Time and Again: Overtime in State Facilities

TIME AND AGAIN: OVERTIME IN STATE FACILITIES Report #231, April 2016 A Little Hoover Commission Letter Report to the Governor and Legislature of California To Promote Economy and Efficiency Little Hoover Commission The Little Hoover Commission, formally known as the Milton Marks “Little Hoover” Commission on California State Government Organization and Pedro Nava Economy, is an independent state oversight agency. Chairman David A. Schwarz By statute, the Commission is a bipartisan board composed of five public Vice Chairman members appointed by the governor, four public members appointed by the Legislature, two senators and two assemblymembers. Scott Barnett David Beier In creating the Commission in 1962, the Legislature declared its purpose: Anthony Cannella ...to secure assistance for the Governor and itself in promoting economy, Senator efficiency and improved services in the transaction of the public business in Jack Flanigan the various departments, agencies and instrumentalities of the executive branch of the state government, and in making the operation of all state Loren Kaye departments, agencies and instrumentalities, and all expenditures of public funds, more directly responsive to the wishes of the people as expressed by Chad Mayes Assemblymember their elected representatives... Don Perata The Commission fulfills this charge by listening to the public, consulting with the experts and conferring with the wise. In the course of its investigations, Sebastian Ridley-Thomas Assemblymember the Commission typically empanels advisory committees, conducts public hearings and visits government operations in action. Richard Roth Senator Its conclusions are submitted to the Governor and the Legislature for their Jonathan Shapiro consideration. Recommendations often take the form of legislation, which the Commission supports through the legislative process. Former Commissioners Who Served During The Study Sumi Sousa Contacting the Commission Commission Staff All correspondence should be addressed to the Commission Office: Carole D’Elia Executive Director Little Hoover Commission 925 L Street, Suite 805 Jim Wasserman Deputy Executive Director Sacramento, CA 95814 (916) 445-2125 Ciana Gallardo littlehoover@lhc.ca.gov Research Analyst This report is available from the Commission’s website at www.lhc.ca.gov. Letter from the Chair Letter from the Chair April 5, 2016 The Honorable Kevin de León The Honorable Jean Fuller President pro Tempore of the Senate Senate Minority Leader and members of the Senate The Honorable Anthony Rendon The Honorable Chad Mayes Speaker of the Assembly Assembly Minority Leader and members of the Assembly Re: 3.75 million hours of overtime Dear Governor and Members of the Legislature: Everyone would agree that 3.75 million hours of overtime in 2014-15 – at a cost of nearly $179 million – is a lot of overtime. But that’s how much nurses and psychiatric technicians working in state facilities put on the clock. Most of that overtime was voluntary. But staff also was forced to work 417,226 hours of overtime in 2014-15, an archaic staffing solution that has been all but abandoned in private and other public health care facilities. In mid-2015, Assemblymember Sebastian Ridley-Thomas asked fellow Commission members to review mandatory overtime in state facilities providing health care. In response, the Commission conducted a public hearing in August 2015 where it heard from representatives from the state departments that use mandatory overtime for nursing staff. It also heard from the nurses and psychiatric technicians who work in state facilities and the unions that represent these workers. Nurses traveled from all over the state and told harrowing tales of colleagues lives shortened by excessive work hours, work-related injuries and stress from uncertain work schedules. Through the Commission’s study process, it learned the state relies heavily on overtime to meet staffing needs and 80 percent of the time, that overtime is voluntary. This contrasts with private and other public sector health care facilities that have moved away from excess overtime for a variety of reasons. In fact, 18 percent of total pay for state nurses is overtime, four times the percentage of pay for registered nurses and healthcare workers nationally. First and foremost, it is unsafe for patients and for workers. Study after study has found that error rates increase for nurses working long hours. The risk of injury for nurses in an occupation that is already high risk increases with long hours. They also pointed to excessive and prohibitive costs associated with overtime. When asked specifically about the use of mandatory overtime, officials from both private and public health facilities say the threat of mandatory overtime would make it difficult, if not impossible, to recruit and retain nursing staff. Little Hoover Commission | 1 Time and Again: Overtime in State Facilities Some 16 states regulate overtime for nursing staff, including California. California was one of the first states in the nation to limit excessively long hours for nurses. In 2001, the state revised the wage order that covers employees working in health care facilities, limiting staff that agrees to alternative work schedules to no more than 12 hours in a 24-hour period. After the wage order amendment, private sector health facilities moved toward 12-hour shifts, which significantly reduced overtime, whether voluntary or mandatory. The wage order, however, does not apply to employees covered by collective bargaining agreements, which includes all state nurses. The unions that represent registered nurses, licensed vocational nurses, certified nursing assistants and psychiatric technicians who work for the state have not been successful in negotiating similar limits on overtime. Due to the lack of traction on this issue at the bargaining table, the Legislature has twice enacted legislation that would specifically eliminate mandatory overtime, once during the Schwarzenegger administration and again during the Brown administration. Both Governors vetoed the legislation with essentially the same message: the issue is best addressed at the bargaining table. The Commission concluded in its review that forced overtime is merely a symptom of the much bigger problem of excess overtime overall in state health care facilities. The Commission found that excessive overtime, whether mandatory or voluntary, is neither safe for patients nor staff, and should be significantly reduced. The Commission also agreed that forcing nursing staff to work overtime makes it difficult to attract and retain quality staff, increasing the need for overtime. Rather than focusing solely and unsuccessfully on mandatory overtime, the state should implement strategies to reduce all overtime. If the state cuts its overtime in half, the need for mandatory overtime in all likelihood would be significantly reduced or eliminated, except in extreme emergencies. The Commission agreed that with 3.75 million hours of overtime on the books in one year, the state clearly is not appropriately staffing its health care facilities. The Commission recommends that the state set a target for reducing all overtime in state health care facilities by 50 percent by 2018 and for using mandatory overtime only in well-defined emergencies. It recommends continuing to reform civil service procedures to make it easier to hire and retain qualified staff. It also recommends providing managers with appropriate flexibility in scheduling and structuring staff. Given additional flexibility, management should then be held accountable for reaching overtime reduction targets. These steps would help reduce the state’s reliance on overtime, but likely will not resolve excess overtime completely. As a result, the Commission also recommends the state conduct an assessment of what staffing is required to safely and cost-effectively run its health care facilities, and based on that assessment, authorize adequate nursing staff to further reduce overtime. The Commission respectively submits these recommendations and stands ready to assist. Sincerely, Pedro Nava Chair, Little Hoover Commission 2 | www.lhc.ca.gov Contents Contents 7 Commission Study Process 7 Overtime Regulations Health and Safety Issues Associated with Long Work Hours ................................................. 8 Overtime Costs ...................................................................................................................... 10 Factors Driving the Need for Overtime .................................................................................. 11 Civil Service Challenges .................................................................................................. 11 Balancing Staff Resources with Fluctuating Patient Needs ............................................ 12 Scheduling Errors ........................................................................................................... 14 Managing Health Care Facilities without Excess Overtime .................................................... 14 16 Summary 17 Recommendations Recommendation 1: The Governor and the Legislature should set a target of reducing overtime for nursing staff working in state health care facilities to 50 percent of the 2014-15 rate by 2017-18 17 and eliminate the use of mandatory overtime except in documented emergencies ......................... Recommendation 2: The administration must continue to prioritize civil service reform, particularly efforts to streamline the hiring process and modernize civil service classifications ........ 