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Office of the Public Auditor CNMI 1 The three manpower agencies had provided 124 nurses to the CHC as of September 30, 2002. EXECUTIVE SUMMARY Hiring of Nurses Directly by the Commonwealth Health Center Versus Contracting Through Manpower Agencies Report No. AR-03-06, dated August 19, 2003 Summary This report presents the Office of the Public Auditor’s (OPA) evaluation of nurses provided to the Department of Public Health’s Commonwealth Health Center (CHC). The evaluation’s objective was to determine whether CHC’s practice of using manpower agencies to hire nurses saves the Department of Public Health and the Commonwealth of the Northern Mariana Islands (CNMI) money without compromising patient care. As of December 31, 2002, three manpower agencies had provided CHC with 126 of its 209 nurses and CHC had directly hired the remaining 83 nurses. OPA found that the hiring of nurses through manpower agencies is less costly than the direct hiring of nurses. However, continuing the current practice of contracting with manpower agencies rather than directly hiring nurses will perpetuate other problems, most notably the difficulty in retaining qualified nurses. More specifically: if CHC were to convert the 124 nurses 1 provided by manpower agencies to direct hire status, it would incur an additional estimated $1.5 million annually, or about 37 percent more than it is currently paying manpower agencies.However, assuming that most non-resident direct hires would elect not to be a part of the CNMI’s retirement system, the CNMI could substantially reduce this additional cost to about $.7 million by converting all CHC nurses on board to direct hire without retirement benefits. As retirement fund membership is currently mandatory, the CNMI would need to amend legislation to make retirement fund membership optional. if CHC were to directly hire National Council Licensure Examination (NCLEX) licensed nurses with five or more years of experience (those at the top of the pay scale), CHC would incur an additional estimated $2.6 million annually, or about 64 percent, more than it is now paying manpower agencies. Likewise, assuming that most non-resident direct hires would elect not to be a part of the CNMI’s retirement system, it could substantially reduce this additional cost to about $1.6 million by converting all CHC nurses on board to direct hire without retirement benefits, again provided legislation was amended to make retirement fund membership optional. Analysis Assuming Direct Conversion of Current Manpower Nurses Assuming CHC Hires Nurses with at Least an NCLEX and 5 Years of Experience in Lieu of Current Manpower Nurses Cost of Direct Hiring $5,587,311 $6,693,472 Less: Cost of Current Manpower Contracts 4,075,300 4,075,300 Additional Annual Cost to Fund Direct Hires $1,512,011 $2,618,172 Percentage Increase in Current Costs 37% 64% Less: Employer’s Retirement Contribution Required Under Law 801,757 1,009,457 Adjusted Annual Cost Increase Under Direct Hiring Net of Retirement Contribution $710,254 $1,608,715

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Page 1: Office of the Public Auditor CNMI EXECUTIVE …opacnmi.com/resources/files/ar0306.pdfOffice of the Public Auditor CNMI 1 The three manpower agencies had provided 124 nurses to the

Office of the Public Auditor CNMI

1 The three manpower agencies had provided 124 nurses to the CHC as of September 30, 2002.

EXECUTIVE SUMMARYHiring of Nurses Directly by the Commonwealth Health Center Versus Contracting Through Manpower Agencies Report No. AR-03-06, dated August 19, 2003

Summary This report presents the Office of the Public Auditor’s (OPA) evaluation of nurses provided to the Departmentof Public Health’s Commonwealth Health Center (CHC). The evaluation’s objective was to determine whetherCHC’s practice of using manpower agencies to hire nurses saves the Department of Public Health and theCommonwealth of the Northern Mariana Islands (CNMI) money without compromising patient care. As ofDecember 31, 2002, three manpower agencies had provided CHC with 126 of its 209 nurses and CHC haddirectly hired the remaining 83 nurses. OPA found that the hiring of nurses through manpower agencies is less costly than the direct hiring of nurses.However, continuing the current practice of contracting with manpower agencies rather than directly hiringnurses will perpetuate other problems, most notably the difficulty in retaining qualified nurses. More specifically:

• if CHC were to convert the 124 nurses1 provided by manpower agencies to direct hire status, it wouldincur an additional estimated $1.5 million annually, or about 37 percent more than it is currently payingmanpower agencies.However, assuming that most non-resident direct hires would elect not to be a partof the CNMI’s retirement system, the CNMI could substantially reduce this additional cost to about $.7million by converting all CHC nurses on board to direct hire without retirement benefits. As retirementfund membership is currently mandatory, the CNMI would need to amend legislation to make retirementfund membership optional.

• if CHC were to directly hire National Council Licensure Examination (NCLEX) licensed nurses withfive or more years of experience (those at the top of the pay scale), CHC would incur an additionalestimated $2.6 million annually, or about 64 percent, more than it is now paying manpower agencies.Likewise, assuming that most non-resident direct hires would elect not to be a part of the CNMI’s retirementsystem, it could substantially reduce this additional cost to about $1.6 million by converting all CHC nurseson board to direct hire without retirement benefits, again provided legislation was amended to makeretirement fund membership optional.

Analysis

Assuming Direct

Conversionof Current Manpower

Nurses

Assuming CHC Hires Nurses with at Least an NCLEX and 5 Years of Experience

in Lieu of Current Manpower Nurses

Cost of Direct Hiring $5,587,311 $6,693,472

Less: Cost of Current Manpower Contracts 4,075,300 4,075,300

Additional Annual Cost to Fund Direct Hires $1,512,011 $2,618,172

Percentage Increase in Current Costs 37% 64%

Less: Employer’s Retirement Contribution Required Under Law

801,757 1,009,457

Adjusted Annual Cost Increase UnderDirect Hiring Net of Retirement Contribution

$710,254 $1,608,715

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Office of the Public Auditor CNMI

A copy of this report is available at the Office of the Public Auditor

Michael S. Sablan P.O. Box 501399Public Auditor Saipan, MP 96950Commonwealth of the Northern Mariana Islands Tel. No. (670) 322-6481Web Site: www.opacnmi.com Fax No. (670) 322-7812

Adjusted Percent Increase in Direct Hiring Cost Without Required Employer’s Retirement Contribution

17% 39%

Manpower agencies offer lower salaries and benefits than nurses hired directly by CHC receive, resulting ingreater nurse turnover among manpower nurses ,which, according to four of six of CHC doctors interviewed,has adversely impacted patient care. OPA found that direct hire nurses stay in the CNMI for a considerably longerperiod than do manpower nurses, resulting in less turnover. The average length of employment of direct hirenurses employed by CHC was 108 months while manpower nurses average only 28 months. CHC is constantlybeing forced to rebuild its nursing staff with inexperienced manpower nurses who arrive to replace those leaving.Most manpower provided nurses use their CNMI job as a stepping stone to the United States (U.S.) and othercountries. Data obtained indicates that once nurses obtain the NCLEX certification needed to practice in theU.S., most seek jobs elsewhere because their current salaries are not competitive with compensation they canobtain elsewhere.

OPA found that many manpower provided nurses would likely stay at CHC if they were paid pay and benefitscomparable to direct hire nurses; likewise many former manpower nurses, now in the U.S., would possibly returnto the CNMI. More specifically, over 90 percent of the manpower nurses interviewed stated that they wouldremain at CHC if they were converted to direct hire status with appropriate salary increases and a benefits packagesimilar to that provided to direct hires.

While there are no easy answers, it appears that the direct hiring of non-resident nurses would allow CHC toretain nurses and thereby help improve patient care. Although the CNMI continues to face a fiscal crisis, it cannotafford to let the health care system deteriorate. In the end, nursing experience and continuity in service, andtheir impact on patient care, cannot be discounted when analyzing the costs of conversion. However, becausethe present environment of financial austerity cannot be ignored, one solution may be to convert back to directhire of nurses over a period of time.

The Acting Secretary of Public Health had no comments on this report other than to state that this issue wasof great importance to the department and the community as a whole.

Two of the three manpower agencies, however, provided comments. One agency advised that the Departmentof Public Health needed to find a compromise solution to resolve disparities and inequities at hand. It contendedthat CHC would have difficulty in retaining qualified nurses even if it hired them directly and if they were equallycompensated. The other agency stated that more than a small pay increase was needed if CHC wanted to hireand retain qualified nurses. Further, the agency stated that CHC could improve its patient care if it improvedits communication and relations with manpower companies.

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Office of the Public AuditorCommonwealth of the Northern Mariana Islands

Audit ReportAR-03-06

Department of Public HealthHiring of Nurses Directly by the Commonwealth HealthCenter Versus Contracting Through Manpower Agencies

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1 CHC is the Commonwealth of the Northern Mariana Islands’ primary health facility under theDepartment of Public Health. In this report, OPA refers to CHC as the contracting entity for nurses, althoughtechnically the Department of Public Health contracts for nurses.

