BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 455
AUTHOR: Hernandez
INTRODUCED: February 21, 2013
HEARING DATE: April 10, 2013
CONSULTANT: Marchand
SUBJECT : General acute care hospitals: patient classification
system.
SUMMARY : Codifies existing regulations requiring hospitals to
maintain, and annually update, a patient classification system,
including regulations requiring the annual updating to be done
by a review committee appointed by the nursing administration,
at least one-half of which is required to be registered nurses
who provide direct patient care. Additionally, requires the
direct care nurses who are appointed to the hospital committee
which reviews the patient classification system to be selected
by the collective bargaining agent, if any.
Existing law:
1.Licenses and regulates health facilities by the Department of
Public Health (DPH).
2.Requires DPH to adopt regulations that establish minimum,
specific, and numerical licensed nurse-to-patient ratios, by
licensed nurse classification and by hospital unit, for
hospitals.
3.Requires the ratios adopted by regulation to constitute the
minimum number of registered and licensed nurses that must be
allocated. Requires additional staff to be assigned in
accordance with a documented patient classification system for
determining nursing care requirements, including the severity
of the illness, the need for specialized equipment and
technology, the complexity of clinical judgment needed to
design, implement, and evaluate the patient care plan and the
ability for self-care, and the licensure of the personnel
required for care.
Existing regulations:
1.Define "patient classification system," in part, as a method
for establishing staffing requirements by unit, patient, and
shift.
Continued---
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2.Require a hospital's administrator of nursing service to
develop a written staffing plan based on patient care needs
determined by the patient classification system.
3.Require the reliability of the patient classification system
for validating staffing requirements to be reviewed at least
annually by a committee appointed by the nursing administrator
to determine whether or not the system accurately measure
patient care needs, and requires at least half of the members
of the review committee to be registered nurses who provide
direct patient care.
This bill:
1.Requires DPH to adopt regulations that require hospitals to
establish and maintain a patient classification system
designed to accurately measure patient's care needs, and to
establish a patient classification system review committee to
review and approve the reliability of the patient
classification system, as follows:
a. Requires at least one-half of the membership of the
review committee to be composed of registered nurses who
provide direct patient care; and,
b. Requires the review committee to be appointed by the
nursing administration of the facility unless the
registered nurses are represented by a collective
bargaining agent, in which case the registered nurses are
required to be appointed by the bargaining agent.
2.Requires the patient classification system to be reviewed and
updated at least annually.
3.Requires DPH to periodically review and update its regulations
as needed.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1.Author's statement. This bill codifies existing regulations
relating to patient classification systems, and adds a
requirement that the collective bargaining agent, if any,
appoint the direct care nurses to the committee that reviews
the patient classification system annually. Existing
regulations already require hospitals to establish a patient
classification review committee, and already require that at
SB 455 | Page
3
least half of the membership of this committee be composed of
direct care registered nurses. This bill simply requires that
the collective bargaining agent selects the registered nurses
that get appointed to this important committee, when the
registered nurses are already represented by a collective
bargaining agent.
2.Nurse to patient ratios and patient classification systems.
In 2004, regulations implementing nurse-to-patient ratios in
California hospitals pursuant to AB 394 (Kuehl), Chapter 945,
Statutes of 1999, went into effect. However, long before
California had specific nurse-to-patient ratios, hospitals
were required by regulation to establish a patient
classification system. This patient classification system is a
method by which hospitals establish staffing requirements by
unit, patient, and shift, and includes a method by which the
amount of nursing care needed for each category of patient is
validated for each unit.
The regulations implementing the AB 394 nurse-to-patient ratios
law set the minimum ratio of nurses to patient by unit,
including one-to-one in operating rooms, one-to-two in
intensive care units, and one-to-five in general
medical-surgical units. These regulations also incorporated
the patient classification system requirement. In essence, the
specific nurse-to-patient ratios establish the minimum number
of nurses by unit, while the patient classification system
determines whether there needs to be a higher level of
staffing beyond the minimum ratio after taking into
consideration factors such as the severity of the illness, the
need for specialized equipment and technology, and the
complexity of clinical judgment needed to evaluate the patient
care plan, among other factors. The nurse-to-patient ratio
regulations require that the minimum ratios must be met at all
times.
Finally, the regulations require the reliability of the patient
classification system for validating staffing requirements to
be reviewed at least annually by a committee appointed by the
nursing administrator to determine whether the system
accurately measures patient care needs. At least half of the
members of this committee are required to be registered nurses
who provide direct patient care.
3.Prior legislation. SB 1246 (Hernandez) of 2012, contained very
similar provisions to this bill, among several other
SB 455 | Page 4
provisions. In addition to the provisions that are similar to
this bill, SB 1246 also required periodic inspections by DPH
to include a review of compliance with nurse staffing ratios
and patient classification systems, and eliminated a
requirement that DPH promulgate regulations further defining
the criteria for assessing administrative penalties, thereby
allowing existing fine authority to go into effect. SB 1246
was vetoed by Governor Brown.
AB 394 (Kuehl), Chapter 945, Statutes of 1999, requires DPH to
adopt regulations specifying nurse-to-patient ratios, by unit,
for general acute care hospitals, acute psychiatric hospitals
and special hospitals. Additionally, requires hospitals to
adopt written policies and procedures for nursing staff
training. Provided that the ratios shall constitute the
minimum number of registered and licensed nurses that must be
provided; requires hospitals to assign additional staff in
accordance with a documented patient classification system.
