BILL ANALYSIS
SENATE HEALTH AND HUMAN SERVICES
COMMITTEE ANALYSIS
Senator Martha M. Escutia, Chair
BILL NO: AB 394
A
AUTHOR: Kuehl
B
AMENDED: June 23, 1999
HEARING DATE: June 30, 1999
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FISCAL: Business and Professions/Appropriations
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CONSULTANT:
Miller
SUBJECT
Health facilities: nursing staff
SUMMARY
Establishes specified nurse to patient staffing ratios in
specified health facilities and limits the nursing-related
duties performed by unlicensed assistive personnel.
ABSTRACT
Existing Law:
1.Provides for the licensure and regulation of nurses by
the Board of Registered Nursing, and of health care
facilities by the Department of Health Services (DHS).
2.Establishes, by regulation, nurse to patient staffing
ratios in intensive care units.
3.Requires, by regulation, specified health facilities to
implement a "patient classification system" (PCS) for
determining patient nursing care needs that reflects an
assessment made by an registered nurses, patient
requirements, the patient care delivery system, and
generally accepted standards of nursing practice; and
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provides for shift-by-shift staffing based on those
requirements. Requires additionally that a written
staffing plan be developed and implemented for each
patient care unit by the administrator of nursing service
based on patient care needs determined by PCS, as
specified.
This Bill:
1.Finds and declares the basic principles of staffing in an
acute care setting should be based on patient care needs.
2.Prohibits specified types of health facilities from
assigning unlicensed personnel to perform nursing
functions in lieu of a registered nurse and from
assigning unlicensed personnel, under the direct clinical
supervision of a registered nurse, to perform functions,
as specified, which require scientific knowledge and
technical skills.
3.Requires that by March 1, 2000, acute care hospitals
determine and provide nursing staffing according to
regulations developed by DHS.
4.Directs DHS to adopt minimum, specific numerical
nurse-to-patient ratios on a shift-by-shift, day-by-day
basis. Ratios are to ensure safe and adequate patient
care which shall be adequate to permit: assessment,
nursing diagnosis, planning, intervention, evaluation
and, when justified, patient advocacy.
5.Presumes specified ratios to be minimum ratios: one
nurse to two patients in critical care units (burn,
labor/delivery, recovery, emergency, and intensive care).
Licensed vocational nurses are permitted to constitute
up to 50 percent of nursing unit staff. One nurse to
three patients shall be the ratio for pediatric/step-down
and intermediate care patients; one nurse to four
patients is ratio for specialty and telemetry units; one
nurse to six patients in general medicine. DHS shall not
adopt any lower unit nurse/patient ratio unless such
reduced ratios allow for all elements of nursing care to
be provided, and that each ratio provides safe and
adequate care, and that ratios do not include unlicensed
personnel. Failure of DHS to produce ratios by March
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2000 shall default to those ratios described here.
6.Requires general acute care hospitals, acute psychiatric
hospitals, and special hospitals, to adopt written
policies and procedures for training and orientation of
direct patient care staff. Allows for a waiver of the
nurse to patient ratio provisions for rural general acute
care hospitals, as specified.
7.Requires orientation and demonstrated competence, as
specified, before assigning a nurse or other direct
patient care staff to nursing units or clinical areas.
Requires all temporary personnel to receive the same
amount and type of orientation as provided to permanent
staff.
8.Stipulates this bill is not intended to preclude any
person from performing any function within their scope of
practice, and should any conflict occur between the
provisions of this bill and any provision or regulation
defining the scope of nursing practice, the scope of
practice provisions shall control. Contains a "crimes"
disclaimer.
FISCAL IMPACT
According to the Appropriations Committee analysis, to the
extent this bill increases staffing levels in hospitals,
potentially significant annual General Fund costs to the
Medi-Cal program, due to increased reimbursement rates for
hospital inpatient services. DHS previously estimated this
bill's staffing level requirements would increase Medi-Cal
costs by $10 per patient per day. In 1996-97, Medi-Cal
covered 3.8 million inpatient days. Accordingly, if all
hospitals incurred the $10 per day cost estimated by DHS,
this bill would result in annual GF costs of $19 million.
However, it is likely this bill will result in
substantially lower costs, to the extent some hospitals
already meet or exceed the ratios specified in this bill.
BACKGROUND AND DISCUSSION
According to the author and sponsor, the California Nurses
Association (CNA), registered nurses are a critical
component in guaranteeing patient safety and the highest
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quality of health care. CNA states that over the past
several years many hospitals, in response to managed care
reimbursement contracts, have cut costs by reducing their
licensed nursing staff. In some of those hospitals, the
ratio of licensed nurses to patients requires nurses to
perform at unprofessional levels of care. Numerous studies
have documented that patients in hospitals today are sicker
and require more intensive nursing care than patients of
several years ago. In addition, numerous studies have also
documented a clear and direct relationship between low
skill mix (i.e., less licensed nursing staff to higher
numbers of patients) and increased infections, higher
mortality rates, increased illness and errors.