Office of the Public AuditorCommonwealth of the Northern Mariana Islands

World Wide Web Site: http://opacnmi.com1236 Yap Drive

Capitol Hill, Saipan, MP 96950

Mailing Address:P.O. Box 501399Saipan, MP 96950

E-mail Address:[email protected]

Phone: (670) 322-6481Fax: (670) 322-7812

August 19, 2003

Dr. James U. HofschneiderSecretary of Public HealthP.O. Box 500409 CKSaipan, MP 96950

Dear Dr. Hofschneider:

Subject: Hiring of Nurses Directly by the Commonwealth Health CenterVersus Contracting Through Manpower Agencies (Report No.AR-03-06)

On August 19, 2002, you requested the Office of the Public Auditor (OPA) to determine whetherthe Commonwealth Health Center’s (CHC)1 practice of contracting with manpower agencies fornurses saves the Department of Public Health (DPH) and the Commonwealth of the NorthernMariana Islands (CNMI) money without compromising patient care. For the last eight years suchagencies have provided CHC with a large portion of its nursing staff.

BACKGROUND

In 1995, the Department of Public Health entered into contracts with four manpower agenciesto provide a portion of CHC’s nursing staff. Such contracts were considered necessary due to theanticipated departure of non-U.S. citizen nurses dictated by Public Law 7-45. The sunsetprovision in Public Law 7-45 allowing DPH and other agencies to employ non-resident workerswas due to expire on September 30, 1995.

DPH has contracts with three agencies to provide nurses for CHC: Paras Enterprises (Paras),Saipan Employment Agency Services Inc., (SEAS), and Marianas Health Services (MHS). As ofDecember 31, 2002, these three agencies were providing CHC with 126 nurses as follows: Paras -59, SEAS - 63, and MHS - 4. At that time, CHC had 83 other nurses on board that it had hireddirectly.

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2 The National Council Licensure Examination (NCLEX), developed by the National Council of StateBoards of Nursing, is a national nurse licensure examination required in the United States and its territories forlicensure. This examination, although offered in the CNMI, is not a requirement for licensure in the CNMI.

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OBJECTIVE, SCOPE AND METHODOLOGY

The objective of OPA’s review was to determine whether CHC’s practice of using manpoweragencies to hire nurses saves the DPH and the CNMI money without compromising patient care.To determine the least costly source of nurses, we conducted cost analyses using both manpowercontract and direct hire data.

In our analyses we annualized all computations and estimates and relied on, as necessary, previouscost analyses. We interviewed DPH officials, manpower agency personnel and officials, as well asCHC doctors, unit managers, nurses and other CNMI officials as to the impact, if any, on patientcare resulting from the use of manpower-provided nurses. We reviewed and compared retentionrates for manpower agency nurses and direct hire nurses in the same or similar positions. Weobtained data from doctors and unit managers indicating the training that CHC needed to provideto manpower versus direct hire nurses. We examined the effect of nurses passing the NationalCouncil Licensure Examination2 (NCLEX) and CHC’s ability to retain these certified nurses.Finally, we compared the quality of nursing staff being provided by manpower agencies with thatof CHC direct-hire nurses by reviewing: (1) the type of nursing degree obtained, (2) years ofnursing service, and (3) credentials received (such as NCLEX or other certificates).

We conducted our review at DPH’s office in Saipan from August to December 2002. This reviewwas performed, where applicable, in accordance with Government Auditing Standards issued bythe Comptroller General of the United States. Accordingly, we included such tests of records andother auditing procedures as were considered necessary in the circumstances. Due to the limitedscope of our review, we did not evaluate any other internal controls.

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3 As per a list provided by CHC’s Nursing Services Section.

4 In July 2002, DPH published a request for proposal (RFP02-CHC-0092) to extend the services ofmanpower agencies beyond September 30, 2002. These manpower service contracts were subsequently extended.

5 This does not consider taking in new applicants who have NCLEX certification and additional years ofexperience.

6 Base contract cost means the basic rate the manpower agency charge for each category of nurses, anddoes not include any additional cost that may be charged such as overtime pay.

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RESULTS OF REVIEW

OPA found that the hiring of nurses through manpower agencies is less expensive than the directhiring of nurses. However, continuing the current practice of contracting with manpoweragencies, rather than directly hiring nurses, will perpetuate other problems, most notably thedifficulty in retaining qualified nurses. Manpower provided nurses do not receive pay and fringebenefits (i.e. retirement benefits, housing, night differential, holiday pay, sick leave, annual leave,and health insurance) equal to their direct hire counterparts. In the end, the higher turnoveramong manpower provided nurses and their resulting replacement with less experienced nursespotentially adversely affects the quality of patient care provided.

Direct Hiring of Nurses Will Result in Greater Costs

According to CHC,3 124 manpower nurse positions in DPH contracts with manpower agenciesscheduled to end on September 30, 20024 could ultimately be replaced by direct hire nurses. Weconducted two analyses, one which assumed conversion of all current manpower nurses to directhire, and another which assumed that CHC would only hire NCLEX licensed nurses with at leastfive years of experience. OPA found that:

• if CHC were to convert the 124 nurses provided by manpower agencies to direct hirestatus, it would incur an additional $1,512,011 annually over what it is currently payingmanpower agencies5. This represents about 37 percent more than the contract amount6.See Appendix A for low-end analysis.

• if CHC were to directly hire NCLEX licensed nurses having five or more years ofexperience (those considered at the top of the pay scale), CHC would incur an additional$2,618,172 annually, or about 64 percent, more than the base contract cost it is now payingmanpower agencies. See Appendix B for high-end analysis.

The additional costs associated with direct hiring of nurses are due largely to personnel benefits,many of which manpower agencies do not provide. Under the low-end analysis, total annualpersonnel benefits amount to 43 percent of total costs whereas under the high-end analysis theyamount to 40 percent of such costs. See Appendices A and B for total annual total personnelbenefit costs under both analyses.

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Assuming that most non-resident direct hire nurses would elect not to be a part of the CNMI’sretirement system, the CNMI could substantially reduce the additional costs associated with directhiring by making CNMI retirement participation optional for prospective non-resident direct hirenurses. If the non-resident direct hire nurses elected not to participate, the estimated additionalcosts would be:

• $710,254, assuming conversion of all CHC nurses on board to direct hire (see AppendixC for low-end analysis), or

• $1,608,715, assuming that CHC hired only NCLEX licensed nurses having at least fiveyears of experience. (See Appendix D for high-end analysis.)

As participation is currently mandatory, the CNMI would need to amend the law to make CNMIRetirement Fund membership optional for the nurses.

A comparison of the additional costs associated with direct hiring under each of OPA’s twoassumptions, namely the direct conversion of the current manpower nurses and hiring only nurseshaving a NCLEX certification and 5 years of experience follows:

Analysis

Assuming Direct

Conversion ofCurrent

Manpower Nurses

Assuming CHC Hires Nurses with at Least an NCLEX and 5 Years of Experience

in Lieu of Current Manpower Nurses

Cost of Direct Hiring $5,587,311 $6,693,472

Less: Cost of Current Manpower Contracts 4,075,300 4,075,300

Additional Annual Cost to Fund Direct Hires $1,512,011 $2,618,172

Percentage Increase in Current Costs 37% 64%

Less: Employer’s Retirement Contribution Required Under Law

801,757 1,009,457

Adjusted Annual Cost Increase UnderDirect Hiring--Net of Retirement Contribution

$710,254 $1,608,715

Adjusted Percent Increase in Direct Hiring Cost WithoutRequired Employer’s Retirement Contribution

17% 39%

OPA’s analyses above do not factor in the additional cost of overtime that manpower agencyprovided nurses receive as OPA was unable to determine whether such overtime resulted fromany periodic shortage of nurses or from the need to cover nurses on annual and sick leave, medicalemergencies, holidays, or training.

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OPA assumed that more experienced direct hire nurses would cost more, but that they would alsoincrease the quality of patient care for patients presented for treatment. OPA further assumed thatthe staff turnover rate for nurses provided by the manpower agencies would decrease if the nurseswere direct hires, thereby reducing the training necessary for new nurses. Finally, OPA assumedthat greater continuity of nurses associated with prolonged nurse employment would also increasethe quality of patient care.

The limited scope of this review did not allow OPA to ascertain the related costs of training newnurses. In addition, OPA did not analyze whether more experienced nurses, with longevity atCHC, might enable CHC to provide improved patient care with less individuals on its nursingstaff.

Manpower Nurses May Negatively Affect the Quality of Patient Care at CHC

1. CHC Faces Difficulty in Attracting and Retaining Qualified Nurses

CHC has had difficulty in attracting and retaining trained and qualified nurses. Much of CHC’shiring of nurses is done by manpower agencies rather than directly by CHC. These agencies offerlower salaries and benefits to nurses than CHC provides to nurses hired directly. Based oninformation obtained, it appears that CHC retains a relatively low percentage of the manpoweragency provided nurses because most manpower nurses use their CNMI employment as a meansof moving to the United States (U.S.) and elsewhere. Data obtained also indicates that once nursesobtain the NCLEX certification needed to practice in the U.S., most seek jobs outside of theCNMI because their current salaries are not competitive with compensation they can obtainelsewhere.