17 Recommendation 3: The administration should ensure management has appropriate flexibility and adequate tools to schedule staff and hold management accountable for reaching overtime reduction targets ................................................................................................................................. 17 Recommendation 4: The Governor and the Legislature should authorize an analysis of short and long-term trends in patient health care needs, staff leave time trends and costs of overtime as compared to the costs of hiring adequate staff. Based on that assessment, the Governor and the Legislature should authorize adequate nursing staff to achieve overtime reduction goals in state facilities providing health care ............................................................................................................ 17 18 Appendices Public Hearing Witnesses ....................................................................................................... 18 19 Notes Little Hoover Commission | 3 Time and Again: Overtime in State Facilities 4 | www.lhc.ca.gov Time and Again: Overtime in State Facilities Time and Again: Overtime in State Facilities N urses serve on the front lines of the state’s toughest incompetent to stand trial and sexually violent predators facilities, providing health and mental health care who have served their time, but have been deemed too in physically and psychologically demanding jobs. They dangerous to regain freedom in California’s communities. not only check vitals and provide medications, but Other state nursing staffers serve the developmentally often help bathe, feed and provide all-around care for disabled population and aging and disabled veterans. those who are ailing, injured or disabled. Nurses are These dedicated professionals – registered nurses, more likely to suffer work-related injuries than most licensed vocational nurses, certified nursing assistants other professionals, whether accidentally being stuck and psychiatric technicians – not only serve the needs by a needle or suffering back injuries from lifting and of challenging populations, but also face one additional moving heavy patients. Nurses also are subject to more work hazard virtually non-existent in health care settings workplace violence than nearly any other profession.1 in the private sector and in much of the public sector. Nursing is a demanding profession in all health care Upon completing a demanding eight-hour shift, state settings but the 14,367 nursing professionals employed nursing staff can be forced to stay and work yet another by the State of California face significant additional eight-hour shift of overtime, for a total 16-hour shift. workplace challenges.2 They work long hours – state The vast majority of overtime for state nurses, nurses logged 3.75 million hours of overtime in 2014-15.3 approximately 89 percent, is voluntary.8 Nurses told the Approximately 85 percent of the entire state nursing staff Commission they prefer to volunteer so that they have worked overtime, earning nearly $179 million in overtime control over when they work extra hours rather than be pay in 2015.4 This overtime is the equivalent of required to stay unexpectedly. But because the state 1,802 employees working 40-hour weeks for a full year.5 relies so heavily on overtime as a staffing tool, at times In this review, the Commission found the state is there are not enough volunteers to staff every shift. significantly out of sync with national data in its use of As a result, state nurses were forced to work more than overtime. Overtime pay for the California nursing staff 417,000 overtime hours in 2014-15.9 reviewed as part of this study is 18.2 percent of total pay, According to the union contracts for State of California that’s four times the percentage of pay for registered nursing staff, this can happen up to twice in one nurses and health care workers nationally.6 The U. S. seven-day work period and up to six times every month. Bureau of Labor Statistics reports that supplemental pay, In most private and public sector health care settings, which primarily is made up of overtime, but can also mandatory overtime is reserved only for the rarest include shift differentials and bonuses, is just 4.4 percent emergencies. It is not considered a staffing tool. A senior of total wages for registered nurses, 3 percent of total official managing a veterans home in Tennessee told wages for health care workers and 4.6 percent for health Commission staff this practice was the equivalent of care staff working in hospitals.7 indentured servitude and that he would be unable to State nurses often provide care for a difficult population. keep employees if he forced staff to work overtime. A majority of the state nursing staff work inside state In testimony to the Commission, a representative from prisons that house convicted felons or in state hospitals the California Association of Psychiatric Technicians, that house the seriously mentally ill, felony offenders described what the association members experience daily Little Hoover Commission | 5 Time and Again: Overtime in State Facilities working for the state: Services uses mandatory overtime the least of these departments overall – just 6 percent of all its overtime “Imagine working in a facility where you – but with the largest nursing staff of some 4,900 nurses have seen three people assaulted on your the effect is still significant.11 The Department of State shift, and then, when you are getting Hospitals had the most mandatory overtime hours – ready to leave to go home, you are told 193,567 hours in 2014-15.12 That is the equivalent of that you need to stay to work another 4,839 40-hour workweeks. The Yountville Veterans Home eight-hour shift. You are tired, your nerves uses a significantly higher percentage of mandatory are frayed and now you have to go for overtime compared to the other state veterans homes – another full shift. Furthermore, you may approximately 34 percent of all its overtime in 2014-15 not have child care available beyond what was mandatory.13 you have already normally scheduled.”10 State officials depend on overtime to ensure that States departments that use mandatory overtime for regulated patient staffing ratios are maintained when nursing staff include California Correctional Health Care there are vacancies, when staffers call in sick, are Services, which provides nursing staff for the California out on Family and Medical Leave Act or for workers Department of Corrections and Rehabilitation, the compensation-related injuries or use vacation or other Department of State Hospitals, the Department of leave time. Developmental Services and the California Department of Veterans Affairs. Mandatory overtime use varies by department and even by facilities within these departments. California Correctional Health Care California State Fiscal Year Total Overtime* Voluntary Overtime* Mandatory Overtime* Departments California Correctional 1,114,540 72,554 2014-15 1,187,094 Health Care Services 94% 6% Department of State 1,627,752 193,567 2014-15 1,821,319 Hospitals 90% 10% Department of 479,315 128,022 2014-15 607,337 Developmental Services 79% 21% California Department 132,687 109,604 23,083 2014-15 of Veterans Affairs 83% 17% 3,748,437 3,331,211 417,226 Total Overtime — 100% 89% 11% *Numbers are shown in hours. Sources: Joyce Hayhoe, Director of Legislation and Communications, California Correctional Health Care Services. Lupe Alonzo-Diaz, Deputy Director of Administrative Services, Department of State Hospitals. Dwayne LaFon, Deputy Director (A), Developmental Centers Division, Department of Developmental Services. August 27, 2015. Written testimony to the Commission. Beth Muszynski, Chief, Research and Program Review, Veterans Homes Division, California Department of Veterans Affairs. January 25, 2016. Written communication. 6 | www.lhc.ca.gov Time and Again: Overtime in State Facilities Commission Study Process maintain patient care and patient and staff safety while reducing the need for overtime. A list of the witnesses who This review of overtime use by the State of California testified is included at the end of this letter. facilities providing health care was conducted in response Additionally, more than a dozen state health care workers to a request from Commissioner and Assemblymember from across the state came to the Commission’s hearing Sebastian Ridley-Thomas in a May 2015 letter to the to provide public comment. The Commission also Commission asking for a review of mandatory overtime. received written comments from health care workers. Assemblymember Ridley-Thomas authored legislation in 2014 that would have banned As part of this review, Commission staff also interviewed mandatory overtime for nurses officials from the Los Angeles County Sheriff’s Department, working in state facilities. It was a representative from the California Hospital Association, enacted by the Legislature but vetoed an official with the California Association of Health by Governor Brown. In his veto Facilities, an official with Washington State Hospitals, the message, Governor Brown indicated executive director of the Western Psychiatric State Hospital this issue would best be resolved Association and a consultant who specializes in staffing and through the collective bargaining organizational development for hospitals and correctional process. Similar legislation in 2005 health care settings. Additionally, Commission staff was vetoed by Governor Schwarzenegger with a similar interviewed veterans home administrators in Tennessee, veto message. Two bills under consideration by the Florida and Maine. Legislature in 2016, AB 840 (Ridley-Thomas), and SB 780 (Mendoza), would prohibit mandatory overtime for nurses and psychiatric technicians who work in state facilities. Overtime Regulations