Editor’s Note: Many of us have know for quite some time that the
industry-funded Joint Commission does not work to maintain standards of
nursing practice, only paperwork standards. It’s facility reviews have been
trumpeted in advance, and all the dirt is swept under the rug. It’s not a bit
surprising that JCAHO is now uttering opposition to efforts to hold health
facilities accountable for unsafe staffing patterns, by the state.
California’s nurse-patient ratio safe staffing legislation, and efforts
elsewhere to establish the same criteria, is a firm rebuke. And nurses
worldwide are on the move to defend their patients and their practice. -
Sandy Eaton, RN

Joint Commission Seeks Input On Draft Standards
Assessing the Effectiveness of Staffing In
Health Care Organizations

Media Contact:
Charlene Hill
Media Relations Manager
630.792.5175
E-mail: chill@jcaho.org

(Oakbrook Terrace, Ill. - March 27, 2001) The Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) today announced the field
review and planned pilot testing of draft standards and performance
indicators to assess the effectiveness of staffing in health care
organizations nationwide. In consultation with a national panel of over 100
experts, the Joint Commission has developed a new approach to assessing
staffing effectiveness that does not depend on staffing ratios; but rather,
utilizes an evidence-based model that relies on the application of sets of
clinical and human resources indicators to screen for potential staffing
issues.

The increasingly apparent national shortage of qualified, professional
personnel, coupled with the growing scrutiny of staffing effectiveness and
its impact on patient safety, have created flashpoints of both concern and
controversy in the health care field. To make matters worse, actual and
contemplated legislative initiatives in multiple states would mandate
specific staff-to-patient ratios - a most undesirable "problem resolution" in
the view of the Joint Commission.

Against this backdrop, the Joint Commission has - for almost two years now -
been working through its Oversight Task Force on Accreditation Process
Improvement and its various advisory groups to progressively develop an
assessment model that is objective and methodologically sound. This model
provides the framework for the draft standards and performance indicators.

In an effort to obtain broad input, the draft standards and indicators, and a
questionnaire have been sent to more than 5,000 individuals and
organizations, including professional associations, consumer groups,
government agencies and organizations accredited by the Joint Commission.
They are also posted on the Joint Commission's Web site
<http://www.jcaho.org/standard/staff_effect_fr_ltr.html> for comment.

Reviewers are asked to provide their opinions on the approach to assess
staffing effectiveness and the proposed standards and indicators, and to
suggest alternative evidence-based models and/or additional indicators
sensitive to staffing effectiveness. The deadline for input is April 15, 2001.

The feedback received will be used to shape the pilot testing of the
standards and indicators later this spring. Organizations participating in
the pilot test will be asked to select and collect data for specified human
resources and clinical indicators and participate in a 'virtual survey'
through a conference call and exchange of documents. The surveyor will review
the organization's rationale for indicator selection, the data collected, the
results of the organization's analysis of the data, and any actions taken on
the basis of the data. The findings of the pilot test will not impact any
organization's accreditation status.

The new assessment initiative relies upon the use of matrices of both human
resources and clinical outcome indicators. The approach both acknowledges the
relationship between human resources and clinical outcomes and recognizes
that no single indicator can reliably describe staffing effectiveness.

Human resources indicators will encompass all staff that provide health care
services - including direct caregivers, such as registered nurses and
respiratory therapists, as well as clinical support professionals responsible
for pharmacy, laboratory and radiology services. The new assessment model
will eventually apply to almost all of the Joint Commission's accreditation
programs.

The assessment model anticipates use of evidence-based indicators specified
plus measures selected by the individual health care organization that
reflect its own unique characteristics.

The proposed model reflects the consensus of a broad-based expert panel that
was convened by the Joint Commission in September. Panelists shared ideas on
ways to improve the current JCAHO approach to the assessment of staffing
effectiveness and provided recommendations regarding those indicators that,
collectively, would best serve as screening tools for identifying potential
staffing effectiveness issues.

Current JCAHO standards require accredited health care organizations to
formulate and meet specific staffing plans that effectively address
identified patient care needs. These staffing plans are usually based on
internal formulae that are sensitive both to numbers of patients and to the
complexity of care required by the mix of patients typically being cared for
by the organization.

Organizations interested in participating in the pilot test should contact
Carol Gilhooley, director, Accreditation Process Improvement, 630-792-5270.