OPA found that direct hire nurses stay in the CNMI for a considerably longer period than domanpower nurses, resulting in less turnover. As of December 31, 2002, CHC employed 209nurses, namely 126 manpower hire nurses and 83 direct hire nurses. The direct hire nurses hadbeen employed by CHC for an average of 108 months, or approximately 9 years, while themanpower nurses averaged only 28 months, or just over two years. Turnover among manpowernurses is much higher than among direct hire nurses.

The two largest providers of manpower nurses, Paras and SEAS, have retained a very lowpercentage of NCLEX certified nurses.

• Most Paras agency nurses who have passed the NCLEX have left the CNMI after a two-year stay in the CNMI. To illustrate as of December 31, 2002, 37 of the 145 nurses thatParas provided had previously passed the NCLEX before being hired.

• However, of the 37, 23 resigned within two years of being detailed at CHC andonly 14 remain at CHC.

• An additional 46 passed the NCLEX after being hired, 35 of which resigned after

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less than two years at CHC, leaving only 11 at CHC.

• Thus, of 83 Paras nurses who had passed the NCLEX , 58 nurses or about 70percent left after an average two-year stay, and only 25 nurses or about 30 percentopted to stay longer.

• Likewise, most SEAS nurses who passed the NCLEX left after a two-year stay. SEAS hadprovided 146 nurses to the CHC as of December 31, 2002, 27 of whom had passed theNCLEX prior to being hired. However, 20 of the 27 left after working an average of a yearand a half. An additional 23 nurses hired by SEAS passed the NCLEX after being detailedto CHC, but only 7 remained after a year and a half. Thus, of 50 nurses who passed theNCLEX, 36 nurses, or about 72 percent, left after less than 2 years.

• Of the remaining 122 manpower nurses (59 Paras nurses and 63 SEAS nurses) stillemployed at CHC, only 39 nurses, or about 32 percent, had passed the NCLEX.

According to seven of eight unit managers and five of six doctors interviewed, CHC expendsconsiderable resources in training a nurse, particularly manpower provided nurses most of whomcome from the Philippines. According to three of eight unit managers and all doctors interviewed,most nurses recruited by the manpower agencies lack independence, assertiveness, and experience.As such, they believe that those nurses need additional training not normally required of U.S.trained nurses. Five of six doctors and seven of eight unit managers advised us that while basicorientation for new nurse hires at CHC lasts two weeks, it may take over a year of training beforedoctors feel comfortable leaving a manpower nurse with patients.

According to most manpower nurses interviewed, many would likely stay at CHC and manyformer manpower nurses now working in the U.S. would possibly return if they were paid payand benefits comparable to direct hire nurses. More specifically, over 90 percent of the manpowernurses interviewed stated that they would remain at CHC if they were converted to direct hirestatus with appropriate salary increases and a benefits package similar to that provided to directhires. The nurses cited other reasons for remaining in the CNMI including: (1) the CNMI’s closeproximity to the Philippines, (2) the CNMI’s climate and culture, and (3) the strong Filipinocommunity in the CNMI. Also, nurses who have maintained contact with former co-workerspresently employed in the U.S. indicated that many of those nurses have expressed a willingnessto return to the CNMI if, and only if, the conversion to direct hire status was implemented.Those nurses would likely return for the same reasons that the current nurses would like to stay.Further, if those nurses did return as direct hire nurses at CHC, they would bring with them theexperience they have gained working in U.S. hospitals.

Four of the six doctors interviewed stated that the quality of nurses provided by the manpoweragencies had adversely affected patient care. For example, those nurses frequently fail to recognizecritical situations, and cannot always properly read patients’ vital signs. OPA’s review of incidentsoccurring during the eight months ending August 29, 2002 substantiates this position. OPA found42 reported incidents involving manpower nurses and 6 reported incidents involving direct hire

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7 As of December 31, 2002, CHC employed 126 manpower hire nurses and 83 direct hire nurses orabout 50 percent more manpower nurses than direct hire nurses.

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nurses even though the average number of manpower nurses was about 50 percent higher7 thandirect hire nurses. • The 42 incidents involving manpower nurses ranged from communication problems to

procedural errors. The nine communication problems reported were primarily conflictsbetween patients/families and nursing staff, resulting in patient anxiety and frustration.The 33 procedural incidents reported included:

• six documentation errors and/or failure to order lab work;• one delay for an intensive care patient admitted for a possible heart attack; • eight self-inflicted needle sticks;• six medication errors;• seven patient falls, three of which were a direct result of poor judgment on the part

of the attending nurse; • two involving improperly administered medication to emergency unit patients who

were subsequently discharged without a reassessment and then collapsed whileleaving the hospital;

• a patient being fed just prior to a procedure, causing a 24 hour delay in thetreatment; and

• two miscellaneous incidents in the emergency unit; one involved a patient beingdischarged before being cleared by the doctor resulting in the patient needing to becontacted at home, requested to return, and be admitted to the hospital for cardiacproblems; and one involved a psychiatric patient who walked out of the emergencyunit unattended resulting in the need to contact the police/security in order tolocate and return the patient to the hospital.

• The six incidents involving direct hire nurses included,

• three communication problems, • one medication error, • one patient fall, and • one provision of questionable care by a midwife during infant delivery.

In addition, four of six doctors and four of eight unit nurse managers interviewed felt that in someinstances CHC had retained manpower nurses who were marginal or who had performed poorly.However, they also advised that, given the shortage of nurses and the time to train new hires, itmight be better to retain the current staff than to request manpower agencies to provide newnurses. They explained that hasty recruitment could result in less qualified replacements whowould not provide the needed performance.

Four of six doctors and three of eight unit nurse managers indicated that once the less experiencedmanpower nurses were trained, they performed at a level equal to direct hire nurses. However,

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after being trained (as indicated by the statistics above), those nurses are more likely to leave forhigher paying jobs in the U.S. Thus, instead of building a foundation of experienced high qualitynursing staff, CHC is forced to accept new entry level nurses provided by manpower agencies toreplace those who have departed.

See Appendix E for a summary of doctors and unit managers responses to the OPA interviewquestions.

2. Disparity in Compensation Between Direct Hire and Manpower Nurses

Nurses provided by manpower agencies receive a compensation package considerably lower thantheir direct hire counterparts who receive housing, annual and sick leave, holiday pay, and medicalbenefits. As such, most of the manpower nurses elect to leave CHC as soon as they pass theNCLEX, resulting in a high turnover of manpower nurses. CHC is then left with lessexperienced manpower nurses and new manpower replacements who need to be trained.

Manpower agency nurses receive an average salary of $19,298, a third less than the $27,948 theirdirect hire co-workers receive on the same work assignments. Furthermore, even thoughmanpower agency nurses have learned new skills and taken on more responsibility, they havereceived little or no pay raises during the last 7 years. In addition, some manpower nurses havebeen required to pay a recruiting fee amounting to about $1,500, the equivalent of one month’ssalary. While direct hire nurses receive night differential, manpower nurses do not.

Other fringe benefits such as housing, annual leave, sick leave, medical, and holiday pay providedto manpower nurses do not compare with the benefits their direct hire counterparts receive. Toillustrate:

• Housing is, for the most part, provided to manpower nurses in the form of two or morebedroom apartments with two nurses to a bedroom with all occupants sharing a living area,kitchen, and one bathroom. More specifically, sometimes up to 12 nurses lived in a sixbedroom apartment with two nurses to a bedroom and with all 12 sharing two bathrooms,a kitchen, and a living room.

• In other cases, the manpower nurses live in a dormitory type arrangement where each

room has an adjoining bathroom shared by the occupant in the next room. In theseinstances, a kitchen and TV room are shared by all occupants.

While the housing is tolerable, it falls short of the housing that off-island direct hire nurses canafford based on the housing allowance they receive, which is $600 per month for those withoutdependents and $800 per month for those with dependents.

In addition, while utilities are normally included as part of the housing provided to manpowernurses, 60 SEAS provided nurses advised OPA and CHC that their manpower agency hadattempted to amend their contracts to require them to pay for utilities. More specifically, SEASmanpower nurses sent a letter, dated August 13, 2002 signed by all its nurses, to the Secretary of

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Health alleging that the cost of their electrical bills was soon to be deducted from their salaries.SEAS justified changes in the proposed amendment that would transfer the burden of paying forutilities to nurses as follows: (1) employment contracts allowed for such a charge; (2) the agencyneeded to cut costs due to the economic crisis; and (3) employees had abused the use of electricity.The nurses stated in their letter that had they not signed the amended contracts, they would befaced with the possibility of not receiving their paychecks, having their employment papers puton hold until they signed the amended contracts, or a refusal to process entry permits. Althoughthe manpower nurses reluctantly signed the amended contracts, SEAS had not deducted utilitycosts from the nurses paychecks.

