READ FIRST TIME 03/05/07.   

     AN ACT Relating to the Washington state patient safety act; amending RCW 70.56.020 and 18.79.202; adding a new section to chapter 70.41 RCW; adding a new section to chapter 71.12 RCW; adding a new section to chapter 72.23 RCW; creating new sections; and providing an expiration date.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION.  Sec. 1   (1) The legislature finds that:
     (a) Research demonstrates the critical role that registered nurses play in improving patient safety and quality of care;
     (b) Greater numbers of registered nurses available to care for hospitalized patients are key to reducing errors, complications, and adverse patient care events;
     (c) Higher nurse staffing levels result in improved staff safety and satisfaction and reduced incidences of workplace injuries;
     (d) Health care professional, technical, and support staff comprise vital components of the patient care team, bringing their particular skills and services to ensuring quality patient care; and
     (e) Addressing nurse staffing issues to meet patient care needs is an urgent public policy priority.
     (2) Therefore, in order to protect patients and to support greater retention of registered nurses, to promote evidence-based nurse staffing, and to increase transparency of health care data and decision making, the legislature intends to establish a program for the development of evidence-based hospital staffing plans.

NEW SECTION.  Sec. 2   A new section is added to chapter 70.41 RCW to read as follows:
     (1) DEFINITIONS. The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
     (a) "Central nursing resource center" means the center established in RCW 18.79.202.
     (b) "Hospital" has the same meaning as defined in RCW 70.41.020, except that "hospital" also includes the state hospitals as defined in RCW 72.23.010 and the psychiatric hospitals licensed under chapter 71.12 RCW.
     (c) "Intensity" means the level of patient needs in terms of nursing care as determined by a registered nurse providing direct patient care, taking into account at least the following factors:
     (i) Severity and urgency of the patient's condition;
     (ii) Complexity of either planning or providing, or both, the care required by the patient;
     (iii) Scheduled or anticipated procedures or events, including those that necessitate increased frequency of assessment or intervention;
     (iv) Age and cognitive and functional ability of the patient, including ability to perform self-care activities;
     (v) Availability of patient social supports including institutional, family, or community support;
     (vi) Level of patient adherence or ability to comply with patient care;
     (vii) Patient and family educational needs, including assessment of learning capabilities of patient and family;
     (viii) Intactness of family unit, the availability of family to provide either emotional support or functional support, or both, and the ability of the family to participate in patient decision-making processes;
     (ix) Communications skills of the patient; and
     (x) Other needs identified by the patient and by the registered nurse.
     (d) "Nursing personnel" means registered nurses, licensed practical nurses, and unlicensed assistive nursing personnel providing direct patient care.
     (e) "Patient assignment standards" means the maximum number of patients that a hospital may assign to a registered nurse at any one time.
     (f) "Patient care unit" means any unit or area of the hospital that provides patient care.
     (g) "Skill mix" means the numbers and relative percentages of registered nurses, licensed practical nurses, and unlicensed assistive personnel among the total number of nursing personnel.
     (h) "Staffing committee" means the committee established by a hospital under subsection (2) of this section.
     (2) HOSPITAL STAFFING COMMITTEES. (a) By January 1, 2008, each hospital shall establish a staffing committee. At least one-half of the staffing committee members must be registered nurses currently providing direct patient care, unless another ratio of registered nurse members is required to be consistent with an applicable provision of a collective bargaining agreement between the hospital and its nursing staff. If registered nurses are represented by a collective bargaining representative, the committee's direct patient care registered nurse members must be selected by that collective bargaining representative.
     (b) Participation in the staffing committee by a hospital employee shall be considered a part of the employee's regularly scheduled workweek.
     (3) PATIENT ASSIGNMENT STANDARDS RECOMMENDATION. (a) By June 1, 2008, the central nursing resource center must forward recommendations to the department as required in this subsection. The recommendations must be evidence-based and must be developed by a task force convened by the central nursing resource center. Among its members, the task force must include representatives of organizations that represent hospitals, including rural hospitals. The recommendations must address:
     (i) Patient assignment standards in hospitals; and
     (ii) The development and implementation of hospital staffing plans, as the secretary may request.
     (b) In developing its recommendations, the task force must consider:
     (i) Current research findings regarding patient safety, outcomes of care, nurse staffing, and related areas;
     (ii) Reports and recommendations issued by authoritative national and state bodies and agencies, including but not limited to the institute of medicine, the joint commission, the national quality forum, and the agency for healthcare research and quality;
     (iii) Guidelines adopted or published by national nursing professional associations, specialty nursing organizations, and other health professional organizations;
     (iv) Relevant information regarding legislation or rules on nurse staffing considered or adopted in other states;
     (v) Different levels of intensity, complexity, or need presented by patients in different types of patient care units; and
     (vi) Availability of health care professional, technical, and support staff whose skills and services are essential to delivering quality patient care.
     (c) The department must post the recommendations forwarded by the central nursing resource center on its web site and allow at least a thirty-day public comment period. By July 15, 2008, the department must publish final recommendations, to be posted on the department's web site and provided to the hospitals.
     (d) On a biennial basis, a task force convened by the central nursing resource center pursuant to (a) of this subsection must review the considerations listed in (b) of this subsection and determine whether the final recommendations published under this subsection should be updated. New recommendations, if any, developed by the task force and forwarded to the department by the central nursing resource center must be posted for public comment as provided in (c) of this subsection, and the department must publish final recommendations within forty-five days of posting the central nursing resource center's recommendations.
     (4) HOSPITAL STAFFING PLANS. (a)(i) By January 1, 2009, each hospital's staffing committee must develop, and the hospital implement, a staffing plan that sets the minimum number and skill mix of nursing personnel required on each shift in each patient care unit.
