This is an archive page. The links are no longer being updated.
REMARKS BY: DONNA E. SHALALA, SECRETARY OF HEALTH AND HUMAN SERVICES PLACE: American Academy Of Nursing, Arlington, Virginia DATE: November 19, 1999
Since 1973 you've been on the front lines: addressing the toughest issues and crafting creative responses to new challenges. And, in the process, you've done something else, too. You've not only helped remind our nation that nursing is a profession was essential to American health care in the 20th century, you're also teaching us that -- if we truly believe in quality -- nursing scholars and leaders will need to play an even greater role in the 21st.
That's why I was particularly proud to name Virginia Betts as my department's first senior advisor on health policy and nursing. Because we understand that when Florence Nightingale challenged hospitals to "do the sick no harm," she wasn't speaking to the problems of the past, but to the challenges of the future.
And we understand something else, too: that the kindness, character and skill of a highly trained nurse is sometimes all that's protecting our loved ones from a system whose bottom line, too often, is less about providing care than it is managing costs. But even though Americans depend on the warm hearts, sharp minds and strong voices of nursing professionals as never before, there isn't a person in this room who needs to be reminded that fulfilling the "Nightingale Pledge" is getting tougher every year.
In his book Return to Paradise, Breyten Bretenbach once wrote: "I came. I saw. I was confused." He could have been writing the textbook for an introductory class on modern health care.
What began a generation ago as winds of change in America's health care system have since grown to hurricane force. And, in the process some of our most sacred assumptions about health care have been uprooted.
Between 1988 and 1995 alone, the proportion of individuals enrolled in managed care soared from 29 percent to 73 percent. As a result, nurses today work in a far different health care system than they did even ten years ago.
As most Americans are well aware, it's a system where shorter hospital stays are the norm, not the exception . . . a system that places greater emphasis than ever before on out-patient services, home health care and skilled nursing facilities as an alternative to hospitals and nursing homes.
Is it a more efficient system? Maybe it is. But it's also one where quality patient care has too often been compromised. A system that all too often fails to do the right thing, at the right time, in the right way for the right patient. That's part of the reason why it's been estimated that 180,000 people in this country die each year from medical errors. That's the equivalent of three jumbo-jet crashes every two days.
I believe revelations like that should motivate us as much as Florence Nightingale's critique of hospitals in the Crimean War did a century ago. And much as her work ushered in the use of research and statistics to measure quality and identify the need for reform, the work of members of this Academy -- and other scholars -- can do the same. It must. Because the collection and analysis of this kind of data isn't just academic. It's often a matter of life and death.
Our research tells us that, today, it's all too often a simple matter of the underuse, overuse or misuse of treatments and procedures. The 1991 Harvard Medical Practice Study found that four percent of hospitalized patients in New York State suffered injuries stemming from treatment. Two thirds were caused by errors -- and nearly 14 percent of them were fatal.
And that's only the beginning. At HHS, our research has found that one-third of the hospitalized elderly who were discharged on one anti-depressant were on a dose below the recommended level. In a similar vein, less than half of diabetic adults had received a dilated eye exam in the past year.
And, over the course of one year, a sample of health plans found that nearly one out of every five hysterectomies performed were inappropriate. These are major problems. The question is: What's the solution?
I think much of the responsibility rests with large purchasers of health care in both the private and public sectors. Even though 90 percent of Americans say quality ought to be a top factor in choosing any health plan, in the past, too many purchasers failed to demand it of the firms they contracted with.
Can consumer pressure improve quality? Absolutely. Last week's announcement by UnitedHealth Group may prove to reflect how that can happen. But the truth is that today relatively few consumers -- institutional or individual -- are even in a position to judge the quality of the health care they receive.
In 1996, together with the Kaiser Family Foundation, we conducted a survey that revealed only 14 percent of the consumers we asked could ever recall seeing any quality data at all to help guide their choice in health plans. That's why we're proud that, at AHCPR, we were able to launch the Consumer Assessment of Health Plans, or CAHPs. It's the biggest initiative yet to help consumers learn about the quality of the plans their families depend on. In fact, today it's available to over 90 million Americans.
But while we're proud of CAHPs, we also know that the vast majority of consumers still have little idea what questions to ask of providers on their own. They don't know how to ask whether a plan will provide all the services our families need, let alone whether a provider or a hospital has had much success treating a certain condition. And, believe me, I'm no exception. I can always pick up the phone and call John Eisenberg at AHCPR, but, lucky for him, not that many people are able to do that.