Manpower nurses receive four holidays a year whereas their direct hire counterparts receive 14.They receive a two-week vacation whereas direct hire nurses receive up to five weeks. Accordingto the nurses, leave is approved only after one year of service under new contracts. In addition, asmanpower agencies incur overtime costs when staff are on vacation, leave requests were frequentlynot granted.

See Appendix F for a summary manpower nurse responses to interview questions.

Other Matters - Inadequate Number of Nurses

According to the December 2002 Nursing Level Statistics prepared by the acting director ofnursing, CHC has filled 226 nurse positions and needs to fill an additional 64. As limited fundinglimits the number of nurse personnel, CHC has a nurse-to-patient ratio of one nurse to every fiveto six patients, and sometimes as many as seven patients. A national media publication has, in anumber of articles, cited studies that show the correlation between nurse staffing and patienthealth.

• A recent study in the Journal of the American Medical Association confirmed the risks topatients cared for by overburdened nurses. This study, which covered more than 200,000surgical patients and 10,000 nurses, documented the link between nurse staffing andincreased risk of patients dying after surgery, as well as with increased nurse burnout andjob dissatisfaction. The study found that when nurse caseloads exceeded four patients, therisk of a patient’s dying increases by about 7 percent for each additional patient. Morespecifically, if one nurse is caring for eight patients, the patients are 31 percent more likelyto die. In addition, each patient added to a nurse’s caseload increased the nurse’s jobdissatisfaction and the likelihood that “burnout” will push them out of nursing.

• Another recent study reportedly found that fewer nurses meant that patients suffered morefrequently from urinary tract infections, falls, and bedsores, and contracted pneumoniamore often.

• In August 2002, the Joint Commission on the Accreditation of Health Care Organizationsreportedly found that inadequate nurse staffing levels contributed to nearly one-quarterof the 1,609 cases of accidental injury or death documented for hospitalized patients since1997.

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Page 10 of 29

CONCLUSION

Our review shows that, although it would be substantially more costly to replace all manpowernurses with direct hire nurses, to continue the current practice of contracting with manpoweragencies will perpetuate other problems, most notably the difficulty in retaining qualified nurses.Relatively lower pay and fringe benefits provided to manpower nurses have resulted in highturnover which has adversely impacted patient care. CHC is constantly being forced to rebuildits nursing staff with inexperienced manpower nurses who arrive to replace those leaving.

While there are no easy answers, it appears that the direct hiring of non-resident nurses wouldallow CHC to retain nurses and thereby help improve patient care. Although the CNMIcontinues to face a fiscal crisis, it cannot afford to let the health care system deteriorate. In the end,nursing experience and continuity in service, and their impact on patient care, cannot bediscounted when analyzing the costs of conversion. However, because the present environmentof financial austerity cannot be ignored, one solution may be to convert back to direct hire ofnurses over a period of time.

COMMENTS

In a letter dated July 16, 2003 (Appendix G), the Acting Secretary of Public Health indicated hehad no comments on our report other than to state that the issue covered was of great importanceto the department and the community as a whole.

Saipan Employment Agency Services, Inc. (SEAS) Comments on OPA’s Draft Report

In a letter dated July 07, 2003 (Appendix H), the President of Saipan Employment AgencyServices Inc. (SEAS) acknowledged the difficulty of retaining CHC nurses, and agreed that giventhe CNMI government’s financial situation, OPA’s suggestion for a compromise solution is a stepin the right direction. He suggested that revisions or changes in the contract terms and conditionsbetween the agencies and CHC could resolve disparities and inequities on the issue at hand andthereby meet the goals and objectives of all the parties concerned.

He contends that CHC will continue to encounter difficulty in retaining qualified nurses evenif it hires them directly. He further contends that CHC mandates the pay and benefits thatmanpower nurses receive, and an increase in such pay and benefits alone would not decrease highturnover because nurses are attracted by permanent residency status obtained in the U.S. andEurope. He said that SEAS manpower nurses would provide him no assurance they would remainin the CNMI even if equally compensated. However, he contends that most direct hire nurseswould stay in Saipan given that they are from the CNMI or Micronesia. Also, the CHC PersonnelOffice has final approval authority over manpower agency hires, and can require a manpoweragency to replace a nurse at no cost if CHC is not satisfied with the nurse hired.

Page 14: Office of the Public Auditor CNMI EXECUTIVE …opacnmi.com/resources/files/ar0306.pdfOffice of the Public Auditor CNMI 1 The three manpower agencies had provided 124 nurses to the

Page 11 of 29

OPA Response

Although the CNMI does not offer salaries and benefits equivalent to those in the U.S. and inEurope, OPA’s analyses show that directly hiring nurses at a rate competitive with otherjurisdictions would entice more qualified nurses to remain in the CNMI. While the CNMI maybe unable to give nurses U.S. resident status, it allows those that meet the requirements of 3CMC§4437(i) and (o) to relocated immediate family members to the CNMI.

OPA disagrees with SEAS’s statement that CHC mandates the pay and benefits that manpowernurses receive. Salaries set forth in the Request for Proposal are only a guideline for prospectiveagencies, and the benefits required are those minimally required under the Non-resident Worker’sAct. While CHC has final approval over nurses hired it is, according to CHC, reluctant to dismissa nurse given the training already provided and the fear that replacements may not be adequate.

Paras Enterprises Comments on OPA’s Draft Report

In a letter dated July 08, 2003 (Appendix I), the Vice President for Operations of Paras indicatedthat OPA had not adequately demonstrated that the direct hiring of nurses would help improvepatient care. He said CHC needs to provide nurses with more than a slight pay increase if it is tohire and retain qualified nurses. Further, he contends that OPA had not addressed the hiddencosts associated with directly hiring non-resident workers, such as the recruitment fees, airfare,and NCLEX training incurred for replacement when NCLEX nurses are lured away to new jobs.In discussing high turnover, he said that while most direct hire nurses have family and culturalties in Saipan, manpower nurses lack such attachment, and many come to Saipan to take theNCLEX and then move on to the U.S. after passing the exam to obtain a higher salary and longercontracts. He believes manpower nurses could provide improved patient care if CHC would improve itsrelations with manpower companies. He stated that poor communications between the DPHadministration and manpower agencies is causing stress and fear among many manpower nurses,and that although DPH had recently initiated efforts to directly hire nurses, it has failed to provideany plan or time line for phasing out the manpower agency provided nurses.

OPA Response

CHC pays manpower agencies an established amount for each category of nurse provided. Tocompare the cost of direct hiring of nurses, OPA attempted to identify all costs associated withhiring of a nurse, i.e. air fare, housing, salary, benefits etc., and compared the total of these costswith what CHC pays manpower agencies. OPA was, however, unable to calculate administrativecosts, such as the cost to recruit nurses because of the difficulty of quantifying such cost, but agreethat this may be an added cost involved in direct hiring.

Page 15: Office of the Public Auditor CNMI EXECUTIVE …opacnmi.com/resources/files/ar0306.pdfOffice of the Public Auditor CNMI 1 The three manpower agencies had provided 124 nurses to the

Page 12 of 29

While Paras claims that manpower nurses, unlike direct hires, have a strong desire to go to theU.S., our interviews with manpower nurses indicated many had strong ties to the community hereand would give consideration to remaining in the CNMI if given equal treatment with direct hirenurses. While Paras also claims that nurses leave because of greater job security in the mainland,OPA must point out that given the shortage of nurses in the CNMI, job security should not bea factor if nurses are performing satisfactorily.

Sincerely,

Michael S. Sablan, CPAPublic Auditor

cc: GovernorLt. GovernorPresident of the SenateSpeaker of the HouseAttorney GeneralSpecial Assistant for Management and BudgetSecretary of FinancePresident, Paras Enterprises Saipan, Inc. (Paras)Vice President, Saipan Employment Agency and Services, Inc. (SEAS)Administrator, Marianas Health Services (MHS)Press

Page 16: Office of the Public Auditor CNMI EXECUTIVE …opacnmi.com/resources/files/ar0306.pdfOffice of the Public Auditor CNMI 1 The three manpower agencies had provided 124 nurses to the

Appendix A

Page 13 of 29

Tota

l Ann

ual C

ost

Cos

tPe

rson

nel B

enef

itTo

tal A

nnua

l

(Not

e 4)

Ann

ual L

eave

Acc

umul

ated

Cos

t fo

r C

ashi

ngEs

timat

ed Y

earl

y

(Not

e 3)

$700/m

o.

