HOUSE BILL REPORT

HB 1095

As Reported by House Committee On:

Health Care & Wellness

Appropriations Subcommittee on Health & Human Services

Title: An act relating to nursing staffing practices at hospitals.

Brief Description: Concerning nursing staffing practices at hospitals.

Sponsors: Representatives Green, Cody, Morrell, Reykdal, Appleton, Ryu, McCoy, Bergquist and Pollet.

Brief History:

Committee Activity:

Health Care & Wellness: 1/29/13, 2/22/13 [DP];

Appropriations Subcommittee on Health & Human Services: 2/25/13 [DPS].

Majority Report: Do pass. Signed by 9 members: Representatives Cody, Chair; Jinkins, Vice Chair; Clibborn, Green, Moeller, Morrell, Riccelli, Tharinger and Van De Wege.

Minority Report: Do not pass. Signed by 7 members: Representatives Schmick, Ranking Minority Member; Hope, Assistant Ranking Minority Member; Angel, Manweller, Rodne, Ross and Short.

Staff: Chris Blake (786-7392).

Background:

Nurse Staffing Plans.

Hospitals are required to establish nurse staffing committees to develop and oversee an annual patient care unit and shift-based nurse staffing plan (nurse staffing plan); conduct a semi-annual review of the nurse staffing plan; and review, assess, and respond to staffing concerns. Nurse staffing plans must consider such factors as:

• patient census, including total patients by unit and shift;

• level of intensity of patients and the nature of the care to be delivered on each shift;

• skill mix;

• level of experience of nurses providing care;

• the need for specialized or intensive equipment;

• the physical design of the patient care unit; and

• staffing guidelines adopted by national nursing associations, specialty associations, and other health professional associations.

If the chief executive officer of the hospital does not approve the nurse staffing committee's plan, he or she must provide a written explanation to the committee.

Hospital Reporting.

State law requires hospitals to report several types of patient care information. Hospitals must report information to the Department of Health about the occurrence of adverse events in the hospital. Adverse events include several types of incidents such as deaths among surgical patients, patient falls, and certain types of assaults. Hospitals must report the occurrence of an adverse event within 48 hours of confirming the incident.

Other hospital reporting requirements relate to the occurrence of health care-acquired infections. Hospitals must report information to federal and private databases with respect to rates of central line-associated bloodstream infections, ventilator-associated pneumonia, and surgical site infections for certain procedures.

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Summary of Bill:

Patient Assignment Limits.

By June 30, 2015, the Department of Health (Department) must adopt patient assignment limits representing the maximum number of patients that a hospital may assign to a registered nurse at any one time. Patient assignment limits may vary for different types of patient care units or areas. The patient assignment limits apply at all hospitals to individual registered nurse assignments for the entire time that a nurse is on duty. The patient assignment limits apply when other nurses are away from the unit or on break. Patient assignment limits are a minimum staffing standard. Patient assignment limits may not be considered an average assignment for a hospital or patient care unit.

Registered nurses may not be assigned to a nursing unit or clinical area unless the nurse has received orientation in the particular clinical area and he or she has demonstrated competence in that clinical area. Temporary personnel must also receive orientation and demonstrate competence.

Nurse Staffing Plans.

Beginning June 30, 2016, hospitals must implement their nurse staffing plans and assign nursing personnel to patient care units according to the plan. Any adjustments in staffing levels required by the nurse staffing plan must be based upon the assessment of a registered nurse providing direct patient care on the particular unit. A hospital chief executive officer's option to not adopt the hospital staffing plan is eliminated. Beginning June 30, 2016, hospitals must submit their nurse staffing plans to the Department at least annually.

Enforcement.

Upon receipt of a complaint, the Department must initiate an investigation and conduct an audit of the hospital's compliance with patient assignment limits, nurse staffing plans, and data submission requirements. If a hospital is found to be out of compliance, it must submit a corrective action plan to the Department. Failure to submit or to comply with a corrective action plan may result in fines of up to $10,000. If the hospital's actions were a knowing or repeat violation, the Department may suspend or revoke the hospital's license or impose increasing fines from $2,000 to $10,000.

Retaliation.

