One Therapist Can Make a Difference
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One Therapist Can Make a Difference
Whistle Blowers Now Protected…at Least in Massachusetts
By Margaret Varnell, BA, RN, RRT
Every once in awhile, ordinary practitioners, like Jack Karvelas, RRT, can find themselves in an extraordinary situation when hospital downsizing impacts their abilities to provide patient care. Despite some overwhelming odds, Karvelas made a conscientious decision to fight rather than take flight, and that decision will pave the way for others to follow his example.
Karvelas, a 23-year veteran of respiratory care, noted improprieties in his hospital and reported them through the proper department channels. When no action was taken, he took his complaints steadily higher. When still no corrective action occurred in-house, he took his case to state legislators, the state Board of Health, the U.S. Health Care Financing Administration (HCFA), the U.S. Department of Health and Human Services (which governs Clinical Laboratory Improvement Amendment provisions [CLIA]) and, finally, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO).
His actions culminated with the signing last month of the Massachusetts Medical Whistle Blowers Protection Act. “State Senator Richard Tisei is the hero in this matter,” said Karvelas. “The community and the patients were in eminent danger, and he put a stop to this.”
TROUBLED TIMES
Moving from Point A to Point B was no easy task. Along the way Karvelas lost his job and endured professional and personally attacks to himself and his family. He, his wife and three children suffered from a loss of income and health care for more than a year.
“I couldn’t believe that these sorts of things were happening in a state that was supposed to be the Mecca of health care,” said Karvelas.” Not just what was happening to me, but to the patients.” Despite the hardships, he persevered, and today he can proudly point to the new Massachusetts law.
Karvelas was a staff practitioner at Melrose-Wakefield Hospital in Massachusetts. Like many hospitals in 1994, his hospital downsized. In their cost-cutting moves, hospital administration eliminated the position of manager of respiratory care. The administrative duties for respiratory care practitioners were taken over by the director of rehabilitative services, a licensed physical therapist. “Before she even took over, I went to the CEO,” said Karvelas. “I was very concerned that the quality of patient care would suffer.”
FOLLOWING PROTOCOLS
Karvelas noted some of the changes in care taking place and began reporting them to his new department head and to hospital administration. “I went through the chain of command, but they wouldn’t make a move to correct the situation,” said Karvelas. “It seemed like they didn’t care. I couldn’t believe they wouldn’t protect the patients. As a practitioner I felt that was my first duty.”
Among discrepancies he noted were staffing shortages. The hospital-staffing pattern was traditionally three practitioners on day shift, two on evenings and one on nights for a normal patient load. “Prior to the transition, we were able to adjust staffing and add on people as patient loads demanded, but all that changed after the new director took over,” said Karvelas.
During 1995 and 1996, he said there were many times when only one practitioner would be in house for day shift, and that sole RCP was expected to provide services for 60 patients on treatments, handle seven ventilator patients and PFTs and be on alert for ER duties. Even on days when staffing was better, patients frequently went without treatments.
There was also the problem of routine maintenance on the equipment, he noted. Controls, QA and proficiency testing were not run on the equipment in the ABG lab for the entire year of 1995, he said. Karvelas alerted his acting department head and his medical director, who directed him to the medical director of the ABG lab. Karvelas reported the only apparent action taken was comments from his manager that he should not go over her head.
Meanwhile, Karvelas said he was being labeled a disgruntled employee and a troublemaker.
IGNORING PROBLEMS
Karvelas felt his complaints were being swept under the rug all the while patient care was going downhill. In the midst of everything, he felt his stress level rising. “I believe that as health care workers, we are holders of the public trust,” he said. “We are supposed to be patient advocates.”
In time, he ended up an inpatient in the facility himself. “It was the stress of putting my name, credentials and career on the line,” he said. While hospitalized, he alleged his co-workers and supervisors accessed his medical records illegally. Karvelas later reported this invasion of his privacy to human resources and risk managers. “But they laughed it off,” he said.