As part of its study process, the Commission held a public hearing on August 27, 2015. At this hearing the As of 2010, 16 states had laws or regulations related to Commission heard from the unions that represent the nurse overtime, including California.14 These laws and nurses and psychiatric technicians, as well as nurses and regulations generally regulate nurse overtime and total psychiatric technicians who work in state facilities. These work hours in two ways: they either prohibit health employees and their union representatives described the care facilities from requiring employees to work more challenges they face and safety issues that arise when they than their regularly scheduled hours, except during a are forced to work excessive amounts of overtime shifts. health care disaster, or they limit the total number of hours worked by nurses in a specific time period. For The Commission also heard from a panel of representatives example, such a regulation could limit a nurse to working from California Correctional Health Care Services, the no more than 12 hours in a 24-hour period or 60 hours receiver appointed by the courts in the long-standing in a seven-day work period.15 Many of these regulations lawsuit over prison medical treatment and the California were implemented in the early 2000s in response to Department of Corrections and Rehabilitation. Another nurse staffing shortages, which resulted in nurses working panel included representatives from the Department increasingly long hours and growing evidence that these of State Hospitals, the Department of Developmental long hours increased error rates causing patient harm. Services and the Department of Veterans Affairs. These department leaders described the scheduling and resource California was one of the first states to regulate nurse challenges that have led them to rely so heavily on overtime overtime. Amendments were adopted by the California as a general staffing tool. These officials acknowledged Industrial Welfare Commission in 2001 to the Public the safety risks associated with working long hours and Housekeeping Industry Wage Order, which covers a suggested that limits on all overtime, both voluntary broad variety of health care facilities. This change to the and mandatory should be reviewed. They also outlined wage order effectively ended mandatory overtime in opportunities for operational improvements that could health care settings in the private sector. The wage order Little Hoover Commission | 7 Time and Again: Overtime in State Facilities provides that an employer can propose an alternative hours, compared with 8.5 hour shifts.20 The risk for workweek agreement, and if the agreement is approved patient care errors almost doubles when critical care by at least two-thirds of the affected employees, it will go nursing shifts last longer than 12.5 hours.21 into effect. The alternative workweek adopted by many Beyond error rates affecting patient care, working long health care facilities is a 12-hour shift. The wage order shifts puts nurses at greater risk for injury. As work established that no employee assigned to work a 12-hour hours increase, injury rates among workers increase.22 shift shall be required to work more than 12 hours in Working long hours also appears to increase the risk for any 24-hour period except in the event of a health care several negative health effects, including a decrease in emergency, as defined by the wage order. A worker could self-perceived general health quality, an increased risk be held for one extra hour if the employee scheduled for hypertension and for coronary heart disease and an to replace the worker on the next shift does not report increase in the time it takes to become pregnant.23 for duty and did not notify the employer more than two hours in advance. Pay is doubled after 12 hours for Nurses working shifts greater than 13 hours also have more workers with these alternative workweek agreements.16 than double the risk for burnout and job dissatisfaction.24 Several studies show working long hours increases the The wage order does not apply to nurses covered by risk for work/family conflict and poor work/life balance. contracts subject to collective bargaining. The bargaining Long and demanding work hours increase risk for sleep units representing state nursing staff have been deprivation, which in turn can lead to fatigue and bad unsuccessful eliminating mandatory overtime through moods, reducing quality time with family and friends and contract negotiation. State nursing and psychiatric straining personal relationships.25 technician contracts are being negotiated again in 2016. Health and Safety Issues Associated with Research on Mandatory Overtime Long Work Hours While much research has been conducted on fatigued nursing staff errors and a growing body of A growing body of research has shown that working long work has begun to assess the effects of long hours hours in health care facilities can lead to health hazards on the health and well-being of nursing staff, limited for both patients and staff.17 Findings from a 2010 study research is available on the effects of mandatory suggest unplanned overtime increases the likelihood overtime. One study of the effects of mandatory that nursing staff will experience a work-related injury or overtime on nurses working in the Philippines found illness and miss work because of it.18 that the more frequently a nurse works mandatory A 2004 U.S. Institute of Medicine Committee on the or unplanned overtime, the greater the odds of Work Environment for Nurses and Patient Safety study experiencing a work-related injury or illness and examining the effects of working conditions on patient missing work because of it. The study found that safety found that nurses with shift durations that exceeded the effect of mandatory or unplanned overtime 12 consecutive hours had significantly higher error rates.19 was significant over and above the effect of the As a result of these and other findings, the committee number of hours worked. The study concluded, recommended that in order to reduce error-producing given its findings, that “national or organizational- fatigue, nursing staff should be prohibited from providing level policies restricting mandatory overtime in the patient care in excess of 12 hours in any given 24-hour Philippines may be worth considering.” period and in excess of 60 hours per seven-day work Sources: Institute of Medicine (US) Committee on the Work period. Environment for Nurses and Patient Safety. 2004. “Keeping Patients Safe: Transforming the Work Environment of Nurses.” Also, Helene Jorgensen and Lonnie Golden, Economic Policy Institute. January 1, Researchers have found that nurses were three times 2002. “Time After Time: Mandatory Overtime in the U.S. Economy.” more likely to make an error when working 12 or more 8 | www.lhc.ca.gov Time and Again: Overtime in State Facilities In written testimony to the Commission, the Department of State Hospitals stated that psychiatric technicians in 2014-15 missed nearly 355,000 hours of work time due “According to the department, the potential to to workplace injuries, or the equivalent of being down be assaulted is a daily threat for nursing staff.” 200 full-time employees. Data on whether these injuries occurred during a regular or overtime shift was not Lupe Alonzo-Diaz, available, but the department did say that hours lost to Deputy Director of Administrative Services, workplace injuries contribute to the need for nursing staff California Department of State Hospitals to work overtime.26 As a result there is an endless loop of nurses working long hours, which leads to increased risk for on-the-job California is taking steps to address workplace violence injuries requiring time off work, resulting in a need for for nurses through regulations being considered by the more overtime to cover the absences. California Occupational Safety and Health Standards Board in response to legislation enacted in 2014, SB 1299 (Padilla). The regulations, discussed at a December 2015 More board hearing, require health care facilities, including Overtime state health care facilities, to develop plans to prevent workplace violence. This includes adequate staffing, among various other precautions.29 It is not yet clear how the proposed regulations will affect nurse staffing in state facilities. Time off work Increased risk of Beyond the data and the research, the Commission heard to recover from on-the-job from several nurses and psychiatric technicians who work injury injury for the state and were invited to testify at the public hearing. In addition, more than a dozen other health care workers came to Sacramento from all over the state to provide public comment and put a face on the human toll that excess overtime takes on staff. These workers Nurses who work in state facilities also are often dealing described their health issues related to working long with some of the most challenging patients, convicted hours in a stressful environment and provided heartfelt felons and others charged with felonies but too mentally witness for co-workers whose lives were cut short by ill to stand trial. Working in prisons and state hospitals stress-related illnesses. A co-worker of a 27-year-old can add additional safety risks for nursing staff in a nurse who died in 2015 as a result of a heart attack wrote profession that is at high risk already to violence in the that prior to his death, the nurse was overly fatigued workplace. Health care and social assistance workers and mentioned it often. In his last week of work, he had in general are five times more likely to suffer workplace worked four double shifts in a five-day period and half violence than most other professionals