HOUSE BILL REPORT

HB 1733

As Reported by House Committee On:

Health Care & Wellness

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

Brief Description: Concerning nursing staffing practices at hospitals.

Sponsors: Representatives Cody, Ryu, S. Hunt, Peterson, Jinkins, Goodman, Ortiz-Self, Hudgins, Reykdal, Walkinshaw, Wylie, Fitzgibbon, Farrell, Sullivan, Bergquist, Dunshee, Moscoso, Appleton, Sells, Pollet, Riccelli, Robinson, Senn, Ormsby, Lytton, Tarleton, Sawyer, Moeller, Fey, Pettigrew, Gregerson, Orwall, Santos, Kirby, McBride, Takko, Gregory, Clibborn, Van De Wege, Tharinger and Kagi.

Brief History:

Committee Activity:

Health Care & Wellness: 2/3/15, 2/13/15 [DP].

Majority Report: Do pass. Signed by 8 members: Representatives Cody, Chair; Riccelli, Vice Chair; Clibborn, Jinkins, Moeller, Robinson, Tharinger and Van De Wege.

Minority Report: Do not pass. Signed by 7 members: Representatives Schmick, Ranking Minority Member; Harris, Assistant Ranking Minority Member; Caldier, DeBolt, Johnson, Rodne and Short.

Staff: Chris Blake (786-7392).

Background:

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.

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Summary of Bill:

Patient Assignment Limits.

By June 30, 2016, 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, 2017, 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, 2017, 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 of the hospital's compliance with patient assignment limits, nurse staffing plans, and data submission requirements. If the hospital has had a violation within the prior 24 months, the investigation must also include an audit. 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; and

• nurses supplied by temporary staffing agencies.

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) Nurses save lives and every patient deserves a nurse. There must be staffing laws that help nurses advocate for patients and their families. As many as 400,000 hospital patients die each year due to preventable hospital errors. Every increase of one patient per nurse is estimated to increase risk of medical errors by 7 percent.

The current staffing law is not working. Hospital administrators are ignoring the recommendations of nurses on the staffing committees. Surveys show that nurses do not believe that staffing committees are effective at securing adequate nursing at their hospitals and favor staffing ratios. Hospital administrators do not meet with nurses. Nurse staffing committees exist for their expertise and there should be accountability for that. If the 2008 nurse staffing committee bill worked, this bill would not be necessary. There needs to be a safety net to start the staffing plans on each unit as a floor for standards. There needs to be an evidence-based, patient-centered approach to staffing, rather than a corporate, business-centered approach. Nurses cannot protect themselves from dangerous patient assignments and this puts nurse licenses at risks.

With the rollout of the Affordable Care Act and changes in reimbursement, quality has taken on a substantial financial aspect. Avoidable readmissions are estimated to cost Medicare $17 billion. Hospitals now face penalties if they do not meet certain measures and nurses can affect these outcomes. State regulation for minimum staffing standards is critical to have a financially stable hospital system in the state and to protect patients from harm. The majority of hospitals in Washington are receiving penalties for readmissions or hospital-acquired conditions at a cost of tens of millions of dollars.

(Opposed) Hospitals are trying to balance patient needs which are adjusted based upon patient volume, patient acuity, and staff skills. Patient needs can be very unpredictable and this limits flexibility and efficiency. Not all nurses have the same levels of experience and competencies and that must be considered. A balanced, team approach to staffing is best for patients.

Human resources should be used in flexible and creative ways, not with rigid ratios. The "at all times" language matches nurses with hospital geographic units, rather than patients. The "at all times" language will prevent nurses from doing many short-term activities that could help the patient if it would put the unit out of ratio. This bill is more about protecting the ratio, than protecting the patient.

Appropriate staffing is essential for patient care, staff satisfaction, and safety, but this bill will limit flexibility in small hospitals and could result in patients being turned away. Staffing decisions should be made at a local level. This bill interferes with nurses' relationships with patients and questions the professional abilities and judgment of nurses. These are unnecessary administrative rules that will result in reduced job satisfaction.

There is no scientific evidence supporting a magic number for staffing ratios. Differences in patient safety and satisfaction between California, which has staffing ratios, and Washington are statistically insignificant. Washington is a frontrunner in many key indicators. Washington's hospitals are doing a good job in using nursing resources.

Persons Testifying: (In support) Susan Jacobson, Washington State Nurses Association; Misty Moulin, UFCW Local 21; and Ann Kline, SEIU 1199NW.

(Opposed) Lisa Thatcher, Washington State Hospital Association; Margo Bykonen, Swedish First Hill; Jeannie Eylar, Pullman Regional Hospital; Joan Chingand Sarah Schwen, Virginia Mason Medical Center; and Gladys Cambell, Northwest One.

Persons Signed In To Testify But Not Testifying: None.