BILL ANALYSIS �
SB 455
Page 1
Date of Hearing: July 2, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
SB 455 (Ed Hernandez) - As Amended: June 25, 2013
SENATE VOTE : Not relevant.
SUBJECT : General acute care hospitals: patient classification
system.
SUMMARY : Requires a committee for each general acute care
hospital to review, at least annually, the reliability of its
patient classification system. Requires at least 50% of the
committee members to be registered nurses (RNs) who provide
direct patient care, and requires that these RNs be appointed by
their bargaining agent, if any. Specifically, this bill :
1)Requires a committee, currently established through
regulation, for each general acute care hospital to review, at
least annually, the patient classification system with respect
to the reliability of this system for validating staffing
requirements to determine whether or not the system accurately
measures patient care needs.
2)Requires at least 50% of the committee members to be RNs who
provide direct patient care and appointed by the bargaining
agent, if any. In the absence of a bargaining agent, requires
that these RNs be appointed by the nursing administrator.
Requires the remaining members of the committee to be
appointed by the nursing administrator.
3)Clarifies that it is the intent of the Legislature to
supersede specified subdivisions of the California Code of
Regulations, which relate to the committee reviewing the
effectiveness of the patient classification system for
validating staffing requirements, and not to affect any other
provision of law.
EXISTING LAW :
1)Licenses and regulates health facilities by the Department of
Public Health (DPH).
2)Requires DPH to adopt regulations that establish minimum,
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specific, and numerical licensed nurse-to-patient ratios by
licensed nurse classification and by hospital unit for all
general acute care hospitals.
3)Requires DPH to consider flexibility for rural general acute
care hospitals in response to their special needs.
4)Defines "hospital units" as critical care units, burn units,
labor and delivery rooms, postanesthesia service areas,
emergency departments, operating rooms, pediatric units,
step-down/intermediate care units, specialty care units,
telemetry units, general medical care units, subacute care
units and transitional inpatient care units.
5)Requires the ratios adopted by regulation pursuant to 2)
above, to constitute the minimum number of RNs and licensed
nurses (LNs) that must be allocated to a unit. 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 hospital RN staffing requirements by unit,
patient, and shift.
2)Define "direct patient care" to mean the provision of health
care services directly to individuals being treated for, or
suspected of having, physical or mental illnesses. Direct
patient care includes preventive care. The first line
supervision of direct patient care are required to also be
considered "direct patient care."
3)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.
4)Require the reliability of the patient classification system
for validating staffing requirements to be reviewed at least
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annually by a committee appointed by the nursing administrator
to determine whether or not the system accurately measures
patient care needs, and requires at least half of the members
of the review committee to be RNs who provide direct patient
care.
FISCAL EFFECT : This bill, as amended, has not been analyzed by
a fiscal committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, by placing the
patient classification committee requirement in statute, this
bill will help ensure hospitals are complying with the law.
Additionally, selecting representatives for workplace
committees is a fundamental tenet of collective bargaining.
2)BACKGROUND . According to the California Department of Health
Care Services (DHCS), regulations implementing
nurse-to-patient ratios in California hospitals pursuant to AB
394 (Kuehl), Chapter 945, Statutes of 1999, went into effect
on January 1, 2004. However, before California had specific
nurse-to-patient ratios, hospitals were required by regulation
to establish a patient classification system. According to
DHCS these regulation became effective on January 1, 1997.
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
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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 RNs
who provide direct patient care.
3)SUPPORT . The United Nurses Associations of California/Union
of Health Care professionals (UNAC/UHP) is the sponsor of this
bill and says that many laws incorporate protections that
could be subject to collective bargaining. Examples include
the minimum wage, the eight hour day, and indeed nurse ratios
in hospitals. California law provides minimum standards for
the minimum wage, the eight hour day, and nurse ratios: these
standards were supported by the labor movement. 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, AFL-CIO (AFSCME) writes that they are the cosponsor
of this bill because hospitals need to respect the right of
the collective bargaining agent to appoint direct care nurses
to the patient classification committee and because of the
importance of pending regulations on hospital fines.
4)OPPOSITION . The California Hospital Association writes in
opposition to this bill that the hospital has the ultimate
responsibility for ensuring quality patient care, including
ensuring appropriate staffing levels. Given this
responsibility, it is inappropriate to require the hospital to
delegate a major component of its assessment tool to a third
party. Requiring a hospital to delegate this authority is
particularly problematic given that the hospital's interests
and the union's interests may not always align. For example,
the hospital may want to have particular units or individuals
represented on the committee. On the other hand, the union
may appoint individuals based on their own priorities such as
leadership development or other factors. Further, the
hospital must maintain the prerogative to appoint staff in
good standing who are eligible and qualified to perform the
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duties vested in the patient classification committee. The
bargaining unit agent is not a hospital representative and
cannot determine performance eligibility requirements.
The California Nurses Association opposes this bill and states
that it would undermine existing Title 22 licensing and
certification regulations that have been carefully vetted
through the Administrative Procedure Act for clarity,
authority, reference and necessity, and that have been refined
through public comments during the exceptionally long and
detailed rulemaking that accompanied AB 394 and should not be
replaced by confusing legislative language. In their zeal for
control over the appointment process to the patient
classification review committee, a goal that is more
appropriately reached through contract negotiation, the
sponsors of this legislation weaken staffing protections for
RNs in unorganized facilities.
5)PREVIOUS LEGISLATION .
a) SB 1246 (Ed Hernandez) of 2012, would have 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 would
have also codified patient classification regulations, as
does this bill. SB 1246 was vetoed by Governor Brown. In
his veto message he states, "This bill seeks to grant the
Department of Public Health greater authority to enforce
hospital nurse staffing ratios and patient classification
system requirements. Everything is already on track to get
this job done. The department will soon release proposed
regulations on administrative penalties that will apply to
a broad range of violations. The rulemaking process should
be completed next year."
b) AB 394 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.
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Provides that the ratios are to constitute the minimum
number of RNs and LNs that must be provided; requires
hospitals to assign additional staff in accordance with a
documented patient classification system.
REGISTERED SUPPORT / OPPOSITION :
Support
American Federation of State, County and Municipal Employees,
AFL-CIO (cosponsor)
United Nurses Associations of California/Union of Health Care
Professionals (cosponsor)
SEIU California
Opposition
Association of California Healthcare Districts
California Hospital Association
California Nurses Association
Analysis Prepared by : Lara Flynn / HEALTH / (916) 319-2097