-------------------------------

World Trade Organization Targets Canadian Health Care System

by Stuart Laidlaw, Toronto Star

March 28, 2001

Despite its failure to get a mandate in Seattle, the World Trade Organization
has been progressing with free trade talks in Geneva for more than a year.

The talks, required to start by 2000 under past trade deals, have been held
with very little fanfare, behind closed doors and with little input from
those affected.

This week, three more days of talks will take place - again in Geneva, again
behind closed doors and again without input from those affected.

And make no mistake about it: health care will be on the table.

Ottawa, of course, has vigorously claimed otherwise. It has, after all,
invoked a feature of existing world trade deals allowing countries to
specifically exempt parts of their economies from international free trade
rules. On the face of it, this would seem to protect our cherished health
care services from foreign and private incursion.

A closer look, however, reveals several concerns.

First off, both the U.S. and Europe have said they will be demanding an end
to such exemptions. If they are successful - and these two working together
make a powerful team - Canada's protection will be gone. Canada's own
bargaining position at these talks - demanding the right to export health
care while not allowing any imports - dangerously undermines our credibility
in arguing to keep health care off the table.

But even if the U.S. and Europe are not successful, and even if we can
successfully negotiate our import-banning, export-pushing trade position,
there is still plenty of reason to worry. That's because, while health care
itself is exempted, much of what makes it up is not.

Take public health insurance. Canada has registered health insurance at the
World Trade Organization as a financial service, leaving the very heart of
medicare vulnerable to trade deals requiring Canada to open the field to
foreign and private investors.

You would hope that this classification applies only to the private health
insurance plans many of us enjoy at work to cover dental care or medication,
but there's nothing in Canada's WTO commitments to spell that out. It just
says "health insurance," leaving it up to the WTO to define for us.

There's more. The Canadian Centre for Policy Alternatives - echoing
sentiments by more conservative trade experts such as John Kirton of the
University of Toronto - argues that Canada could see much of its medicare
system whittled away under the WTO's General Agreement on Trade in Services.

Services such as labs, food services, janitorial services, accounting, data
processing, telecommunications (such as Ontario's new phone-a-nurse service)
and even hospital administration in the form of management consulting are
already under the purview of the WTO's agreement on trade in services.

A foreign company could argue that it is not trying to tell Canada how to run
its health-care system, but just wants a shot at managing parts of it. If the
WTO agrees - and it tends to favour free market arguments - we would be
forced to allow private companies into our health-care system.

Not that private companies aren't already in the health business in Canada -
which further weakens the government's assertion that medicare is safe from
the WTO.

Here's how: The WTO allows governments to exempt any service provided "in the
exercise of government authority," as long as such services are not also
available commercially.

In other words, if a service is exclusively provided by the government, it is
exempt. But if that service is provided through a mix of both government and
private interests, it is open to the full force of the WTO.

Health care is such a service. The government, through medicare, obviously
plays a huge role. But much of the health-care system is, in fact, privately
run. Doctors' offices operate as private businesses. So do the labs in many
hospitals, after-hours clinics, dental offices, homecare providers and
nursing homes. Even the hospitals themselves are often private, non-profit
corporations. This makes our health-care system a mixed private-public
system, and therefore subject to WTO rules.

Ottawa's trade negotiators have characterized such concerns as
"hypothetical," and doubt any such challenges would ever materialize.

That is folly, and we need only look as far as the recent death of the Auto
Pact to see the threat to health care.

The 35-year-old pact regulating the manufacturing of cars in North America
was struck down by the WTO last year under its General Agreement on Trade in
Services, the deal being refined and expanded this week in Geneva.

The Auto Pact required that the Big Three automakers make as many cars in
Canada as they sold. Japan and Europe successfully argued before the WTO that
the deal actually regulated the marketing of cars, not the manufacture.


And because marketing is a service, the Auto Pact fell under the General
Agreement on Trade in Services, which requires that countries treat foreign
companies the same way they treat domestic companies. That forced Canada to
lift the tariff on Japanese and European imports.

If the World Trade Organization is willing to stretch the coverage of its
service deal to include auto manufacturing, you can bet it will be willing to
bring Canada's health-care system under its umbrella, too.

Brave words by our negotiators and doubts that it will ever happen are simply
not enough.