Bene

fit C

ost

of

Ann

ual H

ousi

ng

(24%

)C

urre

nt R

ate

Cos

t Ba

sed

onC

ontr

ibut

ion

Retir

emen

tA

nnua

l

(4%

)C

urre

nt Ra

te

Base

d on

Insu

ranc

e C

ost

Hea

lth &

Life

(Not

e 2)

$1,9

53.7

8/y

r.

Goo

ds

of H

ouse

hold

Ship

men

t C

ost

Ann

ualiz

ed

(Not

e 2)

Air

Far

e $270/y

r.

Ann

ualiz

ed C

ost

of

Serv

ice

Cos

t C

ompe

nsat

ion

orTo

tal A

nnua

l

(Not

e 1)

Nig

ht D

iffer

entia

lA

nnua

l Cos

t of

Estim

ated

Cos

t Sa

lary

or

Serv

ice

Ann

ualiz

ed

Posi

tions

C

urre

nt

No.

of

Hou

rly

Rate

Se

rvic

e C

ost

Ann

ual R

ates

of

Sala

ry o

rP

o s

i t i

o n

Esti

ma

ted

Ad

dit

ion

al C

ost

to C

on

vert

Cu

rren

t M

an

pow

er

Ag

en

cy N

urs

es

to D

irect

Hir

eEs

tim

ate

d A

dd

itio

na

l C

ost

to C

on

vert

Cu

rren

t M

an

pow

er

Ag

en

cy N

urs

es

to D

irect

Hir

e a

s a

Perc

en

tag

e o

f M

an

pow

er

Hir

ing

Cost

s ($

1,5

12,0

11 /

$4,0

75,3

00)

Act

ua

l Se

rvic

e C

ost

Pa

id t

o M

an

pow

er

Ag

en

cies

in F

Y 2001

Esti

ma

ted

ad

dit

ion

al C

ost

as

a P

erc

en

tag

e o

f FY

2001 A

ctu

al Se

rvic

e C

ost

($1,

512,

011

/ $4

,253

,138

)

Cost

Com

pa

riso

n -

Con

vers

ion

of

Dir

ect

Hir

e v

s C

on

tra

ctin

g T

hro

ug

h M

an

pow

er

Ag

en

cies

Low

-end

Cos

t A

naly

sis:

Ass

umin

g N

urse

s Pr

ovid

ed b

y M

anpo

wer

Age

ncie

s W

ill b

e C

onve

rted

to

Dir

ect

Hir

e St

atus

at

Sala

ry &

Fri

nge

Bene

fit R

ates

App

licab

le t

o Th

eir

Cur

rent

Cre

dent

ials

DIR

ECT

HIR

E -

Esti

ma

ted

cost

ba

sed

on

an

tici

pa

ted

ra

tes

of

sala

ry a

nd

ben

efi

ts t

o b

e p

aid

$3,9

31,2

21$1

,653

,870

$108

,418

$697

,200

$572

,584

$91,

094

$162

,164

$22,

410

$2,2

77,3

51$1

08,4

45$2

,168

,905

83$1

2.56

$26,

131

BSN

NC

LEX

0-1

Yrs.

Exp

.

344,

405

142,

740

9,60

258

,800

50,7

048,

067

13,6

761,

890

201,

665

9,60

319

2,06

27

13.1

927

,437

BSN

NC

LEX

1-2

Yrs.

Exp

.

255,

636

104,

396

7,20

242

,000

38,0

266,

050

9,76

91,

350

151,

239

7,20

214

4,03

85

13.8

528

,808

BSN

NC

LEX

2-3

Yrs.

Exp

.

532,

796

245,

977

13,6

5711

7,60

072

,114

11,4

7327

,353

3,78

028

6,81

813

,658

273,

160

149.

3819

,511

LPN

0-1

Yrs

. Exp

.

78,8

5035

,833

2,04

916

,800

10,8

161,

721

3,90

854

043

,017

2,04

840

,969

29.

8520

,485

LPN

1-2

Yrs

. Exp

.

204,

309

91,4

015,

377

42,0

0028

,389

4,51

69,

769

1,35

011

2,90

95,

377

107,

532

510

.34

21,5

06LP

N 2

-3 Y

rs. E

xp.

179,

348

93,0

154,

112

50,4

0021

,707

3,45

311

,723

1,62

086

,333

4,11

182

,222

66.

5913

,704

Hem

odia

lysi

s Te

chni

cian

0-1

Yrs

. Exp

.

30,8

5515

,746

720

8,40

03,

799

604

1,95

427

015

,108

719

14,3

891

6.92

14,3

89H

emod

ialy

sis

Tech

nici

an 1

-2 Y

rs. E

xp.

29,8

9115

,502

685

8,40

03,

618

576

1,95

427

014

,389

685

13,7

041

6.59

13,7

04O

pera

ting

Rm T

echn

icia

n 0-

1 Yr

s. E

xp.

$5,5

87,3

11$2

,398

,481

$151

,822

$1,0

41,6

00$8

01,7

57$1

27,5

53$2

42,2

69$3

3,48

0$3

,188

,830

$151

,849

124

TOTA

LS

MA

NP

OW

ER H

IRIN

G -

Est

ima

ted

cost

com

pu

ted

pu

rsu

an

t to

ba

se r

ate

s p

rovi

ded

in

th

e c

on

tra

ct

$3,2

77,5

00N

AN

AN

AN

AN

AN

AN

A$3

,277

,500

NA

$3,2

77,5

0095

$16.

59$3

4,50

0Re

gite

red

Nur

se (R

N)

609,

000.

00N

AN

AN

AN

AN

AN

AN

A60

9,00

0.00

NA

609,

000

2113

.94

29,0

00Li

cens

e Pr

actic

al N

urse

(LPN

)

165,

200.

00N

AN

AN

AN

AN

AN

AN

A16

5,20

0.00

NA

165,

200

711

.35

23,6

00H

emod

ialy

sis

Tech

nici

an

23,6

00.0

0N

AN

AN

AN

AN

AN

AN

A23

,600

.00

NA

23,6

001

11.3

523

,600

Ope

ratin

g Ro

om T

echn

icia

n

$4,0

75,3

00N

AN

AN

AN

AN

AN

AN

A$4

,075

,300

NA

$4,0

75,3

0012

4TO

TALS

NA-

not

app

lican

ble

$1,5

12,0

11

37%

$4,2

53,1

38

36%

Not

e 1

- To

fact

or in

nig

ht d

iffer

entia

l, th

e an

alys

is a

ssum

es th

at c

erta

in p

ositi

ons

will

be

assi

gned

and

be

earn

ing

nigh

t diff

eren

tial f

or 1

/3 o

f of t

he to

tal a

vaila

ble

hour

s pe

r ye

ar.

Not

e 2

- To

fact

or in

air

trans

porta

tatio

n &

shi

pmen

t of h

ouse

hold

effe

cts

(Rec

ruitm

ent/

Repa

triat

ion

Cos

ts),

the

anal

ysis

ass

umed

the

follo

win

g:a.

A d

irect

hire

nur

se w

ill m

ost l

ikel

y st

ay fo

r an

ave

rage

of 5

yea

rs th

eref

ore

recr

uitm

ent/

repa

triat

ion

cost

s ca

n be

spr

ead

over

a 5

-yea

r pe

riod.

b. A

s m

ost o

f the

cur

rent

man

pow

er h

ired

nurs

es a

re fr

om th

e Ph

ilipp

ines

, air

trans

porta

tion

and

ship

ping

rat

es a

pplic

able

to th

at d

estin

atio

n w

ere

used

.c.

To

fact

or in

pos

sibl

e ad

ditio

nal a

ir-fa

re c

ost f

or d

epen

dent

s, th

e an

alys

is a

ssum

es th

at 5

0% o

f hire

es h

ave

no d

epen

dent

s an

d 50

% h

ave

at le

ast o

ne d

epen

dent

.N

ote

3 -

To fa

ctor

in h

ousi

ng b

enef

its w

hich

var

y ba

sed

on th

e st

atus

of t

he e

mpl

oyee

, the

ana

lysi

s al

so a

ssum

es th

at h

alf o

f the

hire

es w

ill h

ave

depe

nden

ts a

nd h

alf w

ill h

ave

none

.N

ote

4 -

To fa

ctor

in c

ost o

f acc

umul

ated

ann

ual l

eave

hou

rs, t

he a

naly

sis

assu

mes

that

hal

f of (

104

hrs.

) of a

nnua

l lea

ve h

ours

acc

rued

will

be

used

whi

le h

alf w

ould

be

conv

erte

d to

cas

h.

Page 17: Office of the Public Auditor CNMI EXECUTIVE …opacnmi.com/resources/files/ar0306.pdfOffice of the Public Auditor CNMI 1 The three manpower agencies had provided 124 nurses to the

Appendix B

Page 14 of 29

Tota

l Ann

ual C

ost

Cos

tPe

rson

nel B

enef

itTo

tal A

nnua

l

(Not

e 4)

Ann

ual L

eave

Acc

umul

ated

Cos

t fo

r C

ashi

ngEs

timat

ed Y

earl

y

(Not

e 3)

$700/m

o.