and are nearly of those double shifts were mandated and half were twice as likely to suffer workplace violence than public voluntary. safety professionals.27 In 2013, there were 2,586 The Commission also heard about the challenges of aggressive acts committed by patients against staff in California state hospitals.28 providing excellent care while worrying about child care or elder care after unexpectedly being required to work an extra shift. Little Hoover Commission | 9 Time and Again: Overtime in State Facilities Others spoke of spending many hours sleeping in their of concern for their patients and to assist their co-workers. cars in parking lots after working back-to-back shifts – not Workers also benefit financially from working overtime. feeling alert enough to drive home. Shift work and long To improve worker and patient safety, however, the state hours are among the top five factors that increase the must take steps to reduce the need for excess overtime in risk for automobile crashes.30 One nurse described being state facilities providing health care. awakened by a horn blowing from oncoming traffic as his truck crossed the median and bounced into a ditch while driving home exhausted after a mandatory overtime shift. Overtime Costs He lives 48 miles from the prison where he works, so it is impossible to get adequate rest after working a 16-hour Not only does excess overtime take a toll on the health shift and having to report back for a regular shift eight of state employees, it also is expensive and may leave hours later. Another nurse spoke of a colleague being the state vulnerable to lawsuits resulting from health seriously injured in a head-on collision after leaving work care errors. Although it is not clear whether the state after a mandated shift. is spending more on overtime than it would cost to hire additional staff to significantly reduce overtime, the state Hearing witnesses also spoke of nursing staff being clearly spends an excessive amount on overtime. disciplined for fatigue on the job or for appearing not to be alert or for patient errors. The state can require that California spent more than $1 billion on overtime pay an employee work a 16-hour day and then can penalize for state employees in 2015.33 According to the State the employee for being drowsy. Research shows that the Controller’s payroll database, the amount of overtime risk of struggling to stay awake at work increases by paid to 12,144 state nursing staff in 2015 was nearly 50 percent when shifts exceed 12.5 hours.31 $179 million. Nearly $58 million in overtime was paid to nursing staff employed by California Correctional Based on the research and the testimony the Commission Health Care Services and the California Department of heard from the nurses who work long hours in state Corrections and Rehabilitation in 2015. The Department facilities, it is apparent that overtime, whether voluntary of State Hospitals paid more than $90 million in overtime or mandated, puts both staff and patients at risk for in 2015.34 health hazards. Although the focus of this review as requested is on the state’s use of mandatory overtime, According to testimony provided to the Commission, the Commission concluded that the state should evaluate psychiatric technicians at the Department of State its overall use of overtime if the desired outcome is Hospitals worked an estimated 1.2 million hours of improved health and safety for staff and patients. overtime in 2013-14 at a cost of approximately $53 million.35 A July 2013 audit of the Department of Developmental A representative from the Department of Developmental Services found the state paid $28.6 million in overtime, Services testified to the Commission that “if the intent approximately 9 percent of total employee earnings. The of limiting mandatory overtime is to reduce prolonged audit also found that more than half of that overtime work hours and greater fatigue, then limits on all overtime was paid to just 62 of the 1,838 workers employed need to be reviewed. Staffers are, by far, working more by the department. The auditor recommended the hours voluntarily, and would experience the same fatigue department “reassess its minimum staffing requirements, factors.”32 In response to questions from the Commission hire a sufficient number of employees to cover those regarding the significant use of voluntary overtime, nurses requirements, and examine its employee scheduling participating in the August hearing said they prefer to processes.”36 volunteer to work a shift. This enables them to control when and where they work and decreases their likelihood Hiring sufficient staff, or even filling current vacancies of being forced to work overtime when that may be in nursing positions across the departments that less convenient or conflict with an important family rely heavily on overtime, however, may not save the commitment. Many also volunteer to work overtime out state money. According to a Senate Appropriations 10 | www.lhc.ca.gov Time and Again: Overtime in State Facilities Committee analysis of SB 780 (Mendoza), the bill under departments that use a significant amount of overtime consideration in 2016 that would eliminate mandatory indicated the state would be out of compliance on nurse- overtime for psychiatric technicians, the 53 new positions patient staffing ratios if they did not have the option that would be needed to cover mandatory overtime of mandating staff to work overtime. Witnesses at the hours currently worked by existing staff would cost the August hearing cited numerous factors driving overtime, state approximately $500,000 more each year than using including civil service challenges that make vacancies mandatory overtime. Filling the 53 positions would cost hard to fill, numerous nursing staff being off work on approximately $5.7 million per year in salary, benefits various types of leave, difficulty balancing staff resources and other expenses while paying mandatory overtime with fluctuating patient care needs and inappropriate hours costs approximately $5.3 million per year. The staff scheduling. Department of State Hospitals cost for mandatory Civil Service Challenges overtime in 2014 was approximately $5.7 million. Hiring additional full-time employees to work those hours The Commission has long recommended civil service would total about $7.1 million, resulting in an annual cost reform to make it easier to hire and retain the most increase of $1.4 million.37 qualified employees for state jobs. The California Department of Human Resources and the State Personnel An Assembly Appropriations Committee analysis of the Board are currently working on civil service reform. The bill that would ban mandatory overtime for nursing staff, Commission applauds these efforts and encourages the AB 840 (Ridley-Thomas), indicated the cost of hiring administration to continue to make civil service reform a additional staff to cover the hours currently worked as top priority, particularly efforts to streamline the hiring mandatory overtime would be more than $3 million process and modernize civil service classifications. statewide. Vacancies are a significant driving force of overtime in In written testimony to the Commission, the Department 24/7 state facilities providing health care. Recruiting of State Hospitals indicated there is a gap between cost health care staff is difficult under the best of savings from reducing overtime and the cost of salaries circumstances and is exacerbated not only by outdated and benefits for additional positions. The testimony civil service hiring procedures, but also by the nature of included a breakdown of the additional cost of hiring staff the patient clientele in state facilities and the very real versus using overtime by position: it would cost the state threat of having to work unplanned and unexpected an additional $7,100 per additional psychiatric technician, shifts. Further complicating hiring, many state facilities $11,829 per additional registered nurse and $4,999 per are in remote locations with a limited hiring pool. Other additional licensed vocational nurse.38 state facilities are in expensive urban areas where it is The state could benefit from further analysis of the costs hard to attract and retain entry-level nursing staff. of overtime as compared to adequately staffing to reduce California Department of Veterans Affairs officials or avoid overtime. Such an analysis also should take into described specific challenges in hiring certified nursing consideration the connection between long work hours, assistants, the entry-level nursing staff that does the bulk workplace injuries and workers compensation costs. of the work in skilled nursing facilities. It can take months to fill a vacancy in these entry-level positions, a wait that is too long for low-income workers who can get hired by Factors Driving the Need for Overtime private sector employers much more quickly. California’s certified nursing assistant job classification requires There was general agreement from all participants at the that an applicant not only be certified but also have six Commission’s August 2016 hearing that working long months experience. Private sector employers have an hours in a health care setting is not good for the health advantage in hiring newly certified nursing assistants and safety of state nursing staff and the patients under while providing on-the-job training. Eliminating the their care. Despite this, the representatives from the Little Hoover Commission | 11 Time and Again: Overtime in State Facilities six-month work experience requirement would provide sharing, using permanent intermittent employees and a small step toward making it easier to hire entry level “on call” employees. The state