Reporting Recipe: How You Can Investigate Your State’s Oversight of Its Nurses and Other Licensed Professionals
Nursing boards – and other agencies that oversee such professionals as pharmacists, dentists and mortgage brokers – do not get nearly enough scrutiny. These boards are charged with protecting consumers from unscrupulous or incompetent professionals, but some provide almost no public information about what they do or how they're run. They are sometimes led by ill-qualified political appointees and lack sufficient personnel. But should these boring bureaucracies fail, the implications for your health, finances, and home can be dire.
California’s Board of Registered Nursing is a very recent example.
In July 2009 we published the results of a joint investigation with the Los Angeles Times that uncovered broad breakdowns in California’s regulation of registered nurses. We found that the board took more than three years, on average, to investigate and discipline errant nurses. Positive drug tests, criminal convictions and discipline by other states didn’t trigger immediate consequences. An attempted murderer renewed his license for years while he was in prison. In some cases, even when nurses were convicted of sex offenses, the board never acted at all.
Our investigation of California’s nursing board took us 18 months. But the results were worth it. Within 48 hours, California Gov. Arnold Schwarzenegger replaced the majority of the nursing board and the board’s longtime executive officer resigned. Schwarzenegger also pledged wholesale reform of all health-licensing boards in the state after determining that they, too, suffered from the same problems.
We realize that many newsrooms face competing priorities and limited resources, so we’re making our reporting recipe public.
To be sure, this work is not easy and some of what we did required an enormous investment of time and technology. We understand that many reporters and members of the public will not be able to dedicate the same resources. Still, there are many things you can do to get a good understanding of how well your state regulators are performing.
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While many of the suggestions below refer to state nursing boards, they can easily be translated to the agencies that oversee other professionals. In fact, some of the most interesting stories can be found in the most unlikely agencies–perhaps those overseeing surveyors or veterinarians.
Start by finding the board's Web site and determining what information is available to the public
A list of all nursing boards and their Web sites is available from the National Council of State Boards of Nursing. Some states (like California, Louisiana and West Virginia) have two different boards that oversee registered and vocational/practical nurses. The vast majority, however, license both types of nurses with one board. Get hold of annual reports, newsletters, disciplinary statistics, board meeting minutes, etc.
On a very basic level, fewer than half the states allow members of the public to both verify a nurse's license and view disciplinary documents free online. Our easy-to-use guide will tell you if your state is one of them. If not, askwhy not. Is it realistic to expect that a patient will submit a written request for information on a health provider and pay a fee to get it?
Pick a time period and examine all disciplinary actions taken by the board
When we first embarked on this project, we asked California officials for a list of all nurses disciplined since 2002. Because most disciplinary records are online, we were able to look up each nurse on the list and determine why he/she got in trouble.
It quickly became apparent to us that it took the board a very long time to discipline nurses. We saw some cases in which nurses were disciplined 10 years after their alleged offenses. We also spotted dozens of nurses who moved from hospital to hospital before they were ultimately disciplined.
But there's a difference between a story based on anecdotes and one supported by statistics. Working alongside Los Angeles Times researcher Maloy Moore, we entered each case into a Microsoft Access database, identifying the names of all employers, the nature and date of all convictions and any discipline by other states. We opened large parts of this database to the world when we published our stories. You can see it at http://projects.propublica.org/nurses
Reality check: For all but the largest newsrooms, this may not be a realistic undertaking. We read and entered more than 2,000 reports, some with more than 100 pages.But you can examine a shorter period of time and your state will likely have far fewer disciplinary actions than California (which has more nurses than any other state).
Ask the board how it works
Does it have its own investigators? Its own lawyers? Does it prioritize complaints when they first come in? How often does it suspend nurses' licenses on an emergency basis to protect the public? How many complaints does it receive each year? How many nurses are disciplined and what types of sanctions are imposed (revocations, suspensions, probation, surrendered licenses, work restrictions, reprimands, fines)? How long does it take to process complaints from beginning to end (and how long does it take in each step of the process)?
Be advised, however, that you'll need to do your own reporting to ensure the accuracy of their responses
In California, we found that a complaint had to wind its way through four agencies before a nurse was disciplined. The biggest bottleneck was at the investigative stage, which took more than 600 days, on average. The nursing board shared a pool of fewer than 40 investigators with up to 25 other licensing agencies. Some investigators handled upwards of 100 cases at a time.