4.Support. This bill is sponsored by the United Nurses
Associations of California/Union of Health Care Professionals
(UNAC/UHCP), which states that every hospital is required to
have a patient classification system that provides for
staffing in addition to those required under the nurse ratios.
UNAC/UHCP states that existing regulations require a committee
to annually review the patient classification system and that
half the committee be made up of direct care registered nurses
who provide care in the hospital. This bill adds a requirement
that the direct care nurses by appointed by the collective
bargaining agent, if any. UNAC/UHCP points out that many laws
incorporate protections that could be subject to collective
bargaining, including the minimum wage, the eight hour day,
and the nurse ratios themselves. California law provides
minimum standards for these areas of law, and that appointment
of nurses to the patient classification review committee by a
collective bargaining agent, if any, should be another such
instance.
The American Federation of State, County and Municipal Employees
also supports this bill, stating that hospitals need to
respect the right of the collective bargaining agent to
appoint direct care nurses to the patient classification
review committees.
5.Opposition. The California Hospital Association (CHA) is
opposed to this bill unless amended to remove the provision
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5
giving a third-party labor union the right to appoint specific
members to the patient classification review committee,
arguing that this is an inappropriate infringement on the
hospital's ultimate responsibility for patient care. Under
current regulations, CHA states that the members of the
patient classification committee are appointed by the hospital
nursing administrator, and this bill would change that
process. CHA states that the hospital has ultimate
responsibility for ensuring quality patient care, and given
this responsibility, it is inappropriate to delegate a major
component of its assessment tool to a third party. For
example, CHA states that the hospital may want to have
particular units represented on the committee, while the union
may appoint individuals based on their own priorities such as
leadership development or other factors. Further, CHA states
that the hospital must maintain the prerogative to appoint
staff in good standing who are eligible and qualified to
perform the duties vested in the review committee. The
bargaining agent is not a hospital representative and cannot
determine performance eligibility requirements.
The California Nurses Association (CNA) is also opposed to this
bill, stating that it is strongly concerned about the
potential for this bill to weaken existing hospital
regulations governing patient classification systems by
requiring DPH to adopt and review patient classification
system regulations that already exist. CNA states that
regulations that have been vetted through the Administrative
Procedures Act for clarity, authority, reference and
necessity, and that have been refined though public comments
during rulemaking, as well as tested through the court of law,
should not be replaced by vague legislative language. CNA
states that opening up existing language could result in the
dilution of many important mandates established through prior
rulemaking. CNA states that while the language of this bill is
redundant of some current regulations, it leaves out critical
elements set forth in current regulations, and is concerned
about preservation of these provisions should this bill be
enacted and require DPH to adopt new regulations on the
subject. Finally, CNA states that this bill is unnecessary as
union participation in patient classification review
committees can be achieved through collective bargaining. CNA
states that it has successfully achieved similar provisions in
countless collective bargaining contracts with hospitals, and
for that reason, does not find the need for such a provision
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in statute compelling enough to put out current staffing
regulations at risk.
6.Amendments. To address some of the concerns expressed by the
California Nurses Association, the author is proposing to
amend the bill to do the following (see attached mock-up):
a. Delete the requirement that DPH adopt regulations,
and specify that no new regulations are required or
authorized by this bill;
b. Revise language describing the patient
classification system to more closely mirror the
definition in existing regulations;
c. Delete language requiring the patient classification
system to be approved by the review committee, and delete
the requirement that the patient classification system be
updated annually, as these provisions do not mirror the
language used in existing regulations.
SUPPORT AND OPPOSITION :
Support: United Nurses Associations of California/Union of
Health Care Professionals (sponsor)
American Federation of State, County and Municipal
Employees, AFL-CIO (co-sponsor)
Oppose: California Hospital Association
California Nurses Association
Hospital Corporation of America
BILL NUMBER: SB 455INTRODUCED
BILL TEXT
INTRODUCED BY Senator Hernandez
SB 455 | Page
7
FEBRUARY 21, 2013
An act to add Section 1276.35 to the Health and Safety Code,
relating to health facilities.
LEGISLATIVE COUNSEL'S DIGEST
SB 455, as introduced, Hernandez. General acute care
hospitals:
patient classification system.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1276.35 is added to the Health and Safety
Code,
immediately following Section 1276.3, to read:
1276.35. (a) The State Department of Public Health shall
adopt
regulations that require every health facility licensed pursuant
to
subdivision (a) of Section 1250 to do all of the following:
(1) Establish and maintain a patient classification system
designed to accurately measure a patient's care needs for
establishing staffing requirements by unit, patient, and shift.
(2) Establish a patient classification system review
committee to
review and approve the reliability of the patient classification
system, as follows:
(A) The review committee shall be appointed by the nursing
administration of the facility, except as set forth in
subparagraph
(C).
(B) At least one-half of the membership of the review
committee
shall be composed of registered nurses who provide direct
patient
care.
(C) If the registered nurses are represented by a collective
bargaining agent, the registered nurses shall be appointed by
the
bargaining agent.
SB 455 | Page 8
(3) The patient classification system shall be reviewed and
updated at least annually.
(b) The department shall periodically review and update its
regulations, as needed. No new regulations are required or
authorized for implementation of this section.
SEC. 2. No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution
because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime
or
infraction, eliminates a crime or infraction, or changes the
penalty
for a crime or infraction, within the meaning of Section 17556
of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.
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