also could more actively nurses. In the Department of Veterans Affairs, certified recruit students working toward nursing degrees and nursing assistants worked 75 percent of all mandatory licenses. overtime shifts. Options for creating internal registries Balancing Staff Resources with Fluctuating Patient – employees willing to work on a part-time, temporary Needs or as needed basis – are difficult under the civil service structure, but virtually impossible when there are Each of the departments that used mandatory overtime significant numbers of vacant positions, which is precisely cited fluctuating patient acuity – or the level of medical the challenge in some of the state’s veterans homes. or nursing care an individual requires – as having an immediate impact on staffing needs. As a result, staffing Officials with California Correctional Health Care Services needs can vary unpredictably from day to day and even also cited implementation of a law enacted in 2012, shift to shift. The types of fluctuating patient acuity that AB 340 (Furutani), that prohibits a state employee who affect staffing needs include fall risks, patients needing retires from returning as a retired annuitant for 180 days. wound care, the types and amounts of medications While well-intended and enacted as part of much broader prescribed to patients and various levels of assistance pension reforms, this change has made it somewhat required with daily activities. more difficult for the state facilities that provide 24/7 health care to tap into recently retired employees who Beyond the day to day changes, hearing witnesses have institutional knowledge, experience and expertise. said that the state has failed to take into account the The law does, however, provide state departments an changing demographics of state facility populations. option to hire retired annuitants before 180 days have The 2011 prison realignment, which shifted supervision passed if the department declares that the appointment of many low-level offenders from state prison to local is critically necessary and the appointment is approved law enforcement, has left an older and less healthy by the California Department of Human Resources population of offenders in state prisons, potentially (CalHR). Also, CalHR can delegate this approval authority requiring higher nurse-to-patient ratios. An increasing to departments, which would eliminate this particular number of Vietnam War veterans are moving into state barrier. Those departments reviewed as part of this veterans homes and often have gone decades without study should request, if they have not done so already, adequate health care. They often have greater needs and CalHR should authorize, this delegation of authority than their World War II and Korean War counterparts so that these departments can fill critical vacancies by in terms of substance use disorders and mental health hiring retired annuitants without the otherwise required issues from years of untreated posttraumatic stress waiting period.39 disorders. The population in general is heavier, requiring additional staff for patients who need to be turned or State departments also could encourage employees assisted in getting out of bed. considering retirement to instead participate in the state’s Partial Service Retirement Program which allows Clearly the state could be doing a better job of predicting employees an opportunity to reduce work time and ease adequate staffing or there would not be 3.75 million into retirement. hours of overtime worked annually by the nurses at state facilities. Overtime in a round-the-clock facility is Civil service rules designed in a bygone era prioritize to be expected, but should be the exception and not the hiring full-time employees and often exclude workers rule. Some hearing witnesses told the Commission the who might prefer the flexibility that part-time hours assumptions the state uses to calculate the relief factor would provide to attend school or care for children or do not adequately account for changes in patient acuity, aging parents. Civil service improvements should include leave time, staff injuries and staff vacancy trends. The a full range of options used by many other employers – “relief factor” is the number of total staff required to hiring part-time workers, more actively promoting job 12 | www.lhc.ca.gov Time and Again: Overtime in State Facilities ensure that all shifts in a 24/7 operation are covered after who call in sick around the holidays, calculating leave and sick time. and prisoners who are depressed – all of which creates a perfect storm.”42 At the time of the Commission’s hearing, the Department of State Hospitals was in the process of conducting a Written testimony from the Department of Developmental study to evaluate staffing levels, “including patient to Services stated that overtime is required to meet established staff ratio and relief factors for 24-hour care nursing staffing guidelines. According to the testimony, prohibiting classifications to determine appropriate level of mandatory overtime would likely require new staffing staffing for its current patient population and hospital standards and “there currently is no process for operations.”40 establishing new or additional positions to fill behind or cover for client health and safety/acuity needs, or In written testimony, the California Correctional Health for staff illness and injury – one of the main reasons for Care Services specifically cited the lack of funding to overtime in the developmental centers system.”43 provide one-on-one suicide watches as particularly challenging. When offenders are placed on suicide Written testimony from the California Department of watch, they must be monitored on a one-on-one basis. Veterans Affairs also indicated an inadequate relief factor For the most part, in state facilities, this is handled by to backfill for employees on leave. According to the nursing staff. To fulfill this requirement, the department testimony, furloughs imposed on state workers during will reassign someone to do the suicide watch and the Great Recession led to an increase in the average replace that position through voluntary overtime, employee’s vacation/annual leave balance by 16 days contract registry (temporary staff that may be available as employees used furlough time instead of vacation or to work a shift) or mandatory overtime. In 2014-15, annual leave time. The result is the department does not California paid $12.7 million for staff to work 387,000 hours have adequate backup staff to cover all of the leave time on suicide watch in state prisons.41 that staff has accrued.44 Additionally, CalVet officials told Commission staff that 60 of 248 direct care staffers at the California Correctional Healthcare Services provided a Yountville Veterans Home have been granted “reasonable specific example of the staffing challenges that occur accommodations” for disabilities and cannot be required because of the suicide watches. In December 2014 at to work two consecutive shifts. As a result, the bulk of Corcoran State Prison, the department was authorized the overtime, falls on the remaining staff. The Governor’s for 62 psychiatric technicians. There were 10 vacancies 2016-17 Budget proposes adding 32 nurses at an annual and three employees “temporarily separated,” meaning cost of $2.9 million at the state’s three oldest veterans they were out on long-term sick leave, pending an homes – Yountville, Chula Vista and Barstow – to reduce investigation or on military leave. December is a month reliance on overtime and costly nurse registries. The with many holidays. Children of staff are on winter proposed budget increase is based on an updated relief break from school and many staffers get scheduled and factor that considered patient acuity, training, and clinical approved for vacation time. The holidays also are a time and physical emergencies.45 where people often suffer from depression, including incarcerated offenders who are separated from their Training is another factor cited as a driver of overtime. families and placed on suicide watch. As a result of all of Nurses are required to participate in training for both these factors, in December 2014, psychiatric technicians personal and facility licensing. Staff must participate worked 570 hours of mandatory overtime at Corcoran in a minimum number of hours of training annually, State Prison. According to testimony: regardless of staff shortages. “We have fewer people available, people In addition to vacancies and changes in patient health previously scheduled for time off, people care needs, each department cited employee absences who don’t want to voluntarily work for workers compensation injuries, sick time and various overtime during the holidays, people other employee leave requirements. Written testimony Little Hoover Commission | 13 Time and Again: Overtime in State Facilities provided by the Department of Developmental Services care facilities, primarily in other states, but also officials showed a direct parallel between undelivered hours from with the Los Angeles County Sheriff’s Department and a filled positions (time when employees are away from representative of the California Hospital Association. work for various reasons) and overtime hours. According These public or private health care facilities strive to to the testimony, 90 percent of the overtime is directly minimize overtime in general and only use mandatory related to undelivered hours of filled positions.46 overtime in extreme emergencies. According to these Scheduling Errors officials, limiting overtime reduces health and safety risks, improves staff morale and avoids excess costs. Commission staff also was told that some forced overtime is the