Look into how other boards function, both within your state and in neighboring states
Context is important. If you're going to say your state is performing poorly, it helps to compare it to other states. We surveyed boards in the 15 largest states and found that California lagged far behind. Some states routinely examine their performance and tracked it over time. They shared their metrics and talked about how they ensure problem nurses are removed from practice quickly.
Try to find cases that your nursing board hasn't acted on
Another good way to measure how regulators are performing is to look at what they're not doing. Are dangerous and incompetent nurses practicing with clean licenses in your state? We examined public records to find this out.
While you can't search the personnel files of private hospitals, similar files for public hospitals and state agencies often become available when employees appeal their discipline to a Civil Service Commission. We examined these records to look for nurses who were fired or suspended from their jobs for misconduct. On the nursing board's Web site, however, we found that many had clear licenses. We examined media clippings for nurses who had been convicted of crimes in California. And we looked at the disciplinary logs of neighboring states to see whether nurses who were disciplined in those states had licenses in California. (Links to each state's records are available on our Web site.) We found that many had clear records in California despite losing their licenses elsewhere.
We also undertook a more complicated search that required a little perseverance. We requested two databases: one from the nursing board of every licensee and another from the California Attorney General's office of every sex offender in the state's Megan's Law database. We matched the two using Microsoft Access and found a number of hits. But each of these hits had to be thoroughly investigated to ensure that they were the same person. We located and interviewed anyone who we planned to name in our story.
Each state has different rules about which databases it considers public and how much it charges for them. In New York, for example, the Megan's Law database is not publicly available in a spreadsheet. In Florida, where public records laws are more open, you can request and get a list of everyone who is incarcerated in state prison, which can be matched to licensing databases.
Is your state properly reporting dangerous nurses?
Try to determine whether the licensing agency has reported its disciplinary actions, as required, to the federal government
Federal law requires states to report all sanctions they take against doctors, dentists, nurses, pharmacists, therapists and all other health providers to a central database available for hospital searches. While the database is not open to the public, the Health Resources and Services Administration does provide reporters with a version that does not include individually identifiable information. We analyzed data on registered nurses and were able to spot discrepancies fairly easily. We looked for big drops in reported cases from one year to the next. Look at Indiana's reports in 2004 and 2005 or Tennessee's in 2002 and 2003.
This data should not be used to compare one state against another because it may not be accurate and it is not adjusted for the number of nurses in each state. Another caution: Since September 2009, some states may have gone back and entered old actions they took against nurses. Check with each state before using these figures in a story.
Determine whether your state has a recovery program for drug abusing caregivers
If so, what is the success rate? How is it monitored? What are the criteria for entering the program and what happens if a nurse relapses? Are nurses’ licenses inactivated while they are in the program? How many relapses are allowed before a nurse is kicked out? And when a nurse fails, what happens then? Is his/her license automatically suspended or is there a process in which the nurse can continue to work and care for patients? How long does that process take?
We found that California's program placed too much trust in addicted nurses and had no definitive way of removing them from practice or quickly acting against their license if they flunked out. Using the database we built, we found more than 80 cases in which nurses were confidentially labeled "public safety risks" and kicked out of the program. But our data showed that it took a median of 15 months to file public accusations against them.
State Web sites
The suggestions above refer specifically to state nursing boards but they can be used to review agencies that license other professionals. Some states have an umbrella agency that oversees many of the regulatory boards, from health professionals to contractors, and make lists of disciplinary actions available in one place. Among those are:
We've collected resources on nursing boards specific to each state. Choose your state below:
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Podcast: Reporters Charlie Ornstein and Tracy Weber discuss their reporting on delinquent nurses.
Editor's Note: Why We're Sharing Our Recipe
When Caregivers Harm - Our complete coverage of flawed regulation of healthcare workers California and nationwide
National Database Flawed - A long-awaited federal database of disciplined healthcare workers had significant gaps in records. Following our investigation found, the database's management team was replaced.
Tracking Nurses Nationwide - This interactive map and chart shows the state of nursing records access nationwide.
California Discipline Delayed - Our analysis found that California took three years, on average, to discipline errant nurses. After our report, most of the board and its executive officer either resigned or were removed.
Database of Sanctioned California Nurses - We assembled a database of nearly 2,400 California registered nurses facing discipline between 2002 and Sept. 2009. We also analyzed the gap in time between the board's public accusation and disciplinary decision.