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2018 Massachusetts Ballot Question One: Not Great Governance

This 2018 election, Massachusetts ballot Question One is about nurse-patient ratios. Specifically, they say there should only be so many patients assigned to a nurse, depending on how intensely the patients need help. Ballpark, this is a reasonable idea. The devil is in the details. The following is the summary of some emails I shared with my brother. The views here are my own.

Data on Massachusetts Ballot Question One

The only data I’ve seen on the subject for either side comes from the NIH. Their study addresses staffing ratios in terms of nurse hours, rather than nurse numbers, and looks at ACA penalties as a proxy for outcomes. The basic gist of the study is that medical centers with more nursing hours have fewer ACA penalties. We can therefore expect they have better patient outcomes. More nurse hours = better for patients. Makes sense.

massachusetts ballot question one - derivative of videoplasty - cc-by-sa-4

The Loophole in Massachusetts Ballot Question One

The proposal as drafted has a theoretical loophole. As the ballot initiative concerns nurse numbers rather than hours, and the statute it modifies does not define a “registered nurse” as a full time equivalent, it leaves the law open for dodging.

Imagine I’m the Massachusetts Nursing Association’s hypothetical cost-cutting monster of a hospital administrator. I could meet the requirements of the proposed law by making all my nurses half-time and loading each up at the legal ratio. This would be effectively twice the intended capacity. Each nurse would each have the right number of patients, but they’d have half as many hours to offer care. The drafters of Massachusetts ballot Question One surely do not intend this. Unless there is a definition elsewhere that I haven’t read, this is the loophole they have written.

A Broken Public Discourse around Ballot Question One

I believe that the hospitals have a propaganda machine. So do the MNA. Both sides are using scare tactics, like hospitals shutting their doors and patients dying from neglect. I agree that there is a problem to be solved here. I would like to see this bill iterated on with comments from both sides, and taken up by the legislature. Ballot initiatives are not collaborative projects. Consensus ought to be possible between these two perspectives looking at the same patients.

In fact, with a few exceptions, ballot questions tend to cost at least a million dollars either side. Sometimes much less can get spent, like the repeal of the gas tax indexed to inflation ($100,000 to win; $500,000 to lose). The 2016 Charter schools question cost $6 million to win (and another $12 to lose). Final figures for 2018 Massachusetts Ballot Question One aren’t in, but both sides surely are invested in a victory. There’s no opportunity in the do-or-die ballot process to take criticism from both sides and craft a consensus bill.

Shouldn’t we at least try Massachusetts Ballot Question One?

I would be on board with trying new things. That’s not really the intent of the question, though. Forget the issue for the moment. Forget hospitals vs employees. Let’s think about how best to govern ourselves.

Imagine you were a democracy scientist and you wanted to “try” this. You would need:

  • A control group;
  • Data collection, both on outcomes and on the additional costs (you’re going to have more reports and inspections);
  • A statically significant sample over time;
  • A provision to stop if the experiment started harming people; and
  • A mindset of “we’ll roll this back if it isn’t measurably better, net of costs”.

And probably you wouldn’t limit yourself to nurses, right? Maybe you’d include doctors and support staff in the study as well. Doctors and support staff can be just as overburdened, if not more so.

The question seems to start from an assumption that “more nurses is the right thing to do,” but given the polarization, I have to consider that there may not be consensus on this question.

Couple this with the theoretical loophole about head count vs hours, and I’m more concerned.

I’ll just point out one more thing: the fine print modifies the mission of the Health Policy Commission, which was intended to be about data, and grants it enforcement powers, like the Attorney General. This bill is so far removed from free inquiry about how best to govern ourselves that it dilutes the mission of a data gathering agency. It’s not a “let’s try it” kind of bill.

So for me, the devil is in the details. I think there hasn’t been enough conversation on this bill. And I for one would rather see more effort toward consensus on matters of life and death.


Consensus Decision Making in a Room of 19

I liked a recent experience on the City of Worcester’s Task Force for Sustaining Housing First Solutions. In the current climate of incivility, especially on social media, consensus-oriented approaches to hard problems are especially appealing. Here’s how this one worked.

Worcester Task Force for Sustaining Housing First Solutions, Doug Quattrochi, June 27, 2018

Smart editors, including Barbara Poppe, prepared a set of 26 recommendations. The goal was to have each of the 19 representatives around the room agree that their organizations would officially endorse the recommendations. Each recommendation would be read, and then each representative would give a thumbs up, a thumbs sideways, or a thumbs down.

Thumbs up meant your organization would endorse the recommendation as written.

Thumbs sideways was a request for floor time to ask a question. All questions were asked in series without answers so that commonality of questions could be identified. Then questions were addressed in bulk.

Thumbs down meant your organization would not endorse the recommendation. A thumbs down was expected to come with a proposal for alternate wording.


In about 90 minutes, all 26 recommendations were reviewed and approved unanimously, several with extensive modifications.


The thumbs up/down/sideways technique is notable for how it cuts away discussion about agreement. Oftentimes, volunteer (non-business) groups fall into a dynamic where one person states a shared principle or interest, and others take a long time agreeing or adding their own statements of shared interest. All of this is unnecessary in the context of a document that needs to be approved. The thumbs focused discussion on differences.

By being able to iterate on the text in the room, with most key stakeholders present, objections didn’t stop progress, get overruled, or result in a watered-down document. Instead, they resulted in recommendations that were both more concrete and also more widely supported. It’s hard to have people voting directly on complex issues, but iteration in this way seemed to make it work.

“Thumbs up” were the most common because a substantial amount of work had already been done on the text. We were voting paragraph by paragraph, which made each piece manageable.

“Thumbs sideways” were the second most common. Usually, participants asked their question, received clarification, and turned their vote to a “thumbs up.”

“Thumbs down” were rare. They did occur, most notably when Worcester City Councilor Konstantina Lukes expressed a strong desire for one recommendation to be issued with a “shall” instead of a “should” wording. Much discussion resulted, with the end result that Councilor Lukes gave a thumbs up without changing her insistence on the importance of “shall” and without the wording having been changed. It was a failure to reach consensus that we papered over.

This shows the trouble with strict or 100% consensus decision making approaches. Councilor Lukes held the power to scuttle the entire recommendation, or to present the entire document as non-unanimous. Instead of doing that, she conceded her point and went along with what was a clear majority. Perhaps some more work could have been done to address Councilor Lukes’ concern, or to formally note the concern in the official recommendation.

Besides this last issue, it was a good process. There was official consensus on all 26 points, and true consensus on 25 points. It felt efficient. It felt that all voices were heard. It has certainly produced a better result than simple majority rule would have. I hope to use the technique in the future.

Why is the law so hard to read?

If I could wave a magic wand, I would pass a law that read,

“Every law must be comprehensible by the people it is meant to govern.”

and then I would pass another law that read,

“For the purpose of the law, attorneys are presumed to have infinite intellect, and can punish themselves with whatever legalese in law or regulation they so desire to inflict upon their own profession, but may so punish no one else.”

That way, everyone’s in heaven.