Description of Staffing Enacted/Adopted by Approach
Staffing Committees/Plans
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June 2009, the TX Governor signed into law nurse staffing protections similar to other state approaches, requiring that a governing body of a hospital adopt, implement and enforce a written nurse staffing policy to ensure adequate number and skill mix of nurses available to met patients needs by unit and shift, utilizing a staffing committee. A comprehensive approach, there are also provisions for whistleblower protections and mandatory overtime prohibition. This legislation replaced 2002 regulations which required hospitals (under the administrative authority of a chief nursing officer and in accordance with an advisory committee comprised of nurse members) to adopt, implement and enforce a written staffing plan.
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NV enacted staffing legislation, overriding the Governor's veto June 1, 2009. As a condition of licensing, the law requires that health care facilities (hospitals in counties with a population of 100,000 more and greater than 70 beds) establish a staffing committee comprised of 50% direct care nurses who will develop staffing plans with management. A written report will be submitted to the Director of the Legislative Counsel Bureau (even years) and the Legislative Committee on Healthcare (odd years), providing details of the plan and execution. It is expected that plans will be flexible enough to accommodate for changes in patients, staff, unit design, technology etc.
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OH is the latest state to enact safe nurse staffing legislation, following the Governor's signature on June 12th 2008. Resultant revised Code will provide for a hospital-wide nursing care committee to create an evidenced-based written nursing services staffing plan, guiding assignments of nurses throughout the hospital. In addition to reflecting the current standards by accrediting organizations and government entities, the plan is to consider multiple nurse and inpatient factors to yield minimum staffing levels with care delivered by competent staff. Details are not provided in the bill. Annually, the committee is to evaluate the plan based upon patient outcomes, prevailing standards of care, cost for delivery, followed by recommendations. Copies of the plan are to be available to all staff with a notice to the public in each hospital alerting them to the availability of a copy upon request.
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Effective October (2008), CT nurse staffing legislation will require each hospital establish a hospital wide staffing committee (or an existing committee) responsible for assisting in the development of a nurse staffing plan. Committee membership shall consist of at least 50% direct care RNs. The plan shall include the minimum professional skill mix for each patient care unit in the hospital; identify the hospital's employment practices concerning the use of temporary and traveling nurses; set forth the level of administrative staffing for each patient care unit that ensures direct care staff are not utilized for administrative functions; establish a process review of the staffing plan; and includes a mechanism for obtaining input from direct care staff and other members of the patient care team in the development of the staffing plan.
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The Safe Nurse Staffing Act passed in WA with near unanimous votes in early March (2008), with the Governor signing into law soon after. Highlights include:
- Each hospital, (by September 2008), must establish a nurse staffing committee composed at least half direct care nurses. This committee will develop, oversee and evaluate a nurse staffing plan for each unit and shift of the hospital based on patient care needs, appropriate skill mix of registered nurses and other nursing personnel, layout of the unit, and national standards/recommendations on nurse staffing.
- If the staffing plan developed by the staffing committee is not adopted by the hospital, the CEO must provide a written explanation of the reasons why to the committee.
- The staffing information must be posted in a public area and must include the nurse staffing plan and the nurse staffing schedule, as well as the clinical staffing relevant to that unit. It must be updated at least once every shift and made available to patients and visitors upon request.
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IL (2007) passed the "Patient Acuity Staffing Plan", which provides flexibility for each hospital to meet the ever-changing patient care needs linked to nurse staffing with required input of direct care registered nurses. The legislation requires a nursing care committee comprised of 50% direct care staff nurses who will contribute to the development, recommendation, and review of the written hospital-wide staffing plan. The plan will take into account the complexity of care and clinical judgment required, staff skill mix, the need for specialized equipment and staffing technology as well as every hospital will identify an acuity model for adjusting the staffing plan for each inpatient care unit.
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In 2005, OR enacted legislation strengthening landmark patient protection that became law in 2002. The bill requires hospitals to develop and implement a written hospital-wide staffing plan for nursing services. The staffing plan shall include the number, qualifications and categories of nursing staff needed for all units and be developed by a committee composed of an equal number of hospital managers and direct care registered nurses. The bill also requires that staffing plans be consistent with nationally recognized evidence-based specialty standards and guidelines. Current law provides civil penalties for hospitals which violate the law and random audits of hospitals by the Oregon Health Division.
