Nurse Staffing Committees.
Hospitals are required to have nurse staffing committees, whose membership consist of: (a) at least one-half who are registered nurses providing direct patient care; and (b) up to one-half who are determined by the hospital administration. Nurse staffing committees develop and review staffing plans and respond to staffing variations and complaints presented to the nurse staffing committee.
When developing the staffing plan, the nurse staffing committee (staffing committee) must consider certain statutory factors, such as patient activity, intensity level, nature of care required, and level of experience of staff.
If the staffing plan is not adopted by the hospital, the chief executive officer must provide reasons why the plan was not adopted and either identify the changes to the plan prior to the hospital's adoption or prepare an alternative staffing plan that the hospital will adopt. Hospitals must submit their staffing plans annually to the Department of Health (DOH).
Registered nurses may submit complaints to the staffing committee about variations to the staffing plan and shift-to-shift adjustments. The DOH may investigate complaints about violations of the nurse staffing statutes, as well as complaints related to failure to: establish a staffing committee; submit a staffing plan annually; conduct reviews of the plan; and follow nursing assignments or shift-to-shift adjustments.
The DOH may investigate complaints of nursing personnel assignments and shift-to-shift adjustments only if the complainant submits evidence showing a continuing pattern of unresolved violations for a minimum 60-day continuous period. If the complaint is substantiated, the DOH will issue the hospital a statement of deficiencies. The hospital has 45 days to submit a corrective action plan. If the hospital fails to submit or follow the corrective action plan, the DOH may impose a civil penalty of $100 per day.
The DOH may not investigate complaints in the event of unforeseeable emergency circumstances or if the hospital made reasonable efforts to obtain staffing but was unable to do so. "Unforeseeable emergency circumstance" means: (1) any unforeseen national, state, or municipal emergency; (2) when a hospital disaster plan is activated; (3) any unforeseen disaster or catastrophic event that substantially affects the need for health care services; or (4) when a hospital is diverting patients to another hospital or receiving diverted patients from another hospital.
Various provisions related to the staffing committees and requirements for the DOH to investigate complaints expire June 1, 2023.
Meal and Rest Breaks.
Generally, hospitals must provide certain employees with uninterrupted meal and rest breaks. This rule does not apply:
"Unforeseeable emergent circumstance" means: (1) any unforeseen declared national, state, or municipal emergency; (2) when a health care facility disaster plan is activated; or (3) any unforeseen disaster or other catastrophic event that substantially effects or increases the need for health care services.
The meal and rest break provision applies to a hospital employee who is:
Overtime Restrictions.
Hospitals and other health care facilities (such as hospices, rural health care facilities, and facilities operated by the Department of Corrections) are prohibited from requiring certain employees to work overtime. The definition of "employee" is the same as used in the meal and rest break statutes.
The overtime restriction does not apply to overtime work that occurs:
A violation of the overtime provision is a class 1 civil infraction.
Department of Labor and Industries.
The Department of Labor and Industries (Department) enforces the meal and rest break and overtime provisions, as well as other wage and hour laws and workplace health and safety standards. The Department has procedures for investigating complaints, issuing citations and notices of assessments, handling appeals, and imposing civil penalties.
Staffing Committees and Staffing Standards.
The staffing committee statutes are recodified under the jurisdiction of the Department, rather than the DOH. The expiration date of provisions related to staffing committees and investigations is repealed.
Staffing Standards: Minimum staffing standards are established for hospitals. Direct care registered nurses may not be assigned more patients than the following for any shift (shown as nurse-to-patient ratios):
Direct care nursing assistants-certified may not be assigned more patients than the following for any shift:
A direct care registered nurse or direct care nursing assistant-certified may not be assigned to a nursing unit or clinical area unless that nurse first received orientation sufficient to provide competent care and the nurse has demonstrated current competence in providing care in that area.
Hospitals must implement the minimum staffing standards no later than two years after the effective date of the bill. However, critical access hospitals, hospitals with fewer than 25 acute care beds, and certain sole community hospitals certified by the Centers for Medicare and Medicaid Services, have up to four years to implement the minimum staffing standards.
