Sunday, September 25, 2011

Unions: A Double Edged Sword

Union membership comes with the job at Kaiser Permanente. And while I labor under a brand-spanking-new contract that arguable makes me one of the highest paid nurses on the planet, I often find myself at odds with the advice and tactics of CNA (the California Nurse’s Association).
The work stoppage of September 22nd is a good example. Twenty-two days into a newly minted, CNA negotiated, and extremely generous contract, nurses were asked, by CNA, to honor a one-day work stoppage with workers negotiating their first contract between NUHW (National Union of Healthcare Workers) and Kaiser. I personally found the request shocking and divisive.

Most Kaiser North Valley (greater Sacramento) nurses were surprised to learn that 34 hospitals and 23,000 nurses throughout the Central Valley and northern state were affected by the CNA call-to-action. Clearly this was a CNA flex of muscle and show of power. “The nation’s largest-ever strike by nurses,” CNA reported.
“When I learned that Sutter’s and Children’s nurses were out I thought good, I’m supporting them too,” one colleague said. That’s certainly one way to look at it.  

I’ll assert that few Kaiser nurses had knowledge of a larger, coordinated, and politicized call-to-action by CNA. Why was that information withheld? Why were Kaiser nurses asked to participate while local Sutter nurses did not support the Sutter Bay Area work stoppage?

In my book, withholding information is tantamount to lying. I want “to know”, not “find out” on the evening news. In other arenas it’s called a sucker punch. Shame on you CNA!
Full disclosure and informed choice may not have changed the outcome of the day but that does not negate their obligation, nay duty, to fully disclose. I do have the option to divert my union dues to charity. When my shiner and fat lip heal, I may investigate that option.
Fool me once, shame on you – fool me twice, shame on me.

NOTE: I am debating on sending this to the Sacramento Bee – Letters to the Editor. The problem is two fold. First, it is written as if I unknowingly went out on strike. I did not. I chose to report for work on my day off to support Kaiser through this day. Second… retribution. Kaiser is a CNA stronghold, the issue is polarizing, and … as you learned in my last episode with the robot, I CLUCK, cluck, cluck, cluck, cluck.

Saturday, September 3, 2011

It IS Silicon Valley after all…

I ate in the car and drove into the night. I had a general idea of direction and roads though the connector between I-680 and I-880 was not broadcast and signed many miles upstream – as is both customary and expected on California’s interstates. I exited 680 two miles too soon, pulled into a Chevron to check Google Maps on my iPhone, and backtracked to the interstate to proceed yet again, in a southerly direction. 
Maybe I’m getting to old for this, I thought. I felt intimidated if not a little lonely, pressing on in darkness to an unfamiliar city. My destination was El Camino Hospital of Silicon Valley. I would train nurses working the night shift, get a few hours of shut-eye, and return for a full eight-hour day and two-plus-hour drive home.
One more wrong turn, one more U-turn, and I parked parallel on the street fronting the hospital. Expansive lawns glowed beneath an iridescent moon - their edge an eerie blend of blackness and dappled moon-glow.

El Camino occupies a large, wooded campus with tree-lined drives. The night was clear; stars peeked through the canopy overhead, branches swayed in the bayside breeze. Voices floated, carried on the gentle wind, punctuated by a woman’s laughter. 
I hoisted my bag and felt more alone than ever. My soles scratched against the concrete walk leading to the front entrance. Glass panels revealed a lobby dimly backlit for slumber. The automatic doors were locked shut. A sign pointed toward the Emergency Department (ED) and the secured, nocturnal entrance.

As I turned to go a housekeeper opened the doors, allowing entrée into the silent lobby. I thanked him and followed directions to the ED, to sign-in with Security. I traversed the spacious public section of the main floor. My footsteps echoed against polished tiles and down deserted corridors. 

I paused at the Labyrinth inset into the floor with contrasting tiles. It was beautiful in the pale light, the silent night.
A labyrinth is an ancient symbol that relates to wholeness. Labyrinths have historically been used as meditation and prayer tools. The journey toward the center cleanses the dirt of the road, the weighty cares of life. The journey out is one of rebirth, to consciously dwell in the flesh made holy and whole by the infinite center. Not unfitting, I thought, this commanding labyrinth occupying, nay, consuming the central lobby.

Knee-level, wall sconces cast small, golden puddles of light reflecting off travertine tiles. I moved from puddle to puddle, crossing the hall like a pond - from lily pad to lily pad.
I would later learn that hospital staff travels in a parallel pond – parallel halls and elevators that keep patients, gurneys, and scrubs from the grand and pristine public places. 

Glass doors slid soundlessly, opening ahead of me. The ED glared and blared with a flood of lights and activity, a jarring contrast to the muted spaces behind.
 I looked about. No guard holstering a firearm loitered in the corner. I passed through no metal detectors seeking hidden weapons. 
The young man behind the security desk signed me in and relinquished the binder containing my assignment – those units requiring my in-service. He included a map and general directions before I headed back from whence I came, into the delicious, quiet corridors, to find the fourth floor.