result of poor scheduling. Employees working Private hospitals in California and elsewhere are in state facilities that operate on 24/7 schedules are motivated to limit overtime due to the cost – both in required to request vacation and annual leave time terms of actual overtime payroll expenses and increased months in advance. Yet one nurse told Commission staff staff turnover. Patient satisfaction also declines when in the prison where he worked it was rather common to nurses work long hours, another reason hospitals limit inadvertently put an employee with planned vacation overtime. Many private hospitals have staffing pools of time on the schedule thus creating a need for someone nurses who have indicated they are willing to work two to work overtime to fill the shift. He also said the effort or three days per week. Hospitals use this in-house or to recruit employees to work a voluntary overtime per diem pool first if a staffing shortage arises. Other shift varies from supervisor to supervisor. Improving options for hospitals and health care facilities are nurse scheduling practices and encouraging supervisors to registries or travel nurses – nurses willing to relocate to minimize overtime by making it part of their performance fill a vacancy, usually for three months or longer. Both review are immediate steps that can be taken to reduce of these options are expensive. Although there are best the state’s reliance on excess overtime. practices to be learned from the private sector health care operations, there are significant differences that In testimony to the Commission, a representative of the make staffing state health care facilities more challenging. Department of State Hospitals indicated they were in the California state prisons and state hospitals have no process of rolling out a new automated staff scheduling control over their patient population – the patients application for 24/7 operations, ASSIST. One goal of have been committed to the facilities by the courts. the new scheduling system is to reduce mandatory Comparing California staffing to public facility staffing overtime.47 The Department of State Hospitals should in other states also can be challenging due to the sheer document the effectiveness of the software and share size of the offender and state hospital population in best practices with other state departments with 24/7 California, but again, there are lessons to be learned. operations. A chief administrator of state hospitals in Washington The factors that drive overtime – vacancies, fluctuating told Commission staff that mandatory overtime is an patient care needs, training, leave time – are not unique option but that he has only used it one time. Washington to California state health facilities. Yet California seems to has two state hospitals housing more than 1,100 patients stand alone in its heavy reliance on overtime to meet its with mental illness as well as one childrens’ psychiatric staffing requirements. facility. Like California, Washington uses voluntary overtime to manage staffing shortages, although to a much lesser degree. In 2014, voluntary overtime was Managing Health Care Facilities without 5.5 percent of total payroll. To avoid overtime, Excess Overtime Washington relies on a strong pool of floaters and on- call workers to fill gaps when permanent employees are As previously indicated, Commission staff interviewed a on vacation, sick or injured. Some of the workers in the variety of government officials who manage public health float pool are guaranteed a minimum number of hours 14 | www.lhc.ca.gov Time and Again: Overtime in State Facilities per week. These workers are paid straight wages when The union interprets an emergency as a natural disaster they work, allowing Washington to minimize its overall while management sees inmates needing health care as use of overtime. Washington also builds one anticipated an emergency. Still, the county avoids forced overtime one-on-one suicide watch per 30-bed ward into its through a variety of options. Employees are asked to staffing model. If more than one suicide watch per ward volunteer to come in four hours early or stay four hours occurs, the administrators tap the float pool. Washington after their shift to cover gaps. The staff at facilities in also contracts with a private sector staffing company for close proximity can float between facilities depending registered nurses. Although the size of Washington’s upon need. The county also uses custody staff, not patient population in state hospitals is one-fifth the size nursing staff, for one-on-one suicide watches. Like state of California’s state hospital population, the patient prisons, custody issues make it more difficult to create demographics and health and mental health care needs a staffing pool or list of approved temporary employees are similar. The staffing agency is aware of the nature of as the background checks can take months. If the the work and although the registered nurses provided by temporary staff is not used often enough, it’s not worth the agency do not have a background in psychiatric care, the effort. Like state facilities, the county has a significant the department has not had any issues with the quality amount of nursing staff out on Family and Medical Leave of care they provide. These temporary employees often Act. Of 1,400 staff working in medical services, later apply for permanent positions.48 10 percent is out on Family and Medical Leave Act at any given time. According to the captain, it is no surprise All of the veterans home officials in other states that the health care worker is the first in the family called interviewed as part of the study process said that they upon to care for an ailing relative.51 avoid using overtime as much as possible due to the associated costs. Florida provides a budget for staffing its In addition to interviewing the captain, Commission veterans homes beyond the standard staffing regulations staff also spoke with Susan Turner, a former chief nurse for skilled nursing facilities. For example, a veterans executive for the California Department of Corrections home administrator told Commission staff that she and Rehabilitation who is currently consulting with Los requires a minimum of 42 certified nursing assistants for Angeles County. She suggested that if the state used its a day shift serving 120 veterans. She is able to schedule nursing staff more efficiently there would be less need for 50, knowing that rarely will all show up. Also, staff is overtime. She recommended that the state provide more required to call in four hours before a shift begins if they flexibility by allowing people to work part-time or to job are not able to work leaving time for supervisors to find share. Ms. Turner stated that part of the state’s problem a replacement.49 Tennessee veterans homes have an is that it lacks a staffing pipeline. Private hospitals use unusual structure in that the homes operate as a body, student rotations in addition to staffing pools, registries politic and corporate – in practice meaning in many ways and traveler nurses. All state facilities could benefit from they operate independently from the state. The homes rotations of students who then might be more likely to are not required to follow many of the rules required of seek permanent employment with the state.52 other state departments, including civil service rules. As a result, the home administrator has flexibility both in hiring and in providing competitive pay.50 The Los Angeles County Sheriff’s Department runs the largest county jail system in the country. According to the captain of its medical services bureau, Los Angeles County also tries to limit overtime in general and currently does not use mandatory overtime for health care staffing shortages. The county has an agreement with the union that represents county nurses that states the county will not force overtime absent an emergency. Little Hoover Commission | 15 Time and Again: Overtime in State Facilities Summary general in part due to the associated costs. The state Through its public hearing and study process, the should set a target for reducing overtime in state health Commission learned that working long hours in a care facilities, give state managers and supervisors health care setting, whether voluntary or mandatory, is some flexibility as well as adequate tools to develop detrimental to the health and well-being of nurses and strategies to minimize overtime and then hold state their patients. managers and supervisors accountable for achieving More than a decade ago, the U.S. Institute of Medicine overtime reductions. Cutting the use of overtime in half recommended prohibiting nursing staff from providing should significantly reduce, if not eliminate any need for patient care in excess of 12 hours in a 24-hour work mandatory overtime. And even if the state is effective period and in excess of 60 hours per seven-day work at cutting overtime in half, it will still be using overtime period to reduce error-producing fatigue. The wage in health care facilities at a rate that is twice the national order amendment in 2001 resulted in many of the private average.53 Finally, the state needs to better analyze sector health care providers in California adapting to changes in patient acuity, both short-term and long-term significantly reduce excess overtime and follow the trends, staff leave time trends and schedule staff more Institute of Medicine recommendation. The state, appropriately to avoid the 3.75 million in overtime hours however, remains far behind in implementing staff that nurses worked in 2014-15. scheduling in its facilities that provide health care. It needs to adapt to the standards set by the U.S. Institute of