru.net ; per diem, Emergency Department, NorthCrest Medical Center, Springfield, Tenn I first listen as the caller describes his or her symptoms or otherwise poses the question. I ask them questions to elicit further information, communicating a sense that I am very interested in their problem. Then, when the caller has finished telling me everything they want to tell me, I say something like this: “You know, it is very hard to make a diagnosis of something like you are describing over the phone. It generally takes a physician's hands-on physical examination, and possibly even some laboratory tests or x-rays, to really be sure what is going on. We would be happy to see if you feel like this is something that shouldn't wait until you can see your regular doctor. Do you feel like you could wait until you can call your doctor, or would you like to come on in now so we can check you out?” I also add, when necessary, that I could not possibly recommend treatments if I am not sure what I am treating. With this approach, I have effectively told them the same thing as those who just say, “Sorry, we can't give advice over the phone.” However, I have done it in a way that allows the caller to feel that someone has listened to him or her and offered the best solution considering the limitations of a “telephone consultation,” which in fact is the case. As a result, it avoids both the customer service repercussions of not giving advice and the legal repercussions of giving advice. I have had very few upset callers, and many thank me profusely for listening and helping them. The other advantage is that sometimes you do get someone who describes an ominous symptom, such as crushing chest pain with shortness of breath. Then you can truly give them some advice: “Hang up and dial 911 now!”—Gordon Rogers, RN, CEN, Clinical Supervisor, Emergency Department, University of Missouri Hospital, Columbia, Mo; E-mail:[email protected] Unless you are a separate pediatric hospital, I do not recommend it. We have found that it works best for all ED staff to have a comfort level with every type of patient. Pediatric nurses recruited into an ED setting, versus an inpatient unit, need a lot of support for the transition and are sometimes not interested in working with adults. Similarly, I would be cautious about separating the triages. It will be easy to lose track of, as well as hindering the flexibility to meet, the activity of the entire department.—Phillip Sheard, RN, BAppSC, MCN(NSW), Clinical Nurse Educator, Sydney Hospital Emergency Department, Sydney, Australia; E-mail:[email protected] At one large hospital where I worked, triage of all patients was done at one point. This helped maintain control of what was going on across the entire department. The pediatric patients also had their own after-triage waiting area, with wall murals, books, and toys, which isolated them from the often inappropriate scenes in an adult waiting area. Our 7-bed dedicated pediatric ED area, just off the main emergency department, was staffed by rotating, general senior ED nurses and ED physicians. If any child waited longer than 1 hour to see the physician, we would request additional help from the inpatient medical senior resident (Paed Registrar). However, we recognized that pediatric inpatient nurses have different skills and we did not ask them to float to the emergency department. We created a program to allow pediatric inpatient nurses and ED nurses at the same experience levels (junior/intermediate/senior) to “swap” for shifts. These nurses were included in the staffing numbers but given suitable support and mentoring. This seemed to be the best of both worlds. We all learned from each other and gained a better understanding about the differing roles, functions, and skills. We also arranged an exchange program, as staffing and skill mix allowed, with a dedicated children's hospital in our metropolitan area. Our general ED nurses were able to gain experience in management of chronic or specialized pediatric illnesses often not seen in general emergency departments, such as genetic or oncologic conditions.—Cathi Montague, RN, RM, Emergency Department, Lyell McEwin Health Service, Adelaide, South Australia; President of South Australian Emergency Nurses Association; E-mail:[email protected] Studies document several forms of interviewer bias. Being aware of bias is the first step. It is important to consciously try to avoid these tendencies so they do not lead to discrimination or poor hiring decisions. A few of the more common biases are:•Hiring in the same image: People tend to hire others who remind them of themselves. Although that in itself may not be bad, rejecting others because they are not similar could result in discrimination.•Stereotyping: Having a preconceived opinion about how people of a certain gender, race, age, etc, will perform.