A process is created for hospitals to apply for, and the Department to grant, variances from the staffing standards for good cause. "Good cause" means situations where compliance with the staffing standards is infeasible and a variance does not have a significant harmful effect on the health, safety, and welfare of the employees and patients.
Staffing Committees: Hospitals must have hospital staffing committees whose members must consist of: (1) at least 50 percent direct care nursing and ancillary health care personnel who are nonsupervisory and nonmanagerial; and (2) up to 50 percent who are determined by the hospital administration, and must include the chief financial officer, the chief nursing officers, and patient care unit directors and managers, or their designees.
The factors the staffing committee must consider when developing the staffing plan are amended and narrowed. Changes are made regarding the adoption of the staffing plan. If the staffing plan is not adopted by consensus of the staffing committee, the prior staffing plan remains in effect and the hospital is subject to daily fines of $5,000. The daily fine is $100 for critical access hospitals, hospitals with fewer than 25 acute care beds, and certain sole community hospitals certified by the Centers for Medicare and Medicaid Services.
The chief executive officer must provide feedback to the staffing committee on a semiannual basis prior to the committee's semiannual review and adoption of the staffing plan.
Ancillary health care personnel, patients, collective bargaining representatives, and other individuals are allowed to file complaints to the staffing committee on variations of personnel assignments. All complaints submitted to the staffing committee must be reviewed, regardless of what format the complainant uses to submit the complaint.
Staffing Committee Charters: Staffing committees must file a charter with the Department that includes:
The staffing committee must submit their staffing plan using a form created by the Department. The Department must review submitted staffing plans to ensure they are timely received and completed. Failure to timely submit a staffing plan or a charter will result in a violation and civil penalty of $25,000.
The Department must investigate complaints. The provision limiting investigations to complaints with evidence of a continuing pattern of unresolved violations is removed. Provisions prohibiting investigation of complaints in the event of unforeseeable emergency circumstances or where the hospital documents efforts to obtain staffing are also removed. However, hospitals will not be found in violation of the minimum staffing standards if there were unforeseeable emergent circumstances or the hospital documents that it made reasonable efforts to obtain and retain staffing. What constitutes an "unforeseeable emergent circumstance" is amended to remove: (a) unforeseen disasters or other catastrophic events; and (b) when a hospital diverts patients or receives diverted patients.
No later than 30 days after a hospital deviates from its staffing plan, the hospital incident command must provide the staffing committee an assessment of staffing needs arising from the emergency and the hospital's plan to address the staffing needs. The staffing committee must develop a contingency staffing plan. The hospital may not deviate from its staffing plan for more than 90 days without the approval of the staffing committee.
Failure to follow a corrective action plan is increased from $100 per day, to $5,000 per day, except the $100 per day remains for critical access hospitals, hospitals with fewer than 25 acute care beds, and certain sole community hospitals certified by the Centers for Medicare and Medicaid Services. The fines apply until the hospital follows the corrective action plan for 90 days, after which the Department may reduce the accumulated fine.
The Department must post staffing plans, charters, and violations on its website.
Meal and Rest Breaks and Overtime Restrictions.
Bundling of meal and rest periods is allowed. For any work period in which an employee is entitled to one or more meal periods and more than one rest period, the employee and employer may agree to combine the periods.
Provisions that allowed certain "clinical circumstances" to exempt hospitals from meal and rest break requirements are amended. The requirement to provide uninterrupted meal and rest breaks does not apply when there is a "clinical circumstance" as determined by the employee that may lead to a significant adverse effect on the patient's condition, unless the employer or employer's designee determines that the patient may suffer life-threatening adverse effects.
The definition of "employee" is broadened, thereby applying the meal and rest break provisions and overtime restrictions to an employee who: (1) is involved in direct patient care activities or clinical services; and (2) receives an hourly wage or is covered by a collective bargaining agreement.
Unforeseen disasters or other catastrophic events that substantially affect the need for health care services are removed from the definition of "unforeseeable emergent circumstances."