     (ii) In establishing staffing levels for the staffing plan, the staffing committee must consider the patient assignment standards recommended in the final recommendations published under subsection (3) of this section. If the staffing plan adopts staffing levels that provide lower staffing than the final recommendations published under subsection (3) of this section, the staffing plan must include an explanation of the reasons for the deviation.
     (iii) Staffing plans must be based on at least the following additional criteria for each patient care unit:
     (A) Census, including total numbers of patients on each shift at any one time and activity such as patient discharges, admissions, and transfers;
     (B) Level of intensity of all patients and nature of the care to be delivered on each shift;
     (C) Skill mix;
     (D) Level of experience and specialty certification or training of nursing personnel providing care;
     (E) The need for specialized or intensive equipment;
     (F) The architecture and geography of the patient care unit, including but not limited to placement of patient rooms, treatment areas, nursing station, medication preparation areas, and equipment; and
     (G) Staffing guidelines adopted or published by national nursing professional associations, specialty nursing organizations, and other health professional organizations.
     (iv) Staffing plans must at a minimum:
     (A) Include appropriate limits on the use of agency and traveling nurses;
     (B) Be consistent with the scopes of practice for registered nurses and licensed practical nurses and the scope of legally permissible duties of unlicensed assistive personnel;
     (C) Include adequate staffing to allow for staff time off, illnesses, meal and break time, and educational, health, and other leaves;
     (D) Include a process for review by the staffing committee that ensures compliance with the staffing plan, provides for the committee's review of incidents and staff concerns, and tracks staffing patterns, the number of patients and the patients' conditions, and the intensity of the patients' nursing care needs. These reviews must be performed at least semiannually; and
     (E) Be updated at least annually.
     (v) The staffing plan must not diminish other standards contained in law, rules, or the terms of an applicable collective bargaining agreement, if any, between the hospital and its nursing staff, and must be consistent with any such agreement.
     (b) In implementing the staffing plan, each hospital shall:
     (i) Assign nursing personnel to each patient care unit in accordance with its staffing plan. Shift-to-shift adjustments in staffing levels required by the plan may be made only if based upon assessment by a registered nurse providing direct patient care on the patient care unit, utilizing procedures specified by the staffing committee;
     (ii) Make readily available the staffing plan and staffing levels to patients and visitors upon request; and
     (iii) Make accessible to staff a process for reporting inadequate staffing or staffing at variance with the staffing plan. Any reports made under this subsection must be provided to the staffing committee and the hospital and be retained by the hospital for department review under subsection (5) of this section.
     (5) HOSPITAL STAFFING PLAN REVIEW AND PUBLICATION. (a) Each hospital shall submit its staffing plan and any reports made under subsection (4)(b)(iii) for review by the department at least every eighteen months, which review may be in conjunction with any on-site licensing survey or inspection conducted by the department. The hospital may also submit any additional information related to staffing, including explanations of any staffing at variance with the adopted staffing plan and actions taken to resolve staffing issues.
     (b) In collaboration with Washington state quality forum established in section 5, chapter . . . (House Bill No. 2098), Laws of 2007, the department must develop standards for comparing hospital staffing plans, and each hospital's adherence to its staffing plan in practice, with the final recommendations published under subsection (3) of this section. The department must rate the staffing plans according to the standards and provide the ratings to the Washington state quality forum to be disseminated, at a minimum, on its web site as part of its research regarding health care quality, evidence-based medicine, and patient safety. If the Washington state quality forum is not established, the department shall perform the duties required under this section and post the staffing plan information on its web site.
     (6) HOSPITAL STAFFING REPORTS. (a) Semiannually, hospitals shall collect and submit to the department information regarding nurse staffing. In addition to the skill mix of registered nurses, licensed practical nurses, unlicensed assistive nursing personnel, nurses supplied by temporary staffing agencies including traveling nurses, and nursing care hours per patient per day, such information must also include:
     (i) Death among surgical inpatients with treatable serious complications (failure to rescue);
     (ii) Prevalence of urinary tract infections;
     (iii) Hospital-acquired pneumonia;
     (iv) Incidence of patient falls; and
     (v) Other measures to be established by the department.
     (b) The information submitted under this subsection must be posted along with the ratings of staffing plans as provided in subsection (5)(b) of this section.
     (7) RETALIATION PROHIBITED. A hospital may not retaliate against or engage in any form of intimidation of:
     (a) An employee for performing any duties or responsibilities in connection with participation on the staffing committee; or
     (b) An employee, patient, or other individual who notifies the staffing committee, the hospital administration, or the department that any schedule or nursing personnel assignment fails to comply with the staffing plan, or that the hospital has failed to develop or implement a staffing plan.
     (8) COMPLAINTS. (a) The department must investigate complaints from hospital staff that a hospital has failed to comply with a staffing plan, has failed to develop or implement a staffing plan, or has violated subsection (7) of this section. If there is reasonable cause to believe that a violation has been or is occurring, the department must immediately endeavor to eliminate the violation by conference with the interested parties. If a resolution is not reached, the department must make a finding to that effect. Such findings must be posted along with the ratings of staffing plans as provided in subsection (5)(b) of this section.
     (b) The department shall maintain a toll-free telephone number for patients to use to report the violations listed in (a) of this subsection. The department is not required to investigate such patient reports, but must disclose the report to the hospital and the hospital's staffing committee. In disclosing the report, the department shall not reveal identifying information about the patient.
     (c) Information about complaints or reports under this subsection that does not warrant an investigation may not be disclosed except that the department must notify the hospital and the complainant when a complaint did not warrant an investigation.