•First impressions: It is said that a person's opinion of someone is formed in the first 4 minutes of making contact. Those types of snap judgments can be powerful and can affect the objectivity of the interview. In an unstructured approach, the interviewer may just be asking questions to confirm their preformed conclusions. To avoid this, I recommend having some basic questions that are consistently asked of all candidates.•Halo/horn effect: One or two points (positive or negative) overshadow all other information.•Contrast effect: Rating the candidates only against each other rather than the requirements of the position may make some appear more qualified than they really are. It is important to have a current, welldeveloped job description and compare all candidates against that. Experienced managers develop instincts about people. Most professional human resource information suggests that hiring should be objectively based on a careful analysis of previous work performance, behavioral characteristics, and possibly even pre-employment testing. I recommend that you do not ignore your concerns but explore them. Gut feelings can be an indicator of the need to probe deeper. This could be done through reference checking, testing, the impressions of others, or more extended interviewing. Overall, it is a basic assumption that, qualifications and backgrounds being mostly equal, managers hire the person they like best. This is not necessarily bad. The manager will tend to put more energy and thought into helping the candidates succeed on the job if he or she likes them.1—John Vicik, MSIR, SPHR, Director, Human Resources, Mather LifeWays, Evanston, Ill; E-mail:[email protected] Reference 1. Vicik J. Staff hiring. In: Zimmermann PG, editor. Nursing management secrets. Philadelphia: Hanley and Belfus; 2002. p. 99. New employee socialization is crucial to retention. All employees have a period of proving their competency to gain credibility. First, do not contribute to the problem by making endearing proclamations ahead of time, such as “he is going to work out beautifully.” Such comments set up the employee, and you lose credibility if the candidate does not work out. New employees sometimes behave in a way that irritates the existing staff. These behaviors can include trying to take charge, constantly referencing their last (superior) job, maintaining an “I am the expert” attitude, exhibiting territorialism or self-isolation, failing to respond to suggestion, or lacking initiative. These behaviors may be an effort to quickly prove competence or a result of insecurity. It may indicate that the new employee is not feeling accepted. Privately discuss your observations with the employee. Explore his/her specific areas of concern, provide appropriate encouragement, and reinforce your expectations for teamwork.1—Camilla “Cami” Jones, RN, Director of Emergency and Transfer Services, Columbia Lewis-Gale Medical Center, Salem, Va; E-mail:[email protected] Reference 1. Jones C. Orientation and socialization of new employees. In: Zimmermann PG, editor. Nursing management secrets. Philadelphia: Hanley & Belfus; 2002. p. 104-5. From my years of experience in and with managed care, I know that this is not an unusual request. The patient is probably appealing the decision about his coverage. Refer to the contract you have with the managed care plan. Many contracts include the right of the managed care plan to review all medical records on its members, and many also require that the copies be made at the expense of the provider, whether that is the hospital or medical practitioner. In contrast, most attorneys' offices will offer reimbursement for copying records. Then again, the attorney may be suing you; the managed care plan usually is not. On the other hand, there are some new considerations under the Health Insurance Portability and Accountability Act (HIPAA). The Department of Health and Human Services published these privacy regulations on December 28, 2000, and they must be implemented for employer-sponsored group health plans by April 14, 2003. HIPPA tightens patient confidentiality and the release of medical information (related to past, present, or future conditions) in nonemergencies. Violators are subject to civil penalties and prosecution, with the determining factor not based on the harm done by “on the willingness of the covered entity to achieve voluntary compliance.” Under HIPPA, no information can be released without a signed statement from the patient giving permission, specifying the intended recipient and the scope of information to be released. The only exception is when the life of the patient is in jeopardy.1—Robert D. Herr, MD, MBA, CMCE, Medical Director, Utilization Management, Group Health Cooperative of Puget Sound, Seattle, Wash; E-mail:[email protected] Reference 1. Herr RD. Managed care concerns. In: Zimmermann PG, editor. Nursing management secrets. Philadelphia: Hanley & Belfus; 2002. p. 77.