Bene

fit C

ost

ofA

nnua

l Hou

sing

(24%

)C

urre

nt R

ate

Cos

t Ba

sed

onC

ontr

ibut

ion

Retir

emm

ent

Ann

ual

on C

urre

nt R

ate

(4%

)In

sura

nce

Cos

t Ba

sed

Hea

lth &

Life

(Not

e 2)

@ $

1, 953.7

8/y

r H

ouse

hold

Goo

ds

Ship

men

t C

ost

ofA

nnua

lized

(Not

e2)

Air

Far

e @

$270/y

rA

nnua

lized

Cos

t of

Serv

ice

Cos

tC

ompe

nsat

ion

orTo

tal A

nnua

l

Diff

eren

tial (

Not

e 1)

Cos

t of

Nig

htEs

timat

ed A

nnua

l

Cos

tSa

lary

or

Serv

ice

Ann

ualiz

ed

Posi

tions

Cur

rent

No.

of

Hou

rly

Rate

Serv

ice

Cos

tA

nnua

l Rat

es o

f Sa

lary

or

P o

s i t

i o

n

TOTA

LS

MA

NP

OW

ER H

IRIN

G -

Est

ima

ted

cost

com

pu

ted

pu

rsu

an

t to

ba

se r

ate

s p

rovi

ded

in

th

e c

on

tra

ct (N

ote

5)

Regi

tere

d N

urse

(RN

)

Lice

nse

Prac

tical

Nur

se (L

PN)

Hem

odia

lysi

s Te

chni

cian

Ope

ratin

g Ro

om T

echn

icia

n

TOTA

LS

Esti

ma

ted

Ad

dit

ion

al C

ost

to C

on

vert

Cu

rren

t M

an

pow

er

Ag

en

cy N

urs

es

to D

irect

Hir

eEs

tim

ate

d A

dd

itio

na

l C

ost

to C

on

vert

Cu

rren

t M

an

pow

er

Ag

en

cy N

urs

es

to D

irect

Hir

e a

s a

Perc

en

tag

e o

f M

an

pow

er

Hir

ing

Cost

s($2,6

18,1

72/$

4,0

75,3

00)

Act

ua

l Se

rvic

e C

ost

Pa

id t

o M

an

pow

er

Ag

en

cies

in F

Y 2001

Esti

ma

ted

ad

dit

ion

al C

ost

as

a P

erc

en

tag

e o

f FY

2001 A

ctu

al Se

rvic

e C

ost

($2,6

18,1

72/$

4,2

53,1

38)

Cost

Com

pa

riso

n -

Con

vers

ion

of

Dir

ect

Hir

e v

s C

on

tra

ctin

g T

hro

ug

h M

an

pow

er

Ag

en

cies

Hig

h-en

d C

ost

Ana

lysi

s: A

ssum

ing

That

Onl

y N

urse

s W

ho P

asse

d th

e N

CLE

X &

with

5 Y

rs. of

Exp

erie

nce

Will

be

Hir

ed

DIR

ECT

HIR

E -

Esti

ma

ted

cost

ba

sed

on

an

tici

pa

ted

ra

tes

of

sala

ry a

nd

ben

efi

ts t

o b

e p

aid

$5,4

63,1

89$2

,136

,983

$158

,376

$798

,000

$836

,300

$133

,048

$185

,609

$25,

650

$3,3

26,2

06$1

58,3

91$3

,167

,815

95$1

6.03

$33,

345

BSN

NC

LEX

5+ Y

rs. E

xp.

957,

993

409,

183

26,1

4217

6,40

013

7,98

921

,952

41,0

295,

670

548,

810

26,1

3452

2,67

621

11.9

724

,889

LPN

5+

Yrs

. Exp

.

238,

255

115,

866

5,83

158

,800

30,7

734,

896

13,6

761,

890

122,

389

5,82

811

6,56

17

8.01

16,6

52H

emod

ialy

sis

Tech

nici

an 5

+ Y

rs. E

xp.

34,0

3616

,552

833

8,40

04,

396

699

1,95

427

017

,484

833

16,6

511

8.01

16,6

51O

R Te

chni

cian

5+

Yrs

. Exp

.

$6,6

93,4

72$2

,678

,585

$191

,183

$1,0

41,6

00$1

,009

,457

$160

,596

$242

,269

$33,

480

$4,0

14,8

88$1

91,1

85$3

,823

,703

124

$3,2

77,5

00N

AN

AN

AN

AN

AN

AN

A$3

,277

,500

NA

$3,2

77,5

0095

$16.

59$3

4,50

0

609,

000

NA

NA

NA

NA

NA

NA

NA

609,

000

NA

609,

000

2113

.94

29,0

00.0

0

165,

200

NA

NA

NA

NA

NA

NA

NA

165,

200

NA

165,

200

711

.35

23,6

00.0

0

23,6

00N

AN

AN

AN

AN

AN

AN

A23

,600

NA

23,6

001

11.3

523

,600

.00

$4,0

75,3

00N

AN

AN

AN

AN

AN

AN

A$4

,075

,300

NA

$4,0

75,3

0012

4

NA-

not

app

lican

ble

$2,6

18,1

72

64%

$4,2

53,1

38

62%

Not

e 1

- To

fact

or in

nig

ht d

iffer

entia

l, th

e an

alys

is a

ssum

es th

at c

erta

in p

ositi

ons

will

be

assi

gned

and

be

earn

ing

nigh

t diff

eren

tial f

or 1

/3 o

f of t

he to

tal a

vaila

ble

hour

s pe

r ye

ar.

Not

e 2

- To

fact

or in

air

trans

porta

tatio

n &

shi

pmen

t of h

ouse

hold

effe

cts

(Rec

ruitm

ent/

Repa

triat

ion

Cos

ts),

the

anal

ysis

ass

umed

the

follo

win

g:a.

A d

irect

hire

nur

se w

ill m

ost l

ikel

y st

ay fo

r an

ave

rage

of 5

yea

rs th

eref

ore

recr

uitm

ent/

repa

triat

ion

cost

s ca

n be

spr

ead

over

a 5

-yea

r pe

riod.

b. A

s m

ost o

f the

cur

rent

man

pow

er h

ired

nurs

es a

re fr

om th

e Ph

ilipp

ines

, air

trans

porta

tion

and

ship

ping

rat

es a

pplic

able

to th

at d

estin

atio

n w

ere

used

.c.

To

fact

or in

pos

sibl

e ad

ditio

nal a

ir-fa

re c

ost f

or d

epen

dent

s, th

e an

alys

is a

ssum

es th

at 5

0% o

f hire

s ha

ve n

o de

pend

ents

and

50%

hav

e at

leas

t one

dep

ende

nt.

Not

e 3

- To

fact

or in

hou

sing

ben

efits

whi

ch v

ary

base

d on

the

stat

us o

f the

em

ploy

ee, t

he a

naly

sis

also

ass

umes

that

hal

f of t

he h

irees

will

hav

e de

pend

ents

and

hal

f will

hav

e no

ne.

Not

e 4

- To

fact

or in

cos

t of a

ccum

ulat

ed a

nnua

l lea

ve h

ours

, the

ana

lysi

s as

sum

es th

at h

alf o

f (10

4 hr

s.) o

f ann

ual l

eave

hou

rs a

ccru

ed w

ill b

e us

ed w

hile

hal

f wou

ld b

e co

nver

ted

to c

ash.

Not

e 5

- M

ost o

f the

man

pow

er n

urse

s pr

ovid

ed u

nder

the

curr

ent c

ontra

cts

do n

ot h

ave

NC

LEX

and

five

year

s of

exp

erie

nce.