Sec. 3   RCW 70.56.020 and 2006 c 8 s 106 are each amended to read as follows:
     (1) The legislature intends to establish an adverse health events and incident reporting system that is designed to facilitate quality improvement in the health care system, improve patient safety and decrease medical errors in a nonpunitive manner. The reporting system shall not be designed to punish errors by health care practitioners or health care facility employees.
     (2) Each medical facility shall notify the department of health regarding the occurrence of any adverse event and file a subsequent report as provided in this section. Notification must be submitted to the department within forty-eight hours of confirmation by the medical facility that an adverse event has occurred. A subsequent report must be submitted to the department within forty-five days after confirmation by the medical facility that an adverse event has occurred. The notification and report shall be submitted to the department using the internet-based system established under RCW 70.56.040(2).
     (3) The notification and report shall be filed in a format specified by the department after consultation with medical facilities and the independent entity. The format shall identify the facility, but shall not include any identifying information for any of the health care professionals, facility employees, or patients involved. This provision does not modify the duty of a hospital to make a report to the department of health or a disciplinary authority if a licensed practitioner has committed unprofessional conduct as defined in RCW 18.130.180. As soon as possible, but no later than July 1, 2008, hospitals shall revise their incident reporting procedures to include an evaluation of staffing as part of the incident review process. Hospitals shall also modify their incident form to include an area for the documentation of staffing considerations.
     (4)(a) As part of the report filed under this section, the medical facility must:
     (i) Include the following information:
     (A) The number of patients, registered nurses, licensed practical nurses, and unlicensed assistive personnel present in the relevant patient care unit at the time that the reported adverse event occurred;
     (B) The number of nursing personnel present at the time of the adverse event who have been supplied by temporary staffing agencies, including traveling nurses;
     (C) The number of nursing personnel, if any, on the patient care unit working beyond their regularly scheduled number of hours or shifts at the time of the event and the number of consecutive hours worked by each such nursing personnel at the time of the adverse event; and
     (ii) Conduct a root cause analysis of the event, describe the corrective action plan that will be implemented consistent with the findings of the analysis, or provide an explanation of any reasons for not taking corrective action. Hospitals shall consider staffing as a possible factor contributing to reportable incidents. Staffing considerations may include such factors as fatigue, training, communication, and adequacy.
     (b) The department shall adopt rules, in consultation with medical facilities and the independent entity, related to the form and content of the root cause analysis and corrective action plan. In developing the rules, consideration shall be given to existing standards for root cause analysis or corrective action plans adopted by the joint commission on accreditation of health facilities and other national or governmental entities.
     (c) For purposes of this subsection (4), "nursing personnel" and "patient care unit" have the same meaning as defined in section 2 of this act.
     (5) If, in the course of investigating a complaint received from an employee of a medical facility, the department determines that the facility has not reported an adverse event or undertaken efforts to investigate the occurrence of an adverse event, the department shall direct the facility to report or to undertake an investigation of the event.
     (6) The protections of RCW 43.70.075 apply to reports of adverse events that are submitted in good faith by employees of medical facilities.