Seeking the elevator, I turned down a long and empty hallway illuminated indistinctly by the soft glow of sconces. I stopped to consult the map and something moved. My head snapped up to peer down the dim passage. A brown, narrow box - approximately three feet tall - approached silently. 
“What the … ,” I muttered soto voce’, blinked, and stared hard. It moved along the railing on which I leaned. I retreated to the junction of the main corridor. It advanced. I fled to a safe distance as it reached the junction. “Crossing hallway,” it announced, and cross it did, before proceeding to the elevator to wait for a lift.

The housekeeper approached from behind, laughing.
“What is it?” I asked, eyes as big as saucers.
“A robot,” he said nonchalantly, as if they were commonplace… for they were. “We have many robots here.”
“What do they do?”
“Mostly, they deliver medicine, linens, and pick up the garbage.”
I thought about that during my drive home the next day. While robots are assuredly pricey, they do not acquire injuries hoisting soiled, wet linens and trash – sources of frequent employee injury.

“Where are you trying to go?” he asked.
“To the fourth floor, to the ICU and CCU.”
“Use that elevator,” he pointed to the space where the robot too had waited.
“Thank you,” I said, secretly relieved the robot was gone. I would not have shared that elevator with the robot. Call me chicken… CL-U-U-U-U-U-CK, cluck, cluck, cluck, cluck.

I worked just a few hours and returned before dawn the following morning. We start in the hospital at 0400 and work for several hours catching stragglers on the nightshift. That is followed by a two-hour break during shift change at 0630, when nurses get report, then round on and assess their patients. Time for a cuppa joe and bitta breakfast. A player piano plinked at the base of the grand stairwell leading from the mezzanine lobby to the café and cafeteria below.

While on break I ducked inside the ICU waiting room, to check it out. Soft couches and over-stuffed chairs were arranged in conversational clusters. Tables, telephones, phone books, a work counter, I was instantly impressed. 
The attached kitchenette was fully appointed with sink and counter space for meal preparation, a refrigerator and microwave, table and chairs, and a brightly colored kids table with chairs carved in animal shapes.

When I remember how families camp in hospitals during a loved one’s critical illness – such a waiting area can really support family health on many levels – and trust me, supporting the family supports the patient. In a world that presses for shorter hospital stays, supporting families to indirectly support patients makes sense - monetary and otherwise. 
These inviting waiting rooms sharply contrasted the beautifully aloof lobby whose long, linear, modernistic couches were better suited to airports and waiting than hospitals and communicating.

I had the opportunity to watch many more robots on task, gliding silently through the hospital. 
“Your medications have arrived,” one brown box robot - looking not unlike a steamer trunk - announced upon landing in the nurses station. It waited patiently: no drumming fingers, no rolling eyes, no deep sighs or throat clearing, no playing with its phone, no texting or sexting to another. After one-minute it announced again and without irritation, “Your medications have arrived.” 
This particular robot provides refrigeration and is used to transport newly prescribed medicines requiring immediate administration. Prior to robot delivery, some medicines could be “tubed” in the pneumatic transport system. That or someone had to fetch the drug from the pharmacy. Now, at least in Silicon Valley, a robot makes the delivery announcing politely, “Your medications have arrived.” 
As an aside, routine medications are stored in a locked dispenser whose computer delivers the drug, and only that drug, at the proper time. Pain medications are doled out judiciously. The computer flags unusual activity i.e. a pill ordered for a toddler (toddlers take liquids, not pills), a nurse who removes a particular narcotic at twice the rate of her coworkers. Often, it’s an ordering error; sometimes it’s not. These pharmaceutical computers have made habitual drug theft and abuse by medical personnel much more difficult. Not impossible but more difficult.

On the third-floor, I passed an Asian garden of rock and bamboo. It seemed an odd shade of blue-gray but in the dimness of dawn, it was difficult to discern what color wizardry was at work, if any. After sunrise I clearly saw that the raked “pebbles” of the garden were pieces of blue sea-glass – thousands of them. It was so… curious, surreal, and at the same time, calming.

Speaking of communication – each staff member wears a Vocera  on a lanyard around their neck – a small voice communicator called a “badge”.  
“The Vocera solution enables communication at critical hospital speed, driving better outcomes for the patient and caregiver. … hands-free, voice-controlled, wireless voice communication.”