Page 18: Office of the Public Auditor CNMI EXECUTIVE …opacnmi.com/resources/files/ar0306.pdfOffice of the Public Auditor CNMI 1 The three manpower agencies had provided 124 nurses to the

Appendix C

Page 15 of 29

Con

trib

utio

nof

Ret

irem

ent

With

out

the

Ann

ual C

ost

Tota

l Ann

ual C

ost

Con

trib

utio

n C

ost

Ann

ual R

etir

emen

tTo

tal A

nnua

l Cos

t Be

nefit

Tota

l Ann

ual C

ost

of P

erso

nnel

Serv

ice

Cos

t C

ompe

nsat

ion

orTo

tal A

nnua

l

P o

s i t

i o

n

Esti

ma

ted

Ad

dit

ion

al C

ost

to C

on

vert

Ma

np

ow

er

Ag

en

cy N

urs

es

to D

irect

Hir

eEs

tim

ate

d A

dd

itio

na

l C

ost

as

a P

erc

en

tag

e o

f M

an

pow

er

Hir

ing

Cost

s

Act

ua

l Se

rvic

e C

ost

Pa

id t

o M

an

pow

er

Ag

en

cies

in F

Y 2001

Esti

ma

ted

ad

dit

ion

al C

ost

as

a P

erc

en

tag

e o

f FY

2001 A

ctu

al Se

rvic

e C

ost

Com

pa

riso

n o

f C

ost

- D

irect

Hir

e v

s C

on

tra

ctin

g M

an

pow

er

Ag

en

cies

Low

-End

Cos

t A

naly

sis:

Con

vers

ion

of N

urse

s at

Com

pens

atio

n Ra

tes

App

licab

le t

o Th

eir

Cur

rent

Cre

dent

ials

A

ssum

ing

They

W

ould

Ele

ct N

ot t

o be

a P

art

of t

he C

NM

I Ret

irem

ent

Syst

em

DIR

ECT

HIR

E -

Esti

ma

ted

cost

ba

sed

on

an

tici

pa

ted

ra

tes

of

sala

ry a

nd

ben

efi

ts t

o b

e p

aid

$3,3

58,6

36$5

72,5

84$3

,931

,221

$1,6

53,8

70$2

,277

,351

BSN

NC

LEX

0-1

Yrs.

Exp

.

293,

701

50,7

0434

4,40

514

2,74

020

1,66

5BS

N N

CLE

X 1-

2 Yr

s. E

xp.

217,

610

38,0

2625

5,63

610

4,39

615

1,23

9BS

N N

CLE

X 2-

3 Yr

s. E

xp.

460,

681

72,1

1453

2,79

624

5,97

728

6,81

8LP

N 0

-1 Y

rs. E

xp.

68,0

3510

,816

78,8

5035

,833

43,0

17LP

N 1

-2 Y

rs. E

xp.

175,

921

28,3

8920

4,30

991

,401

112,

909

LPN

2-3

Yrs

. Exp

.

157,

641

21,7

0717

9,34

893

,015

86,3

33H

emod

ialy

sis

Tech

nici

an 0

-1 Y

rs. E

xp.

27,0

563,

799

30,8

5515

,746

15,1

08H

emod

ialy

sis

Tech

nici

an 1

-2 Y

rs. E

xp.

26,2

743,

618

29,8

9115

,502

14,3

89O

pera

ting

Rm T

echn

icia

n 0-

1 Yr

s. E

xp.

$4,7

85,5

54$8

01,7

57$5

,587

,311

$2,3

98,4

81$3

,188

,830

TOTA

LS

MA

NP

OW

ER H

IRIN

G -

Est

ima

ted

cost

com

pu

ted

pu

rsu

an

t to

ba

se r

ate

s p

rovi

ded

in

th

e c

on

tra

ct

$3,2

77,5

00N

A$3

,277

,500

NA

$3,2

77,5

00Re

gite

red

Nur

se (R

N)

609,

000

NA

609,

000

NA

609,

000

Lice

nse

Prac

tical

Nur

se (L

PN)

165,

200

NA

165,

200

NA

165,

200

Hem

odia

lysi

s Te

chni

cian

23,6

00N

A23

,600

NA

23,6

00O

pera

ting

Room

Tec

hnic

ian

$4,0

75,3

00N

A$4

,075

,300

NA

$4,0

75,3

00TO

TALS

NA-

not

app

lican

ble

Cost

Wit

hou

t R

eti

rem

en

tC

ost

Wit

h R

eti

rem

en

t$7

10,2

54$1

,512

,011

317

%1

37%

$4,2

53,1

38$4

,253

,138

417

%2

36%

1 ($

1,5

12

,01

1/

$4

,07

5,3

00

)=3

7.1

0%

or

37

%2 ($

1,5

12

,01

1 /

$4

,25

3,1

38

)=3

5.5

5%

or

36

%3

($7

10

,25

4 /

$4

,07

5,3

00

)=1

7.4

3%

or

17

%4

($7

10

,25

4 /

$4

,25

3,1

38

)=1

6.7

0%

or1

7%

Page 19: Office of the Public Auditor CNMI EXECUTIVE …opacnmi.com/resources/files/ar0306.pdfOffice of the Public Auditor CNMI 1 The three manpower agencies had provided 124 nurses to the

Appendix D

Page 16 of 29

CN

MI R

etir

emen

t Sy

stem

Con

trib

utio

nC

ost

of R

etir

emen

tW

ithou

t th

e A

nnua

lTo

tal A

nnua

l Cos

t

Con

trib

utio

n C

ost

Ann

ual R

etir

emm

ent

Tota

l Ann

ual C

ost

Tota

l Ann

ual C

ost

of P

erso

nnel

Ben

efits

or

Ser

vice

Cos

tC

ompe

nsat

ion

Tota

l Ann

ual

P o

s i t

i o

n

MA

NP

OW

ER H

IRIN

G -

Est

ima

ted

cost

com

pu

ted

pu

rsu

an

t to

ba

se r

ate

s p

rovi

ded

in

th

e c

on

tra

ct5

Ad

dit

ion

al C

ost

to C

on

vert

Cu

rren

t N

um

ber

of

Ma

np

ow

er

Ag

en

cy N

urs

es

to D

irect

Hir

eEs

tim

ate

d A

dd

itio

na

l C

ost

as

a P

erc

en

tag

e o

f M

an

pow

er

Hir

ing

Cost

s

Esti

ma

ted

ad

dit

ion

al C

ost

as

a P

erc

en

tag

e o

f FY

2001 A

ctu

al Se

rvic

e C

ost

Cost

Com

pa

riso

n -

Dir

ect

Hir

e v

s C

on

tra

ctin

g T

hro

ug

h M

an

pow

er

Ag

en

cies

Hig

h-En

d C

ost

Ana

lysi

s: C

onve

rsio

n of

Nur

ses

Who

Pas

sed

the

NC

LEX

& w

ith 5

Yrs

. of

Exp

erie

nce

Ass

umin

g Th

ey W

ould

Ele

ct N

ot t

o be

a P

art

of t

he

DIR

ECT

HIR

E -

Esti

ma

ted

cost

ba

sed

on

an

tici

pa

ted

ra

tes

of

sala

ry a

nd

ben

efi

ts t

o b

e p

aid

$4,6

26,8

89$8

36,3

00$5

,463

,189

$2,1

36,9

83$3

,326

,206

BSN

NC

LEX

5+ Y

rs. E

xp.

820,

004

137,

989

957,

993

409,

183

548,

810

LPN

5+

Yrs

. Exp

.

207,

482

30,7

7323

8,25

511

5,86

612

2,38

9H

emod

ialy

sis

Tech

nici

an 5

+ Y

rs. E

xp.

29,6

404,

396

34,0

3616

,552

17,4

84O

R Te

chni

cian

5+

Yrs

. Exp

.

$5,6

84,0

15$1

,009

,457

$6,6

93,4

72$2

,678

,585

$4,0

14,8

88TO

TALS

$3,2

77,5

00N

A$3

,277

,500

NA

$3,2

77,5

00Re

gite

red

Nur

se (R

N)

609,

000

NA

609,

000

NA

609,

000

Lice

nse

Prac

tical

Nur

se (L

PN)

165,

200

NA

165,

200

NA

165,

200

Hem

odia

lysi

s Te

chni

cian

23,6

00N

A23

,600

NA

23,6

00O

pera

ting

Room

Tec

hnic

ian

$4,0

75,3

00N

A$4

,075

,300

NA

$4,0

75,3

00TO

TALS

NA-

not

app

lican

ble

Cost

Wit

hou

t R

eti

rem

en

tC

ost

Wit

h R

eti

rem

en

t3

$1,6

08,7

151

$2,6

18,1

7239

%64

%

$4,2

53,1

38$4

,253

,138

Act

ua

l Se

rvic

e C

ost

Pa

id t

o M

an

pow

er

Ag

en

cies

in F

Y 2001

438

%2

62%

1 ($

2,6

18

,17

2 /

$4

,07

5,3

00

)=6

4.2

4%

or

64

%2

($2

,61

8,1

72

/ $

4,2

53

,13

8)=

61

.56

% o

r 6

2%

3 ($

1,6

08

,71

5 /

$4

,07

5,3

00

)=3

9.4

7%

or

39

%4

($1

,60

8,7

15

/ $

4,2

53

,13

8)=

37

.82

% o

r 3

8%

5 M

ost

of t

he m

anpo

wer

nur

ses

prov

ided

und

er t

he c

urre

nt c

ontr

acts

do

not

have

NC

LEX

and

five

year

s of

exp

erie

nce.