A hospital may not retaliate against employees, patients, or other persons who notify a collective bargaining agent or the Department when nurse staffing either: (1) violates the hospital's nurse staffing plan or patient assignment limits; or (2) is believed to be insufficient or unsafe.

A hospital may not penalize a registered nurse for refusing to accept an assignment that violates the hospital's nurse staffing plan or nurse unit orientation requirement. Prior to refusing the assignment, the registered nurse must inform the hospital in writing that, according to the nurse's professional judgment and nursing practice standards, he or she has concluded that accepting the assignment would place one or more patients at immediate risk of serious harm or injury.

Reporting to the Department.

Twice a year hospitals must submit specific information about nurse staffing and patient care to the Department. The Department must determine effective means for making the information available to the public, including posting the information in the hospital and on the Internet. The information includes:

• nurse staffing skill mix, by level of license;

• nursing hours per patient day;

• nurse voluntary turnover rate;

• nurses supplied by temporary staffing agencies;

• death among surgical inpatients with treatable serious complications;

• rates of patient falls with injury;

• physical restraint prevalence;

• catheter-associated urinary tract infection rate;

• central line-associated blood stream infection rate;

• psychiatric patient assault rate;

• pressure ulcers; and

• other measures established by the Department.

Findings.

Legislative findings are established relating to the role that registered nurses play in hospitals with respect to reducing errors, complications, and adverse events. Findings are also made relating to greater nurse staffing levels and its role in patient safety, nurse retention, and safe working conditions.

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Appropriation: None.

Fiscal Note: Available.

Effective Date: The bill takes effect 90 days after adjournment of the session in which the bill is passed.

Staff Summary of Public Testimony:

(In support) There has been much recent research about the number of patients that a nurse can care for safely. Hospitals are reducing staffing so much that nurses cannot do the job that they love and patients are suffering. A statewide solution is needed to create standards for the maximum number of patients per nurse. This bill will require that there be enough nurses per shift so that patient care comes first. Increasing nurse staffing can reduce medical errors and save lives. A recent survey of registered nurses shows that many nurses have seen hospital understaffing harm or kill patients. With changes in hospital reimbursement practices, better staffing will save money. Nurse staffing levels is a public health issue. Goals for efficiency and productivity have led to staff cuts and reductions in quality care.

This bill builds on hospital staffing committees which have made much progress in some hospitals toward safe staffing levels, while others have made little or no progress. There has been a pattern over the past couple of years that shows the nurse staffing committees have become less relevant in terms of staffing decisions. In some cases nurse staffing committees have stopped meeting or nurses are not released to participate in the meetings. Some nurse staffing committees are basing decisions on budgets and not patient safety. This bill gives the necessary authority to the nurse staffing committees to make safe staffing plans that are actually implemented. This bill uses the current staffing committees which recognize the unique nature of each hospital. Current law allows hospitals to ignore staffing committee plans.

(Opposed) Washington hospitals are safer than those in California where there are nurse ratios. In California, nurse staffing ratios have led to cuts in other supportive positions in order to meet the required nurse levels. In California it has been reported that unexpected costs for implementing ratios have reached $1 million per year. California nurses are unhappy with staffing ratios because they cannot choose when to take a break or eat lunch and they feel that their professional judgment has been undermined.

The experience and unique abilities of nurses and the unique needs of patients are lost in a staff ratio system. Charge nurses are best at making staffing decisions on their units because they know the staff and they know the patients. This bill will devalue the professionalism of nurses by taking away their judgment regarding staffing decisions. Hospitals already use nurse quality indicators. The bill's requirement that minimum staffing ratios be maintained at all times discourages the safe movement of patients. Mandated ratios are an inflexible tool that is not proven to improve nursing care to patients. The data requirements are duplicative. Ratios are not the solution, but an idea that has been proven to be ineffective. The additional cost for rural hospitals to comply with nurse staffing ratios will worsen an already difficult financial situation. In rural areas it is difficult to find enough nurses to meet the requirement.

Nurse staffing committees have worked well because they have a collaborative model of integrated decision-making. Nurse staffing committees would lose their relevance if the Department of Health (Department) established staffing standards. The requirement to send nurse staffing plans to the Department creates an unnecessary burden with little benefit. This bill sets rigid staffing standards at a time when flexibility is needed to creatively meet patient needs.