Mandated Staffing Ratios
Another legislative approach to address nurse staffing is to mandate specific nurse to patient ratios.
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In 1999, legislation was enacted in CA calling for regulations to be adopted that would define the same unit specific nurse to patient ratios to be utilized in all nursing units in all California hospitals. Currently, a few states now require specific ratios in specialty areas such as intensive care and labor and delivery units, but none require ratios in every patient care unit in every hospital as required in the California regulations. California Governor Arnold Schwarzenegger suspended the law scheduled to take effect January 1, 2005 that would have required one nurse for every five patients in medical-surgical units, a change from the current ratio of one nurse for every six patients. A judge ruled that the governor’s administration overstepped its authority and barred the administration from delaying the implementation of the staffing ratios. The mandated ratios represent minimum requirements that may be adjusted based upon patient acuity. California hospitals have been required to utilize a patient classification system, described in regulations by the California Department of Health Services, since 1986. The system is intended to set nursing staffing levels that identify the nursing care requirements of individual patients, and indicate to the hospital the amount of nursing staff needed to provide the identified care by patient, by unit and by shift. The California staffing ratio legislation, first enacted in 1999 with subsequent amendments is enhanced by the continuation of the mandated use of a patient classification system.
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In 2006, FL passed legislation addressing minimum staffing requirements for nursing homes. The rules to be developed were to call for 2.7 hours of direct care/ resident/day as of January, 2007; with at least one certified nursing assistant per 20 residents and a minimum of one licensed nurse for 1.0 hour of direct care/ resident/day and never below one nurse for 40 residents. That same year, FL was also successful in enacting law requiring a registered nurse presence in the operating room during the entire surgical procedure.
Disclosure/Reporting of Nurse Staffing
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(2011) IL amended the Hospital Licensing Act, stipulating that a copy of a written staffig plan for nursing care services shall be provided to any member of the general public upon request; effective January 1, 2012.
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NY is added to the states having enacted disclosure legislation (2009). The new law requires Health care facilities will be required to make available to the public information on nurse staffing and patient outcomes as specified by the Commissioner in rules and regulations; the least of which will include the number of RNs, LPNs, and unlicensed personnel providing direct care and the ratio of patients per care giver, expressed in actual numbers, in terms of total hours of nursing care per patient, and including adjustment for case mix and acuity and broken down in terms of the total patient care staff, each unit and shift. Other reportable information relates to incidence of adverse outcomes such as medication errors, patient injury, decubitus ulcers, nosocomial infections, including urinary tract infections.
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In 2006, legislation was enacted in VT which adds a provision to the Bill of Rights for Hospital Patients requiring public access to information related to nurse staffing ratios.
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RI enacted legislation in 2005 requiring every licensed hospital to annually submit a core-staffing plan to the department of health in January of each year. The plan must specify for each patient care unit and each shift, the number of registered nurses, licensed practical nurses, and/or certified nursing assistants who shall ordinarily be assigned to provide direct patient care and the average number of patients upon which such staffing levels are based.
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In 2005, NJ enacted legislation requiring a general hospital or nursing facility to complete and post daily staffing information for each unit and each shift. This information will also be provided to the Commissioner of Health and Senior Services monthly and the Commissioner shall in turn make it available to the public on a quarterly basis.
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In 2003, IL passed legislation instituting a Hospital Report Card, which in addition to reporting patient outcomes would report on nurse staffing plans, orientation & training.
Another Approach to Staffing
- In 2009, MN (HB1760) included a provision the law in which health care facilities must consider staffing levels and their impact upon an adverse event when conducting root cause analysis.
Waived/Modified
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In 2004, ME enacted legislation that removed established staffing systems consisting of required minimum nurse to patient staffing ratios, adjustable to accommodate for change in patient needs (acuity). The new legislation directed the Maine Quality Forum Advisory Council to make recommendations related to minimum staffing ratios to the legislature and in their December 3, 2004 report, the Forum stated that there is no reliable scientific evidence that mandated registered nurse to patient staffing ratios are a guarantor of quality and safety of in-patient care. Rather the Forum recommended the collection of 15 nurse-sensitive indicators in hospital settings. They concluded the best approach would be though standardization of staffing plans and acuity tools and therefore, minimum ratios are not expected to be implemented in the foreseeable future.
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Also in 2004, DC waived enactment of staffing ratios, previously legislated in 2002 due to the nursing shortage.
Last updated 12/20/2011