The situation continued to deteriorate. Because he felt he was getting no response from the “proper internal channels,” Karvelas began filing complaints with external agencies including the Massachusetts Board of Respiratory Care, HCFA and JCAHO. He also contacted his state senator and representative. The hospital publicly denied the allegations made by Karvelas and fired him in January 1997.
The average person probably would have washed his hands of the entire situation at that point and walked away.
But Karvelas followed up on the external complaints. A subsequent HCFA investigation documented clear instances of patients not receiving therapy that was ordered. HCFA’s surveyors reported they reviewed 13 charts for patients with RT orders and found eight records lacked documentation for the treatments ordered. For example a patient admitted for pneumonia was ordered to receive Q6 bronchodilator therapy. Yet the patient did not receive the 3 a.m., 9 a.m. or 6 p.m. treatments. The survey team then conducted a retrospective review of 15 patients with RT orders and found nine lacked documentation that therapy has been provided.
INVESTIGATIVE REPORTS
HCFA’s report revealed that during the first week of February 1997, only two practitioners staffed the day shift on 2/1, 2/2, 2/3 and 2/7. Interviews with staff members revealed that staff were frequently required to work overtime and double shifts. If a therapist were called to an emergency situation, there was no one to whom to shift the work assignment.
The HCFA investigation revealed that QCs were not being performed as required. For example, their report cites an incident on 11/16/96 in which a control was run with unacceptable results on one machine. Only one control was run on the department’s other analyzer on that day and it was within acceptable limits. Both machines, however, were used for patient care.
Perhaps the more shocking revelation of the HCFA report was that between 9/1/96 and 2/13/97, some 700-blood gas samples were mishandled and their reports questionable. Practitioners did not label the samples appropriately after they drew them. According to the HCFA report, the documentation was insufficient to determine if the results reported on patients were, in fact, their results.
OTHER FINDINGS
In fairness, the Massachusetts Department of Public Health, the Massachusetts Board of Respiratory Care, and JCAHO verified these findings to varying degrees in their investigations as well. The Department of Public Health verified Karvelas’ co-workers had breeched his privacy by illegally accessing his medical record.
After Karvelas was fired, he worked part time at another hospital for almost a year. He also worked with his state legislators to draft a bill to protect others trying to do the right thing.
“This guy was a good therapist doing his job. We were amazed that this sort of legislation would be needed to protect both patients and practitioners trying to fix a corrupt system,” said State Rep. Brian Cresta, a Republican. Cresta worked with other legislators and formed a coalition to draft the bill. After three years of work, the bill was signed.
This legislation states: “No employer or duly authorized agent of an employer shall discharge, refuse to hire or in any other manner discriminate against an employee because the employee has made a report to the board as required under this section, or has testified or in any manner cooperated with an inquiry or proceeding pursuant to this chapter, unless the employee knowingly participated in a fraudulent proceeding.” The law permits employees to seek remediation through the court system should they be discriminated against.
“Unfortunately, I don’t think this is an isolated case,” said Cresta. “I hope the national HMO reform legislation will incorporate these protections.” The Republican lawmaker also credits the Massachusetts State Nurses Association for joining the fray and providing grass roots support for the legislation.
“This legislation is helpful to all health care practitioners, both licensed and unlicensed, because it allows those who take care of patients to be able to speak out for the patient’s safety and their quality of care without fear of reprimand,” said Gloria Craven, RN, MS, director of Legislation and Government for the Massachusetts State Nurses Association.
PROFESSIONAL MODEL
Commenting on the issue, said Sen. Tisei, co-sponsor of the bill, “The hospital released Jack specifically because he brought these issues to me. In fact, they stated this in his termination letter. I was surprised to learn that most health care workers are at-will employees and have little or no protection to speak out under the law.
“Karvelas was a catalyst for this legislation,” he said. “It is important that health care professionals can speak up for patient safety and not fear for their livelihood.”
His efforts have been worth the struggle, Karvelas said. “At the end of the day, I can look myself in the mirror and know that I did the right thing. Health care is about taking care of people. That’s our job, and that’s what I did.” *
Margaret Varnell, is an ADVANCE field correspondent.
