ProPublica nurse investigation asks the right questions

It's safe to say that most health writers pay attention when Tracy Weber and Charlie Ornstein publish something.

They have been called the Woodward and Bernstein of health reporting. The comparison fits because these two have few peers in their ability to dig for documents, cajole sources into talking and embarrass powerful public figures.

They established themselves at the Los Angeles Times, where they won the Pulitzer Prize (and beat this writer). Then they moved to the nonprofit journalism startup ProPublica, where they have continued to work with the Times and publish great investigative stories. Their series, When Caregivers Harm, has been one of most fascinating and upsetting investigations of the decade.

The first few sentences of the latest installment, published on Dec. 6, promises an incredible piece of reporting:

Firms that supply temporary nurses to the nation's hospitals are taking perilous shortcuts in their screening and supervision, sometimes putting seriously ill patients in the hands of incompetent or impaired caregivers. Emboldened by a chronic nursing shortage and scant regulation, the firms vie for their share of a free-wheeling, $4-billion industry. Some have become havens for nurses who hopscotch from place to place to avoid the consequences of their misconduct.

It only gets better.

Reading between the lines, the investigation offers writers a series of must-ask questions for any one digging into health care. Here are a few to remember:

1. How might hospitals be taking short cuts? Hospitals hire temp agencies because they provide nurses on the cheap with no long-term commitments. As the stories show, the low cost can mean that the agencies skimp on screening the nurses in the program.

2. Why would someone want this job? Most nurses want the paycheck, stability and benefits that come with a full-time gig. Employees in temp agencies, like substitute teachers, are often highly-skilled professionals who don't want a regular 9-to-5 job. But Weber and Ornstein found that some of the nurses who work for temp agencies ended up there by default. The head of the Arizona nursing board said that for bad nurses, "I think it's easier to hide in the registries."

3. Does this person have a criminal record? Health writers often think of police reporting as something they did at their first internship. When you are dealing with a poorly-run hospital or a doctor's group that dominates a rundown part of town, you need to think like a police reporter. Work court and law enforcement sources and search for documents, both public and secret, that show evidence of dangerous behavior. Consider that every unusual death at a hospital is investigated by the county coroner's office, usually part of the sheriff's operation. Using law enforcement records, ProPublica was able to show how a temp firm hired nurses despite serious criminal convictions. One firm hired a California nurse whose license had been suspended and who had been convicted of stealing drugs.

4. What constitutes bad care? Weber and Ornstein provide some great examples of nurses who have "fallen asleep on the job, failed to perform critical tests or stolen drugs intended to ease patients' pain or anxiety." We often think the only measure of poor quality care is the number of unexpected patient deaths. Any deviation from the standard of care that exacerbates or prolongs a patient's suffering could be a sign of an institution that is a menace. Just ask yourself this question: Do you want your mother to be cared for in a hospital where the nurses are stealing drugs or catching 40 winks while they should be monitoring her vital signs?

5. Why is this person's resume so long? Temps by nature jump from job to job, but whenever you see a health worker – or hospital CEO – who has never stayed in one place for more than a year, you should find out why. As ProPublica notes, when complaints start coming in about temp nurses, the agencies often just switch the nurses to another hospital. Sound like another shell game scandal? One agency kept sending one nurse to hospitals even though she had a dirty dozen of convictions, including prostitution, on her rap sheet.

6. What is the scope of the situation? ProPublica found out that the California Board of Registered Nursing had surveyed health employers to find out how many temps are working. Nearly 20,000 registered nurses in the state, or about 6 percent, are temps. Too often, reporters present a series of scary situations but never explain how common they are.

7. How do the regulators stack up? Weber and Ornstein wrote such a powerful examination of the California Board of Registered Nursing in July that the governor immediately cleaned house. Now, they point out that even with some of the reforms, the board "is among a minority that does not require hospitals, agencies or anyone else to report even serious lapses by nurses, including temps."

8. What is the letter of the law? Raphael Obiora made a frightening point when asked by Weber and Ornstein why he hadn't told his temp agency that he had had been put on probation by the California Nursing Board for stealing drugs. "I don't have to tell you nothing," he said. "You have to check." Regulations can look good on paper, but if they don't actually require health workers to inform their employers, or the public, of their misdeeds, then the rules are meaningless.

9. If a health worker makes a mistake, are they given a chance to learn from it? This is what a scientific environment should foster: open and frank discussion of anything that puts patients at risk. What ProPublica found, though, was that "temp nurses often are just exchanged for replacements, never receiving further guidance."

10. Lastly, how can you make this tricky topic clear to readers? One of the ways ProPublica has done this over and over is with compelling graphics. Here's one that shows how a nurse with a drug problem kept landing new jobs.

Keep watching ProPublica for more real-world lessons into how to find out what is going on behind the scenes in health care.