For the purposes of exemptions to the overtime restrictions: (1) the prescheduled on-call time must not exceed more than 24 hours per week; and (2) the health care facility's "reasonable efforts" to obtain staffing are not reasonable if overtime is used to fill vacancies from chronic staff shortages that persist longer than three months.
Department of Labor and Industries.
A person may file a complaint with the Department alleging violations of the staffing provisions, meal and rest break requirements, and overtime restrictions. Procedures are established for the issuance of citations and notices of assessments, appeals, and other processes. The Department must enforce the overtime restrictions using citations and notices of assessments for violations rather than by civil infractions.
Unless different amounts are provided in specific provisions, the Department may impose a maximum penalty of $1,000 for each violation, up to three violations; $2,500 for the fourth violation; and $5,000 for each subsequent violation.
Department of Health Report.
By November 1, 2023, the DOH must submit a report to the Legislature assessing the current nurse reciprocity laws, compacts, and rules, and alternatives to those laws.
(In support) Staffing shortages started long before COVID-19 and hospitals have set the stage for this crisis by systemically under-staffing for years. Staffing shortages are the main reasons health care workers burn out and leave the profession. Staffing shortages increase the chances of patient death. Relying on travel nurses is not the answer and travel nurses do not know the community. Hospitals did not honor the staffing committees' concerns. Some hospitals do not even submit the required staffing plans. Hospitals abused the flexibility they were given. It is time for legislative intervention. It is a myth that there are not enough nurses. Short staffing prolongs hospital stays and prevents timely discharges of patients.
(Opposed) The bill is highly prescriptive and reduces local flexibility needed to address complex needs. The ratios make it impossible to maintain the level of service needed and treat nurses and patients as numbers rather than people with different needs and skill levels. California has staffing ratios and still faces staffing shortages. There is a nation-wide shortage and thousands of vacancies. This bill will worsen the staffing crisis and will lead to delays and denial of care. Hospitals are paying collectively bargained wages, bonuses, and tuition reimbursements and still have difficulty finding enough nurses. The bill removes the narrow circumstances for when uninterrupted rest breaks are not required. These exceptions were designed to address unforeseen emergencies and they were negotiated in 2019. There will be an impact on small rural hospitals. The private cause of action creates litigation costs and will not solve the problem.
(Other) Amendments are needed to help the Department implement provisions of the bill. There will be fiscal impact to the Department.
(In support) Hospital workers are burned out, and patients are being impacted. This problem predates COVID-19, although the pandemic has accelerated the problem. The fiscal note needs additional analysis and work, but it indicates that there is a failure of the University of Washington to budget and staff to meet their nurse staffing plans or to provide uninterrupted meals and rest breaks despite current laws already requiring it. This is not due to a lack of supply of nurses, but because hospitals are spending money on the wrong priorities such as executive bonuses and traveling nurses while still making millions in net income. Large fiscal impacts from previous legislation have never materialized in the way the hospitals describe in the fiscal notes, and hospitals in California with similar legislation have not seen hospitals close.
(Opposed) The bill would require Washington hospitals to employ an estimated 10,000 additional nurses and 8,000 additional certified nursing assistants. Adding one extra nurse to the patient-to-nurse ratio translates to hiring two or more additional nurses depending on how many shifts that hospital needs to cover each day and how many of those nurses would be part-time. Hospitals do not have the resources to hire the large amounts of staff to be compliant with the provisions of the bill. There is currently a nationwide shortage of nurses, which makes it a challenge to fill vacancies, but especially in small, rural communities. Many hospitals are public entities with a board of commissioners ultimately responsible to the voters and taxpayers who would be negatively impacted by this bill. Hospitals are part of the community's infrastructure and bring in workers and industry that would be impacted if they were to close or eliminate services because of the increased costs from this bill. The private right of action would not accomplish more than what is in current law and is already being enforced by the Department of Labor and Industries related to meal and rest breaks. The fiscal note was built on models using real world data and the University of Washington took a conservative approach when making assumptions about the future, but they will continue to refine their analysis if the bill progresses.