Persons Testifying: (In support) Representative Green, prime sponsor; Julia Weinberg and Anne Tan Piazza, Washington State Nurses Association; Chris Barton and Joanne Metropolis, Service Employees International Union 1199NW; and Linda Lewandowsky, United Food and Commercial Workers Union 21.

(Opposed) Kate Bechtal, MultiCare Health System; Laurie Brown, Fransiscan Health System; William Berko, Seattle Children's Hospital; Joan Ching, Virginia Mason; Patty Cochrell, Harrison Hospital; and John White, Klickitat Hospital.

Persons Signed In To Testify But Not Testifying: None.

Majority Report: The substitute bill be substituted therefor and the substitute bill do pass. Signed by 6 members: Representatives Morrell, Chair; Cody, Green, Jinkins, Kagi and Ormsby.

Minority Report: Do not pass. Signed by 3 members: Representatives Harris, Ranking Minority Member; Ross and Schmick.

Staff: Mary Mulholland (786-7391).

Summary of Recommendation of Committee On Appropriations Subcommittee on Health & Human Services Compared to Recommendation of Committee On Health Care & Wellness:

Department of Health (Department) audits of hospitals for complaints related to patient assignment limits, orientation requirements, and nurse staffing plan requirements are limited to occasions in which a hospital has had a final finding of a violation within the previous 24 months.

The requirements that hospitals report deaths among surgical inpatients, rates of patient falls with injuries, physical restraints, catheter-associated urinary tract infections, central-line-associated blood stream infections, psychiatric patient assaults, pressure ulcers, and other measures established by the Department are removed.

Appropriation: None.

Fiscal Note: Available.

Effective Date of Substitute Bill: The bill takes effect 90 days after adjournment of the session in which the bill is passed.

Staff Summary of Public Testimony:

(In support) Nurses are the most trusted professionals in annual surveys of the public. Nurses working at bedsides catch medical errors when they happen. Nurses say that when hospitals are adequately staffed, it greatly increases the number of prevented errors. Researchers have found a link between nurse staffing and hospital-acquired infections. Adequate nurse staffing is a public safety issue. All Washingtonians deserve to have safe hospitalizations. High nursing staff turnover is extremely costly for hospitals.

Nurses become frustrated and demoralized when staffing is inadequate and seek employment elsewhere. Addressing the issue of nurse retention makes economic sense for hospitals and the public. No hospitals in California have closed as a result of the new nurse staffing ratios set under a similar policy, and the cost has been minimal. Washington cannot afford to have a professional nursing shortage. There are benefits to patient safety, satisfaction, and quality of care from lower nurse turnover. Washington needs to address the workforce environment that hurts patients and undermines nurses.

Hospital financial models focus on payments for higher-quality care. There is a financial incentive for hospitals to achieve and maintain adequate nurse staffing levels to prevent hospital-acquired infections and other incidents. Registered nurse retention should be a priority given the investment the state has made in nursing education.

(Opposed) There is a fiscal impact to implementing nurse staffing plans and patient assignment limits. This bill would require hospitals to maintain ratios and limits at all times. This means that nurses cannot leave their units without violating the ratio. In California, this has led hospitals to eliminate nursing positions in order to hire relief nurses to cover breaks and lunches. This drives up costs without benefiting quality of care or patient satisfaction. The bill also removes the flexibility for nurses to schedule their lunches and breaks. These costs may cause hospital closures in communities. Washington is already performing well on key performance measures compared to California. There is no evidence that mandated ratios improve patient care.

There is a concern that the bill would allow nurse staffing committees to make decisions without oversight of publicly elected commissioners. Nurse staffing committees have an important role, but they should not have the authority to make system-wide financial decisions. Patient needs must be balanced with finite resources. The bill would add administrative costs for collecting, analyzing, and reporting data without improving patient care. The fiscal impact is real and substantial on every public hospital district in Washington.

Persons Testifying: (In support) Representative Green, prime sponsor; Sofia Aragon, Washington State Nurses Association; and Chris Barton, Service Employees International Union Healthcare 1199 NW.

(Opposed) Cindy Mayo, Providence Centralia Hospital; and Eric Moll, Mason General Hospital.

Persons Signed In To Testify But Not Testifying: None.