Medicine in 2004, and going forward, continue to monitor research and staffing trends to ensure that workers and patients are protected from practices that result in injuries and errors. The state will likely meet resistance in following the national standard from those Overtime in California workers who are dependent upon overtime to maintain Fiscal Year 2014-15 their quality of life. In the long run, however, eliminating excessive overtime benefits the health of staff and 14,367 nursing professionals patients. employed by the State of California. It is inexcusable that California state facilities rely heavily 3.75 85% million hours of the entire on overtime as a staffing tool when other public sector of overtime. nursing staff worked health care providers have succeeded in reducing overtime. overtime in general and avoiding mandatory overtime in all but extreme emergencies. The departments are $179 1,802 million in employees not solely to blame as they must comply with outdated overtime pay. working 40-hour weeks civil service rules that make it harder and take longer to for a full year. fill vacancies and more difficult to implement creative staffing tools that could help minimize the need for excess overtime. They also are governed by budget and 18.2% of total 4x the percentage staffing allocations that may not be based on accurate pay for state nurses is of pay for registered assumptions for employee leave time and fluctuating overtime. nurses & healthcare workers nationally. patient needs. Managers in private sector health care facilities and those interviewed in public sector health care settings as part of this study process were motivated to limit overtime in 16 | www.lhc.ca.gov Time and Again: Overtime in State Facilities Recommendations Recommendation 1: The Governor and the Legislature Recommendation 4: The Governor and the Legislature should set a target of reducing overtime for nursing should authorize an analysis of short and long-term staff working in state health care facilities to 50 percent trends in patient health care needs, staff leave time of the 2014-15 rate by 2017-18 and eliminate the trends and costs of overtime as compared to the costs use of mandatory overtime except in documented of hiring adequate staff. Based on that assessment, the emergencies. Governor and the Legislature should authorize adequate nursing staff to achieve overtime reduction goals in Recommendation 2: The administration must continue state facilities providing health care. to prioritize civil service reform, particularly efforts to streamline the hiring process and modernize civil service classifications. Recommendations specifically related to reducing overtime in state facilities providing health care include:  Allowing greater flexibility in hiring part-time staff, job sharing and establishing staffing pools with permanent intermittent or “on call” employees for health care staff.  Revising the minimum qualifications for a certified nursing assistant to not require six months of patient care experience if the applicant has achieved certification and has had adequate hands on instruction on potential job duties.  Delegating authority, as allowed by statute, from the California Department of Human Resources to state departments with health care facilities to be able to hire retired annuitants without the otherwise required 180-day waiting period to fill critical vacancies in nursing positions.  Actively recruiting nursing students to work rotations in state facilities providing health care. Recommendation 3: The administration should ensure management has appropriate flexibility and adequate tools to schedule staff and hold management accountable for reaching overtime reduction targets. Little Hoover Commission | 17 Time and Again: Overtime in State Facilities Appendices Public Hearing Witnesses August 27, 2015 Lupe Alonzo-Diaz, Deputy Director of Administrative Beth Muszynski, Chief of Research and Program Services, California Department of State Hospitals Review, Veterans Homes Division, California Department of Veterans Affairs Kelly Harrington, Director, Division of Adult Insti- tutions, California Department of Corrections and Lessie Moore, California Association of Psychiatric Rehabilitation Technicians Chapter Vice President and Psychiatric Technician, Patton State Hospital, City of San Joyce Hayhoe, Director of Legislation and Bernardino Communications, California Correctional Health Care Services Coby Pizzotti, Consultant, California Association of Psychiatric Technicians Dwayne LaFon, Deputy Director (A), Developmental Centers Division, California Department of Cheryl Schutt, Statewide Chief Nurse Executive, Developmental Services California Correctional Health Care Services Luisa Luema, Licensed Vocational Nurse, California Eric Soto, California Association of Psychiatric Department of Corrections and Rehabilitation, Technicians Chapter President and Psychiatric California Correctional Health Care Services and Technician, Metropolitan State Hospital, City of member of SEIU Local 1000 Norwalk Margarita Maldonado, Vice President for Bargaining, SEIU Local 1000 18 | www.lhc.ca.gov Notes Notes 7 U.S. Bureau of Labor Statistics. State-Approaches.html. Accessed March 10, 2015. “Employer Costs for December 29, 2015. 1 Bureau of Labor Statistics, U.S. Employee Compensation – December Department of Labor. November 19, 2015. Table 2. Civilian Workers by 15 Sung-Heui Bae, Carol S. Brewer, 2015. “Nonfatal Occupational Injuries Occupational and Industry Group.” and Christine T. Kovner. 2011. “State and Illnesses Requiring Days Away From Also, “Employee Costs for Employee Mandatory Overtime Regulations and Work, 2014.” Page 9. Compensation New Release.” http:// Newly Licensed Nurses’ Mandatory and www.bls.gov/news.release/ecec.t02.htm Voluntary Overtime and Total Work 2 Michele Hawkins, Program Accessed March 16, 2016. Figure was Hours.” Nursing Outlook. Management and Analysis Bureau, State calculated by adding the supplemental Controller’s Office. February 17, 2016. pay and wages and salaries columns to 16 Industrial Welfare Commission. “Report of Civil Service Employees, determine total pay, then calculating July 2014 “Order No. 5-2001 Regulating Including Department, Facility, the percentage of supplemental pay of Wages, Hours and Working Conditions Classification and Regular and Overtime the total. Supplemental pay includes in the Public Housekeeping Industry.” Pay Data for Payments Issued in Calendar employer costs for employee overtime 17 C.C. Caruso, J. Geiger-Brown, Year 2015.” Written communication to and premium pay, shift differentials and M. Takahashi, A. Trinkoff, A. Nakata, Commission staff. (The number includes nonproduction bonuses. Department of Health and Human registered nurses, licensed vocational Services, Centers for Disease Control nurses, certified nursing assistants, and 8 Lupe Alonzo-Diaz, Dwayne LaFon, and Prevention, National Institute for psychiatric technicians.) Joyce Hayhoe, Beth Musszynski. Refer Occupational Safety and Health. May to endnote 3. 3 Lupe Alonzo-Diaz, Deputy Director 2015. “NIOSH Training for Nurses on Shift of Administrative Services, California 9 Lupe Alonzo-Diaz, Dwayne LaFon, Work and Long Work Hours.” http:// Department of State Hospitals. Also, Joyce Hayhoe, Beth Muszynski. Refer to www.cdc.gov/niosh/docs/2015-115/ Dwayne LaFon, Deputy Director (A), endnote 3. Accessed December 23, 2015. Developmental Centers Division, California Department of Developmental 10 Coby Pizzotti, Consultant, California 18 A.B. de Castro, K. Fujishiro, T. Rue, Services. Also, Joyce Hayhoe, Director Association of Psychiatric Technicians. E.A. Tagalog, L.P.G. Samaco-Pacquiz, of Legislation and Communications, August 27, 2015. Written testimony to and G.C. Gee. June 2010. “Associations California Correctional Health Care the Commission. Between Work Schedule Characteristics and Occupational Injury and Illness.” Services. August 27, 2015. Written 11 Joyce Hayhoe, Director of International Nursing Review. testimony to the Commission. Also, Legislation and Communications, Beth Muszynski, Chief, Research and California Correctional Health Care 19 Institute of Medicine (US) Committee Program Review, Veterans Homes Services. August 27, 2015. Written on the Work Environment for Nurses Division, California Department of testimony to the Commission. and Patient Safety. 2004. “Keeping Veterans Affairs. January 25, 2016. Patients Safe: Transforming the Work Written communication. (Department of 12 Lupe Alonzo-Diaz, Deputy Director Environment of Nurses.” Also, Helene Veterans Affairs did not include overtime of Administrative Services, California Jorgensen and Lonnie Golden, Economic hours for the West Los Angeles facility.) Department of State Hospitals. August 27, Policy Institute. January 1, 2002. “Time 2015. Written testimony to the Commission. After Time: Mandatory Overtime in the 4 Michele Hawkins. Refer to endnote 2. U.S. Economy.” 13 Beth Muszynski, Chief, Research and 5 This calculation is based on a 40-hour Program Review, Veterans Homes Division, 20 Ann E. Rogers, Wei-Ting Hwang, workweek multiplied by 52 weeks, which California Department of Veterans Affairs. Linda D. Scott, Linda H. Aiken, David equals 2,080 hours. 3,748,437 overtime January 25, 2016. Written communication. F. Dinges. July/August 2004. “The hours divided by 2,080 equals 1,802.13. Working Hours of Hospital Staff Nurses 6 Michele Hawkins. Refer to endnote 2. 