Four weeks ago in this space, John Core, former head of the milk marketing
board, urged farmers to keep a close eye on the agricultural talks in Geneva
to ensure that Ottawa's negotiators stick to their commitments to protect
Canadian farmers.

"It will not be acceptable at the end of the talks for our negotiators to
say, `We tried,'" he wrote.

It's a warning we all should heed.

Stuart Laidlaw is a member of The Star's editorial board.
Copyright 1996-2001. Toronto Star Newspapers Limited

----------------------------

Inside the AFL-CIO
Issued Every Tuesday
Column #2 March 27, 2001

New Steelworkers-Nurses Alliance To Challenge SEIU on Organizing

by Harry Kelber

The United Steelworkers of America has formed an alliance with the California
Nurses Assn. to organize millions of hospital workers who have no union
protection.

The new group, known as the Health Care Workers Alliance, will join a crowded
field in which at least eight international unions have staked out
jurisdictional claims by organizing at least one hospital. But the Alliance's
toughest task will be to compete successfully with the Service Employees
International Union, which has organized 710,000 health care workers and is
recognized by the AFL-CIO as the dominant union in the industry.

Instead of organizing hospital by hospital, the Alliance plans to target
chains of hospitals and entire regions, as well as other segments of the
industry, according to Steelworkers' President Leo Gerard. The 700,000-member
union has increased its organizing budget from $12 million in 1997 to $40
million this year, he added.

"We will be able to change the dynamics in the industry and make it a 'caring
system' again," said CNA President Kay McVay. "By working with the USWA, we
will have additional power to protect the professional practice of nurses."

In recent years, a "catch-all" organizing approach has become so prevalent
that unions with no direct connection to the health care industry have been
trying to organize workers all over the country. Operating Engineers, Food
and Commercial Workers, Teachers, Communications Workers, Teamsters,
Laborers, Public Employees, Steelworkers and Mine Workers have all jumped
into the fray. The Service Employees, the largest and fastest-growing AFL-CIO
union, have organized more health care workers than all the others combined.

Why the focus on hospitals? Because they have been relatively easy to
organize. Unions can boast a win rate of about 60% of all National Labor
Relations Board elections at hospitals, according to the SEIU, while the
overall average win rate for 1999 was 51.3%. Lately, however, more hospitals
are hiring professional union-busters who specialize in crushing organizing
drives.

Gerard notes that only about 10% of the nation's 11 million health care
workers are organized and that employment in the health care industry is
projected to increase to between 17 and 18 million by 2010. There are "tons
of opportunities" for unions, he says, citing areas in New Mexico, Nevada,
Arizona and Florida where the unionization rate in health care is only 2 to
3%.

The CNA's aggressive organizing tactics have enabled it to double its
membership to 35,000 in the past few years. The alliance with the
Steelworkers will allow CNA to capitalize on its contacts with tens of
thousands of pro-union nurses.

The Service Employees have not responded publicly to the challenge posed by
the Alliance. But whatever its reaction, SEIU can be expected to charge the
Steelworkers with violating Article XX of the AFL-CIO Constitution, which
deals with jurisdictional disputes, since it has clearly established
dominance in the health care field.

Within the AFL-CIO, questions are sure to be raised about the Steelworkers'
decision to choose the independent union as its organizing ally. CNA has a
reputation for taking non-traditional stands on economic, social and
political issues. For example, it supports universal health insurance and a
national Labor Party, and it endorsed Ralph Nader for president in 2000.

The Alliance has launched its first campaign at two Columbia-HCA hospitals in
San Jose, Cal. - Good Samaritan and Mission Oaks - where CNA already
represents nurses and they will work with the Steelworkers' organizers.

The USWA-CNA alliance is, in part, a response to AFL-CIO President John
Sweeney's complaints that the Steelworkers aren't doing enough organizing.
Adding to the USWA's resentment is Sweeney's frequent praise for SEIU, the
union he headed before becoming the top AFL-CIO official in 1995.

Scattered within so many unions, hospital workers cannot speak with one voice
about their needs and aspirations. Ultimately, there may have to be a
conference of all unions in the health care industry to agree on a unified
national organizing strategy. In the meantime, jurisdictional conflicts can
and should be avoided, particularly since there are more than enough
hospitals and nursing homes out there to keep organizers occupied for years.

This new weekly column, "Inside the AFL-CIO," can be viewed every Tuesday at
(www.la