Hospital staff: physicians, nurses, techs, transporters, housekeepers, 
e-v-e-r-y-o-n-e logs into the communication program when they don their badge.
“Computer,” Capt. Kirk commanded, “Find Mr. Sulu.”
The Vocera is more like than unlike the communicators of Star Trek. No flip phone, it is a single unit about four inches long, two inches wide, and one inch thick. It can receive outside calls and texts, it can page, and all commands are voice activated. 
Vocera works like this: Bones presses the button, “Call Lorin Bacon.” On the other end of that call Vocera ask, “Can you take a call from Dr. (Bones) McCoy, ship surgeon of the Starship Enterprise?” A “yes” response routes the call through. A “no” response rolls the call into voicemail. (Where Bones is likely to leave a dramatic message. “Good God woman, I’m a surgeon not a phone operator! I need help in the OR. Get here before my patient dies!”) See, that’s the thing about Bones: drama, drama, drama! I want a man without drama! But I digress -  :-D 
If a call is placed to one who is not logged into the system, the caller is notified and given an option to leave voicemail. Vocera claims to reduce hospital-wide, overhead pages by greater than 80%. 
On another note, it forces one to learn the names of one’s coworkers – including those that are often invisible: environmental services (the housekeepers and refuse guys), the linen guys, the pacemaker techs, the dietary techs…
It’s slick; Beam me up Scotty!

Typically, I set-up at the nurses station for my 10-minute in-service. Several nurses gather, I deliver my schpeel, answer questions, and wait for the next group. I had more than a few occasions to observe robots in the line of duty.
“Your linens have arrived.” Emergency linens? I’m unsure any linens should be delivered by robot. That forces a $50/hour nurse to stop and deal with linens. I’d rather they come up the good-old-fashioned-way, via the $20/hour guy with the big linen cart who restocks the entire floor for an entire 24-hour period.
Still, I’ll concede there may be benefit to robot delivered linens, though in my chronic and terminal myopia, I fail to see it.

As I waited at the counter of the nurse’s station, I felt a presence at my right elbow and turned. I was startled by a robot (a tall, brown box) nearly six-foot tall! 
(Pause in think: you KNOW I like em brown, long, and lean. It occurs to me that this robot actually meets my basic physical criteria. He was kinda square though.) My apologies – I digress yet again for a bitta humor.
Apparently, I stood in the glide path. “Don’t move,” the nurse sitting before me advised, “It will recalculate and move around you.” All four wheels beneath the robot must articulate 180-degrees and independently for it paused briefly, then moved sideways and proceeded once again, returning to the glide path along the railing once it was able. Brown-long-and-lean was a garbage robot, come to deliver a large, empty blue bin and retrieve the full one. Each garbage bin station is assigned a digital locator. On command, robots exchange blue bins. 
Earlier I overheard a robot commanding, “Clear the halls.” This one made no such declaration and moved without a sound. It stopped within arm’s reach without a peep. These were not personable robots with manners and command of language. They did not engender the desire to fraternize in trash compactors (ala Star Wars) or spend time making their acquaintance. They made no endearing noises, possessed no British sensibilities. Not like R2D2, even less like C3PO.

Our team had been inside El Camino for four consecutive days. Few nurses had missed our “refresher.” My colleague Kris would follow on the evening shift, the final shift. We were done.
We were there to teach nurses the care, feeding, and maintenance of central lines, those large bore IV’s that extend into the central circulation (the superior or inferior vena cava). In the medical environment of decreasing reimbursements and the ever-present threat of litigation, keeping central venous access devices patent (unobstructed) and de-bulked of bio-matrix (blood clots) prevents infection, insures timely therapy, and cuts costs. A win-win. 
In the world of diminishing education budgets, the pharmaceutical company imbedded our highly skilled team to train nurses.

I have participated in these blitzes for many years and even traveled as far away as Seattle. It takes a large team to cover a hospital sixteen hours each day, for the better part of a week. As busy as nurses are, I find them eager and apt students. They want to understand, do it better, and get it right. They want the best for their patients.

I used to say I like perfection – that as a group, nurses are perfectionists – and we are. But I have come to realize it is not perfection but excellence that I like. I seek excellence and am inspired by those who pursue it in care delivery and patient outcomes. 
I am also inspired by beauty and utilitarian art. Beauty can touch me without notice or fanfare and alter my experience of the now. Beauty pulls me out of myself, beyond my smallness, connecting me to others and the infinite. Utilitarian art brings beauty to every day objects like lobby floors and third floor gardens… and I am tugged at every turn.
One definition of integrity is workability, something could be said to possess integrity when it works. I witnessed a high degree of workability at El Camino, from Vocera communicators, to numerous and comfortable family waiting areas, to vegetarian menus, to robots that do the heavy lifting.

What is there to say of an organization that recognizes the nature and nurture of humans, then provides the tools and stimulus for humans to succeed, exceed, and excel? Whoa! 
I intend to follow El Camino Hospital of Silicon Valley with interest. Methinks their eye is not just on the ball, but on the stitch of ball, and they are swinging for an intergalactic home run.