14 American Nurses Association. and Patient Safety.” Health Affairs. March 7, 2011. Nursing World. Total pay for state nursing staff in 2015 “Mandatory Overtime: Summary of 21 Linda D. Scott, Ann E. Rogers, Wei- included $983,564,266 of regular pay State Approaches.” http://nursingworld. Ting Hwang, Yawei Zhang. January 2006. and $178,957,477 of overtime pay. Total org/MainMenuCategories/Policy- “Effects of Critical Care Nurses Work pay did not include lump-sum or other Advocacy/State/Legislative-Agenda- Hours on Vigilance and Patients’ Safety.” categories of pay. Reports/MandatoryOvertime/ American Journal of Critical Care. Mandatory-Overtime-Summary-of- Little Hoover Commission | 19 Time and Again: Overtime in State Facilities 22 A. E. Dembe , J. B.Erickson, R.G. 26 Lupe Alonzo-Diaz, California 39 California Government Code Section Delbos, S. M. Banks. 2005 “The Impact Department of State Hospitals. Refer to 7522.56, (f) (2). of Overtime and Long Work Hours on endnote 12. Occupational Injuries and Illnesses: 40 Lupe Alonzo-Diaz. Refer to endnote 12. New Evidence from the United States.” 27 Bureau of Labor Statistics, U.S. Occupational and Environmental Department of Labor. Refer to endnote 1. 41 Joyce Hayhoe. Refer to endnote 11. Medicine. 28 California Department of State 42 Joyce Hayhoe. Refer to endnote 11. Hospitals. April 2014. “Violence Report: 23 C.C. Caruso, et al. Refer to endnote 43 Dwayne LaFon. Refer to endnote 32. DSH Hospital Violence 2010-2013. 17. Citing C.C. Caruso, E.M. Hitchcock, R.B. Dick, J.M Russo and J.M. Schmit, 44 Diane Vanderpot, Undersecretary of 29 California Occupational Safety and Department of Health and Human Veterans Homes, California Department Health Standards Board. December Services, Centers for Disease Control of Veterans Affairs. August 27, 2015. 17, 2015. “Title 8, California Code of and Prevention, National Institute for Written testimony to the Commission. Regulations, New Section 3342, General Occupational Safety and Health. 2004. Industry Safety Orders, Workplace “Overtime and Extended Work Shifts: 45 2016-17 Governor’s Budget. Violence Prevention in Health Care.” Recent Findings on Illnesses, Injuries, January 7, 2016. Also, California and Health Behaviors.” Also citing M. Department of Veterans Affairs. Budget 30 National Sleep Foundation. Virtanen, K. Heikkilä, M. Jokela, J.E. Change Proposal. January 7, 2016. “Drowsy Driving: Who’s At Ferrie, F.G. Batty, J. Vahtera J, and M. Risk? DrowsyDriving.org. http:// Kivimäki. 2012. “Long Working Hours 46 Dwayne LaFon. Refer to endnote 32. drowsydriving.org/about/whos-at-risk/ and Coronary Heart Disease: A Systemic Accessed December 17, 2015. 47 Lupe Alonzo-Diaz. Refer to endnote 12. Review and Meta-analysis.” American Journal of Epidemiology. Also citing P. 31 C.C. Caruso, et al. Refer to endnote 48 Mark Kettner, Chief Administrator/ Tuntiseranee , J. Olsen, A. Geater, and O. 17. Citing L.D. Scott, A.E. Rogers, Financial Officer, Behavioral Health Kor-anantakul. 1998. “Are Long Working W.T. Hwang, Y. Zhang. 2006. “Effects Administration, Washington State Hours and Shiftwork Risk Factors for of Critical Care Nurses Work Hours Department of Social and Health Subfecundity? A Study Among Couples on Vigilance and Patients’ Safety.” Services. October 22, 2015. Personal from Southern Thailand. Occupational American Journal of Critical Care. communication with Commission staff. and Environmental Medicine.” 32 Dwayne LaFon, Deputy Director 49 Kay Maley, Administrator, Clyde 24 C.C. Caruso, et al. Refer to endnote (A), Developmental Centers Division, Lassen Veterans Home, St. Augustine, 17. Citing A.W. Stimpfel, D.M. Sloane, California Department of Developmental Florida. December 1, 2015. Personal and L.H. Aiken. 2012. “The Longer the Services. August 27, 2015. Written communication with Commission staff. Shifts for Hospital Nurses, the Higher testimony to the Commission. the Levels of Burnout and Patient 50 Ed Harries, Executive Director, Dissatisfaction.” Health Affairs. 33 Michele Hawkins. Refer to endnote 2. Tennessee State Veterans Home Board. December 17, 2015. Personal 25 C.C. Caruso, et al. Refer to endnote 34 Michele Hawkins. Refer to endnote 2. communication with Commission staff. 17. Citing K. Albertsen , L. Rafnsdottir, A. Grimsmo, K. Tomasson , and K. 35 Coby Pizzotti. Refer to endnote 10. 51 Kevin Kuykendall, Captain, Medical Kauppinen. 2008. “ Workhours and Services Bureau, Correctional Services 36 California State Auditor. July 9, Worklife Balance.” Scandinavian Journal Division, Los Angeles County Sheriff’s 2013. “Developmental Centers: Poor- of Work, Environment & Health. Also Department. October 23, 2015. Personal Quality Investigations, Outdated Policies, citing, D.S. Carlson and P.L. Perrewe. communication with Commission staff. Leadership and Staffing Problems, 1999. “The Role of Social Support in and Untimely Licensing Reviews Put the Stressor-Strain Relationship: An 52 Susan Turner, RN, Ph.D, Principal/ Residents at Risk.” Report 2012-107. Examination of Work-Family Conflict.” CEO, Turner Healthcare Associates, Journal of Management. Also citing Inc. October 27, 2015. Personal 37 Senate Committee on J.H. Greenhaus, A.G. Bedeian, and K.W. communication with Commission staff. Appropriations. May 28, 2015. SB 780 Mossholder. 1987. “Work Experiences, (Mendoza) Bill Analysis. Job Performance and Feelings of 53 U.S. Bureau of Labor Statistics. Personal and Family Well-Being.” Journal Refer to endnote 7. 38 Lupe Alonzo-Diaz. Refer to endnote 12. of Vocational Behavior. 20 | www.lhc.ca.gov Little Hoover Commission Members Chairman Pedro Nava (D-Santa Barbara) Appointed to the Commission by Speaker of the Assembly John Pérez in April 2013. Advisor to telecommunications industry on environmental and regulatory issues and to nonprofit organizations. Former state Assemblymember. Former civil litigator, deputy district attorney and member of the state Coastal Commission. Elected chair of the Commission in March 2014. Vice Chairman David A. Schwarz (R-Beverly Hills) Appointed to the Commission in October 2007 and reappointed in December 2010 by Governor Arnold Schwarzenegger. Partner in the Los Angeles office of Irell & Manella LLP and a member of the firm’s litigation workgroup. Former U.S. delegate to the United Nations Human Rights Commission. Scott Barnett (R-San Diego) Appointed to the Commission by former Speaker of the Assembly Toni Atkins in February 2016. Founder of Scott Barnett LLC, a public advocacy company, whose clients include local non- profits, public charter schools, organized labor and local businesses. Former member of Del Mar City Council and San Diego Unified School District Board of Trustees. David Beier (D-San Francisco) Appointed to the Commission by Governor Edmund G. Brown Jr. in June 2014. Managing director of Bay City Capital. Former senior officer of Genetech and Amgen. Former counsel to the U.S. House of Representatives Committee on the Judiciary. Serves on the board of directors for the Constitution Project. Senator Anthony Cannella (R-Ceres) Appointed to the Commission by the Senate Rules Committee in January 2014. Elected in November 2010 an re-elected in 2014 to the 12th Senate District. Represents Merced and San Benito counties and a portion of Fresno, Madera, Monterey and Stanislaus counties. Jack Flanigan (R-Granite Bay) Appointed to the Commission by Governor Edmund G. Brown Jr. in April 2012. A member of the Flanigan Law Firm. Co-founded California Strategies, a public affairs consulting firm, in 1997. Loren Kaye (R-Sacramento) Appointed to the Commission in March 2006 and reappointed in December 2010 by Governor Arnold Schwarzenegger. President of the California Foundation for Commerce and Education. Former partner at KP Public Affairs. Served in senior policy positions for Governors Pete Wilson and George Deukmejian, including cabinet secretary to the Governor and undersecretary for the California Trade and Commerce Agency. Assemblymember Chad Mayes (R-Yucca Valley) Appointed to the Commission by former Speaker of the Assembly Toni Atkins in September 2015. Elected in November 2014 to the 42nd Assembly District. Represents Beaumont, Hemet, La Quinta, Palm Desert, Palm Springs, San Jacinto, Twentynine Palms, Yucaipa, Yucca Valley and surrounding areas. Don Perata (D-Orinda) Appointed to the Commission in February 2014 and reappointed in January 2015 by the Senate Rules Committee. Political consultant. Former president pro tempore of the state Senate, from 2004 to 2008. Former Assemblymember, Alameda County supervisor and high school teacher. Assemblymember Sebastian Ridley-Thomas (D-Los Angeles) Appointed to the Commission by former Speaker of the Assembly Toni Atkins in January 2015. Elected in December 2013 to represent the 54th Assembly District. Represents Century City, Culver City, Westwood, Mar Vista, Palms, Baldwin Hills, Windsor Hills, Ladera Heights, View Park, Crenshaw, Leimert Park, Mid City, and West Los Angeles. Senator Richard Roth (D-Riverside) Appointed to the Commission by the Senate Rules Committee in February 2013. Elected in November 2012 to the 31st Senate District. Represents Corona, Coronita, Eastvale, El Cerrito, Highgrove, Home Gardens, Jurupa Valley, March Air Reserve Base, Mead Valley, Moreno Valley, Norco, Perris and Riverside. Jonathan Shapiro (D-Beverly Hills) Appointed to the Commission in April 2010 and reappointed in January 2014 by the Senate Rules Committee. Writer and producer for FX, HBO and Warner Brothers. Of counsel to Kirkland & Ellis. Former chief of staff to Lt. Governor Cruz Bustamante, counsel for the law firm of O’Melveny & Myers, federal prosecutor for the U.S. Department of Justice Criminal Division in Washington, D.C., and the Central District of California. Full biographies available on the Commission’s website at www.lhc.ca.gov. “Democracy itself is a process of change, and satisfaction and complacency are enemies of good government.” Governor Edmund G. “Pat” Brown, addressing the inaugural meeting of the Little Hoover Commission, April 24, 1962, Sacramento, California