Sec. 4   RCW 18.79.202 and 2005 c 268 s 4 are each amended to read as follows:
     (1) In addition to the licensing fee for registered nurses and licensed practical nurses licensed under this chapter, the department shall impose an additional surcharge of five dollars per year on all initial licenses and renewal licenses for registered nurses and licensed practical nurses issued under this chapter. Advanced registered nurse practitioners are only required to pay the surcharge on their registered nurse licenses.
     (2) The department, in consultation with the commission and the workforce training and education coordinating board, shall use the proceeds from the surcharge imposed under subsection (1) of this section to provide grants to a central nursing resource center. The grants may be awarded only to a not-for-profit central nursing resource center that is comprised of and led by nurses. The central nursing resource center will demonstrate coordination with relevant nursing constituents including professional nursing organizations, groups representing nursing educators, staff nurses, nurse managers or executives, and labor organizations representing nurses. The central nursing resource center shall have as its mission to contribute to the health and wellness of Washington state residents by ensuring that there is an adequate nursing workforce to meet the current and future health care needs of the citizens of the state of Washington. The grants may be used to fund the following activities of the central nursing resource center:
     (a) Maintain information on the current and projected supply and demand of nurses through the collection and analysis of data regarding the nursing workforce, including but not limited to education level, race and ethnicity, employment settings, nursing positions, reasons for leaving the nursing profession, and those leaving Washington state to practice elsewhere. This data collection and analysis must complement other state activities to produce data on the nursing workforce and the central nursing resource center shall work collaboratively with other entities in the data collection to ensure coordination and avoid duplication of efforts;
     (b) Monitor and validate trends in the applicant pool for programs in nursing. The central nursing resource center must work with nursing leaders to identify approaches to address issues arising related to the trends identified, and collect information on other states' approaches to addressing these issues;
     (c) Facilitate partnerships between the nursing community and other health care providers, licensing authority, business and industry, consumers, legislators, and educators to achieve policy consensus, promote diversity within the profession, and enhance nursing career mobility and nursing leadership development;
     (d) Evaluate the effectiveness of nursing education and articulation among programs to increase access to nursing education and enhance career mobility, especially for populations that are underrepresented in the nursing profession;
     (e) Provide consultation, technical assistance, data, and information related to Washington state and national nursing resources;
     (f) Promote strategies to enhance patient safety and quality patient care, including encouraging a safe and healthy workplace environment for nurses and making recommendations pursuant to section 2 of this act; and
     (g) Educate the public including students in K-12 about opportunities and careers in nursing.
     (3) The nursing resource center account is created in the custody of the state treasurer. All receipts from the surcharge in subsection (1) of this section must be deposited in the account. Expenditures from the account may be used only for grants to an organization to conduct the specific activities listed in subsection (2) of this section and to compensate the department for the reasonable costs associated with the collection and distribution of the surcharge and the administration of the grant provided for in subsection (2) of this section. No money from this account may be used by the recipient towards administrative costs of the central nursing resource center not associated with the specific activities listed in subsection (2) of this section. No money from this account may be used by the recipient toward lobbying. Only the secretary or the secretary's designee may authorize expenditures from the account. The account is subject to allotment procedures under chapter 43.88 RCW, but an appropriation is not required for expenditures. Grants will be awarded on an annual basis and funds will be distributed quarterly. The first distribution after awarding the first grant shall be made no later than six months after July 24, 2005. The central nursing resource center shall report to the department on meeting the grant objectives annually.
     (4) The central nursing resource center shall submit a report of all progress, collaboration with other organizations and government entities, and activities conducted by the center to the relevant committees of the legislature by November 30, 2011. The department shall conduct a review of the program to collect funds to support the activities of a nursing resource center and make recommendations on the effectiveness of the program and whether it should continue. The review shall be paid for with funds from the nursing resource center account. The review must be completed by June 30, 2012.
     (5) The department may adopt rules as necessary to implement chapter 268, Laws of 2005.

NEW SECTION.  Sec. 5   A new section is added to chapter 71.12 RCW to read as follows:
     Establishments licensed under this chapter shall establish a staffing committee and implement a staffing plan as required under section 2 of this act.

NEW SECTION.  Sec. 6   A new section is added to chapter 72.23 RCW to read as follows:
     State hospitals shall establish a staffing committee and implement a staffing plan as required under section 2 of this act.

NEW SECTION.  Sec. 7   Section 4 of this act expires June 30, 2013.

NEW SECTION.  Sec. 8   This act may be known and cited as the Washington state patient safety act.