Tip Sheets

How well does your state oversee nurses (and pharmacists, dentists, psychologists...)?

By Tracy Weber, ProPublica

Nursing boards - and agencies that oversee such professionals as pharmacists, dentists and psychologists - 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 patients can be dire.

It's important to remember that nurses, not doctors, provide the bulk of the care patients receive in hospitals and nursing homes. Nurses are charged with monitoring patients' conditions, giving them medications and keeping their pain under control. They are responsible for alerting doctors if patients aren't doing well and coordinating with others on the care team, including therapists, respiratory care providers and dieticians. Ensuring that regulators properly oversee nurses is crucial for ensuring quality patient care.

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 lesser known agencies-perhaps those overseeing psych techs or chiropractors.

Start by finding your state's board website and determining what information is available to the public

A list of all nursing boards and their websites is available from the National Council of State Boards of Nursing (https://www.ncsbn.org/515.htm). Some states (like California, Louisiana and West Virginia) have separate boards overseeing registered nurses and lesser skilled vocational/practical nurses. The vast majority, however, license both types of nurses with one board. 

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. We put together a list, with contact info here: http://projects.propublica.org/tables/state-nurses-records-lookup (note: this chart has not been updated for a year, but it's a start!)

If your state doesn't, ask why 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?

Roam the site looking for annual reports, newsletters, disciplinary statistics, board meeting minutes, etc. These will help give you an overview of how the board works and what kind of statistics they keep and report. It will also flag you to the names of key personnel charged with overseeing investigations.

Look at how much the Texas Board of Nursing provides to the public about its operations (http://www.bon.state.tx.us/about/July09/5-1-2.pdf. The same is true in Virginia (http://www.dhp.virginia.gov/About/2009Q3/default.htm.  Ask the board in your state for similar information.

Pick a time period and examine all disciplinary actions taken by the board

When we first embarked on our nursing 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. You may be surprised to find that the board literally can't answer these questions...we were!

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. Good story we never got to: spend a day with an investigator. In California, the same investigator digging into a medical mishap was also responsible for nail salons and other non-health related investigations. What is the expertise of those charged with investigating the cases?

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 website) 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.

Also does your state fingerprint its health care licensees? If not, you have a story-especially if you can find felons working freely.

Some states also require court clerks, insurers and/or attorneys to report malpractice settlements and judgments. Nurses are infrequently named in lawsuits, so this is a good way to find such cases-and see if the board followed up.

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 spit 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. http://projects.propublica.org/state-boards/subjects/nursing/reports#TN

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: Illinois, Indiana, New York, Pennsylvania, Tennessee, Utah, Vermont, Virginia and Wisconsin.