That's why I believe that, in the years to come, it will become the special mission of the nursing profession to help Americans navigate their way through this new health care system. Much as you've always been the leading edge in providing health care in the hospital and the home, I see America's nurses emerging as a new force for the education of health care consumers. To a great extent that's already the case. But let me be clear: Promoting quality depends on more than educating consumers -- it also depends on empowering professionals, and that's why we need the Patients' Bill of Rights.
But don't take my word for it, just ask Suzette Sewell.
Suzette is an RN, MSN, CCRN who worked at a hospital in Kentucky until she was terminated for -- quote -- "insubordination." What did she do that was insubordinate?
Suzette, together with 37 other nurses, signed a letter expressing the concern that staff was being assigned to units to perform procedures they hadn't been adequately trained for.
But you don't need to hear those stories from me, because to be a leader in this profession is to understand the scope of the problem. And to know what it means when families and health professionals find themselves having to fight just to make sure patients get the treatment and quality care they need. And that's what makes the Patients' Bill of Rights so important.
That's why, even though Congress has yet to take final action to pass our Bill of Rights, the President has already enacted an executive order which guarantees its protections to the 80 million Americans in federal health insurance plans. Even more, we're also telling any prospective insurer, that if you want to join in the federal system - you must honor the Patients' Bill of Rights.
But let me be clear: America's commitment to quality -- and strengthening the nursing profession -- can't end with the P.B.O.R. In many respects, that's where it needs to begin. It was just a year ago that AHCPR released the landmark study by Christine Kovner and Peter Gergen. You'll recall that their analysis found that patients undergoing major surgery at hospitals with limited nursing staffs clearly run a higher risk of developing complications. The report not only demonstrated once again the critical importance of quality research, it underscored a concern nursing professionals have been raising for years.
And, as everyone here is well aware, we're beginning to see legislative efforts take shape in several states to win the staffing guarantees similar to those Governor Davis recently signed into law in California. In the past, policy makers have generally taken a very cautious stance toward codifying staffing ratios. But, unless providers play a more proactive role in responding to what America's nursing professionals are saying -- I'm convinced that may change. You and I know that any contract settlement or state law setting nurse staffing ratios will prove a hollow victory unless hospitals have the trained professionals to fill those positions.
Today, they often don't -- and, as the leaders of this profession, I know you understand that poses one of the biggest threats to quality of all.
No one in this room needs to be reminded that, during the shortages of the last three decades, RNs averaged in age from the early 20s to mid 30s. Those, of course, are the nurses who are more likely to respond to financial incentives to work longer hours.
Well, today's nurses are older. They're not looking to work extra hours. In fact, many are planning for their retirement. That's in large part the genesis of the staffing problem we have today -- and the staffing crisis we may be faced with tomorrow.
Because, as it stands now, as the current generation of nurses prepare for retirement, America may not have the skilled professionals we need to replace them with. Some think that will inevitably lead to lower school admission standards. While that's a response, you and I understand it's not an answer.
Instead of sanctioning the erosion of the profession --whether through deskilling or lowered admission standards -- I think it's up to us to work together to strengthen it. I think that begins with making the nursing profession more attractive. In short, we need to guarantee that nursing professionals continue to enjoy the kind of respect . . . the kind of autonomy . . . and the kind of rewards they've earned through their skill and their commitment.
We need to expand public understanding of the nursing profession and -- that includes investing in nursing research.
I'm proud of our support for the National Institute for Nursing Research. I'm equally proud of the research that's focused on patients produced by a generation of nursing scholars many of whom are represented here today in this distinguished academy.
Florence Nightingale once described statistics as "the most important science in the world." Yet, today, America still has no coherent agenda for nursing research. That's one challenge that I invite you to continue to help us respond to.
But, as you know, there's another challenge that goes beyond research. It's strengthening nursing education nationwide. The fact is we need to look two and three generations ahead and invest today in the scientific literacy of America's young people. We want to help young girls and boys develop an interest in nursing today -- and prepare them to meet tough standards at nursing schools tomorrow.
Because if there's one thing I've learned as HHS Secretary it's that a strong, growing, highly skilled nursing profession isn't the byproduct of a quality health care system -- it's a precondition for it.
A moment ago, I shared some of Florence Nightingale's words with you. In closing, let me share some others. Nightingale once said -- and I quote -- "the most important lesson to be given to nurses is to teach them what to observe."
In that spirit, I want to challenge you to continue to not only observe, but to act. I want to challenge you to help see to it that tomorrow's nurses are prepared to meet the challenges of a new and constantly changing health care system. I want to challenge you to continue to act to make the nursing professional the voice of those who, all too often, are too weak to speak for themselves.
And, above all else, I want to challenge you to continue to produce research of the first order.
Thank you.