Page 20: Office of the Public Auditor CNMI EXECUTIVE …opacnmi.com/resources/files/ar0306.pdfOffice of the Public Auditor CNMI 1 The three manpower agencies had provided 124 nurses to the

Appendix E

Page 17 of 29

Sum

ma

ry o

f R

esp

on

ses

of

Sele

cted

Doct

ors

an

d U

nit

Ma

na

gers

to I

nte

rvie

w Q

uest

ion

s

Con

cern

ing

Nu

rses

Pro

vid

ed

by

Ma

np

ow

er

Ag

en

cies

as

of

Dece

mb

er

31, 2002

Dir

ect

Hir

ing?

Nee

d to

Go

Back

to

Kee

p in

You

r O

wn

Uni

tH

ow M

any

Wou

ld Y

ouC

are?

Aff

ecte

d Pa

tient

Has

Qua

lity

Bein

g Re

tain

ed?

Uns

atis

fact

ory

Nur

ses

Man

pow

er N

urse

s?Be

caus

e of

Mor

e Ba

d In

cide

nts

Nur

ses?

Par

with

DPH

O

nce

Trai

ned,

at

Nee

d M

ore

Trai

ning

?

Tabu

latio

n of

Res

pons

e

and

Bene

fits?

Unj

ustly

Tre

ated

in P

ayK

eep

in Y

our

Ow

n U

nit

How

Man

y W

ould

You

Car

e?A

ffec

ted

Patie

ntH

as Q

ualit

y

Bein

g Re

tain

ed?

Uns

atis

fact

ory

Nur

ses

Man

pow

er N

urse

s?Be

caus

e of

Mor

e Ba

d In

cide

nts

Nur

ses?

Par

with

DPH

Onc

e Tr

aine

d, a

t

Nee

d M

ore

Trai

ning

?

Tabu

latio

n of

Res

pons

e

Doct

ors

:

Yes

All

No

No

No

Yes

No

Doc

tor

1

May

be N

otAl

lYe

sN

AYe

sN

AYe

sD

octo

r 2

Yes

80%

to 9

0% o

f tot

al

Tole

rabl

e Le

vel

Yes

No

Yes

Yes

Doc

tor

3

Yes

than

50%

90%

; On

Floo

r -

less

Out

patie

nt-

80 to

Yes

Yes

NA

Yes

Yes

Doc

tor

4

Yes

1/3

of to

tal

Yes

Yes

Yes

NA

Yes

Doc

tor

5

Yes

10%

to 1

5% o

f tot

alYe

sYe

sYe

sYe

sYe

sD

octo

r 6

5 Ye

s4

Yes

4 Ye

s3

Yes

4 Ye

s5

Yes

1 N

o1

No

1 N

o2

No

0 N

o1

No

1 To

lera

ble

1 N

A1

NA

2 N

A

Nu

rse U

nit

Ma

na

gers

:

Yes

All

No

No

NA

Yes

Yes

Uni

t Man

ager

1

Yes

All

Yes

Yes

No

Yes

Yes

Uni

t Man

ager

2

Yes

10 o

f 15

in u

nit

Yes

Yes

NA

Yes

Yes

Uni

t Man

ager

3

Yes

tota

lm

ore

than

50%

of

Yes

Yes

Yes

NA

Yes

Uni

t Man

ager

4

Yes

6 of

11i

n un

itYe

sYe

sN

AN

AYe

sU

nit M

anag

er 5

Yes

the

unit

No

agen

cy n

urse

s in

NA

No

NA

NA

Yes

Uni

t Man

ager

6

Yes

All

NA

No

NA

NA

No

Uni

t Man

ager

7

NA

80%

in u

nit

Yes

No

NA

NA

Yes

Uni

t Man

ager

8

7 Ye

s5

Yes

4 Ye

s1

Yes

3 Ye

s 7

Yes

0 N

o1

No

4 N

o1

No

0 N

o1

No

1 N

A2

NA

6 N

A5

NA

NA-

No

Answ

er

Page 21: Office of the Public Auditor CNMI EXECUTIVE …opacnmi.com/resources/files/ar0306.pdfOffice of the Public Auditor CNMI 1 The three manpower agencies had provided 124 nurses to the

Appendix F

Page 18 of 29

Sum

ma

ry o

f M

an

pow

er

Ag

en

cy N

urs

es

Resp

on

ses

to I

nte

rvie

w Q

uest

ion

at

Dece

mb

er

31, 2002

Satis

fied

with

Pay

and

Ben

efits

Hir

edD

irec

tlyW

ill S

tay

if

Sala

ry

Ann

ual

CH

CSe

rvic

e A

tYe

ars

of

Expe

rien

ceN

ursi

ngYe

ars

of

Cer

tifie

dN

CLE

XFe

e Pa

idRe

crui

tmen

tA

mou

nt o

f

Age

ncy

Man

pow

er

Nur

seM

edic

alPa

yH

olid

ayLe

ave

Vac

atio

nSi

ck L

eave

Util

ities

Hou

sing

Prov

ided

Empl

oyer

Pay

Regu

lar

NA

NA

NA

NA

NA

No

No

Yes

$17,

680

1.5

6.5

no$1

,000

PARA

S1

No

No

No

No

NA

NA

No

Yes

20,3

8413

23ye

sN

ON

ESE

AS2

NA

NA

NA

NA

NA

Yes

Yes

No

16,6

407

20no

300

PARA

S3

NA

NA

NA

NA

NA

No

NA

Yes

23,1

926

12ye

s40

0M

HS

4

NA

No

No

No

No

Yes

NA

Yes

18,7

201

7no

1,30

0SE

AS5

Yes

No

No

No

No

No

No

Yes

18,5

740.

256

yes

1,50

0SE

AS6

No

No

No

No

Yes

No

NA

Yes

23,1

507

25ye

s30

0PA

RAS

7

Yes

Yes

Yes

Yes

Yes

No

No

Yes

21,9

861.

56.

5ye

sN

ON

EM

HS

8

NA

No

NA

No

NA

NA

No

Yes

21,9

863

24ye

sN

ON

EPA

RAS

9

NA

No

No

NA

No

No

No

Yes

18,7

201

10no

1,56

0SE

AS10

Yes

No

No

NA

No

Yes

No

Yes

21,9

866

16ye

s1,

500

SEAS

11

No

No

No

No

No

Yes

NA

Yes

18,7

201.

58

no1,

500

SEAS

12

No

No

No

No

NA

NA

No

Yes

22,7

148

13ye

s1,

000

PARA

S13

Yes

No

No

Yes

No

No

No

Yes

18,5

747

14ye

s30

0SE

AS14

No

No

No

Yes

Yes

No

No

Yes

21,9

861.

510

.5ye

s1,

500

SEAS

15

No

No

No

Yes

Yes

No

No

No

16,6

4011

15no

1,00

0PA

RAS

16

No

No

No

No

No

No

No

Yes

21,9

861.

57

yes

1,20

0SE

AS17

No

No

No

No

No

No

No

Yes

21,9

8615

22ye

s1,

250

SEAS

18

No

No

No

No

Yes

Yes

No

Yes

21,9

862

7ye

sN

ON

EPA

RAS

19

Yes

No

No

Yes

Yes

Yes

No

Yes

18,5

747

17ye

s1,

200

SEAS

20

5 Ye

s-25

%1

Yes-

5%1

Yes-

5%5

Yes-

25%

6 Ye

s-30

%6

Yes-

30%

1 Ye

s-5%

18 Y

es-9

0%Av

e. S

alar

yAv

e. Y

rs.

Ave.

Yrs

.14

Yes

-70%

Aver

age

Fee

SEAS

- 5

5%

9 N

o-45

%16

No-

80%

15 N

o-75

%10

No-

50%

8 N

o-40

%11

No-

55%

15 N

o-75

%2

No-

10%

$20,

309

5.09

13.4

86

No-

30%

$1,0

51PA

RAS

- 35

%

6 N

A-30

%3

NA-

15%

4 N

A-20

%5

NA-

25%

6 N

A-30

%3

NA-

15%

4 N

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HS

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N/A

- N

ot a

pplic

able

Page 22: Office of the Public Auditor CNMI EXECUTIVE …opacnmi.com/resources/files/ar0306.pdfOffice of the Public Auditor CNMI 1 The three manpower agencies had provided 124 nurses to the

Appendix G

Page 1of 1

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Appendix H Page 1 of 8

Page20 of 29

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Appendix H Page 2 of 8

Page 21 of 29

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Appendix H Page 3 of 8

Page 22 of 29

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Appendix H Page 4 of 8

Page 23 of 29

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Appendix H Page 5 of 8

Page 24 of 29

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Appendix H Page 6 of 8

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Appendix H Page 7 of 8

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Appendix H Page 8 of 8

Page 27 of 29

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Appendix I

Page 1 of 2

Page 28 of 29

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Appendix I

Page 2 of 2

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Published by Office of the Public Auditor, P.O. Box 501399, Saipan, MP 96950Telephone No. (670) 322-6481 Fax No. (670) 322-7812

Web Site: http://opacnmi.com E-Mail: [email protected]