CNA states that hospitals are enjoying their third straight
year of record profits according to the American Hospital
Association yet they are still lacking adequate nursing
staff. CNA reports that it has received hundreds of
letters from nurses who point to poor and unsafe care due
to too few nurses assigned to acute care facilities.
Additionally, CNA states the existing patient
classification system is incomprehensible and that DHS has
a difficult time reviewing these systems for noncompliance.
However, last year, DHS received very few complaints
regarding ICU staff issues, because the statutory licensed
nurse numerical ratios required in those units are very
easy to evaluate, either they are staffed at appropriate
levels or they are not.
In 1998, the DHS surveyed over 160 acute care hospitals
during the Consolidated Accreditation and Licensing Survey
and found that most of the hospitals surveyed were not in
compliance with Title 22 patient classification. 61% of
the facilities were out of compliance with Title 22 with
87% deficient in the specific sections that require the
facility to establish a PCS and to staff based on the
patient needs. CNA argues that the Title 22 regulatory
scheme was the preferred scheme for staffing supported by
the hospitals and is the basis for their argument opposing
the ratios articulated in AB 394. However, it is clear
that the majority of facilities are not complying with
Title 22.
In a recent national survey of 7,500 RNs by Boston College
School of Nursing, Assistant Professor Judith
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Shindul-Rothchild, RN, Ph.D., found the following: 60%
noted a reduction on the number of registered nurses
providing direct care while 40% reported substitution of
unlicensed personnel for registered nurses. The study
found disturbing increases in unexpected patient
readmissions, complications, medication errors, wound
infections, patient injuries and patient deaths. Two out
of five RNs said they would not recommend a family member
receive care at their facility. Studies by CDC and
American Nurses Association have found a clear link between
nursing ratios and positive medical outcomes.
Hospitals which oppose strict, numerical nursing ratios
argue that such fixed ratios are unrealistic, unnecessary
and unlikely to result in improved patient care. Hospitals
point out that the current shortages of nurses will prevent
compliance by hospitals, and will impose very substantial
new costs on hospitals. Opponents, correctly, report that
California ranks last among the 50 states in the proportion
of registered nurses per 100,000 population. In Los
Angeles County, the proportion of nurses per 100,000
patients is one-half of the same ratio among Mid-Atlantic
or North Central states. Hospitals believe they cannot
find or recruit the numbers of nurses necessary to meet the
standards of AB 394.
Hospitals, in opposition, note that the issue of adequate
nursing staff in hospitals was addressed 1997 when DHS
promulgated regulations requiring nursing staff to
fluctuate in relation to the amount and type of nursing
care needed by particular patients on a given unit. The
regulations require hospitals to determine the amount of
nursing care needed each shift by each patient. Thus, when
patients on a unit get sicker and need more care,
additional nursing staff must be assigned. Conversely,
when the patients on the unit improve and need fewer hours
of nursing care, less staff will be used.
DHS' Licensing Division initially considered regulations
requiring staffing ratios for registered nurses. However,
upon closer consideration the Department abandoned ratios
and embraced the patient classification process that aligns
staffing to the health care needs of the patients and at
the same time avoids inefficient use of staff. The
Department spent more than three years working with key
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statewide nursing and hospital organizations, including the
California Nurses Association and CHA, to develop the final
regulations, which became effective on January 1, 1997.
The DHS Licensing Division has been responsible for
enforcing these regulations for the last two and one-half
years. The Department has reported us that hospitals are
implementing these regulations and that compliance is
generally good. Where there have been compliance issues,
DHS has issued citations and the affected hospitals have
made the required corrections.
The sponsors of AB 394 allege patient care is suffering due
to a lack of registered nurses in hospitals. Hospitals
claim neither impartial observers nor impartial studies
confirm these allegations. Hospital licensing and
accreditation entities have not reported a general problem.
Congress recently asked the Institute of Medicine to look
into these issues. The Institute's study stated that
little empirical evidence is available to support anecdotes
alleging that hospital quality of car has been adversely
affected by changes in the staffing patterns of nursing
personnel. In addition, the independent Public Policy
Institute of California found that the average number of
nursing hours per patient day rose continuously from 1977
through 1996. The Institute found that registered nurses'
hours per patient rose even after adjustment for increasing
severity of patient conditions.
Related legislation, AB 675 (Thomson) is also before the
committee. AB 675 is intended to assure compliance with
patient classification system without numerical ratios.
PRIOR ACTIONS
Assembly Floor: 42-29 Pass
Assembly Appropriations: 14-4 Do Pass
Assembly Health: 8-0 Do Pass
POSITIONS
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Support: California Nurses Association (sponsor)
AIDS Community Research Consortium
American Nurses Association California
Board of Registered Nursing
California Advocates for Nursing Home Reform
California Applicants' Attorneys Association
California School Nurses Organization
California Society for Oriental Medicine
California State Council
Congress of California Seniors
Consumer Attorneys of California
Democratic Women's Club of Santa Cruz County
Emergency Nurses Association
Gray Panthers of San Francisco
Marin Healthcare District
Neighbor to Neighbor
Older Women's League of California
Planned Parenthood
San Francisco Board of Supervisors
United Nurses Association of California
14,227 individual nurses
Oppose: Adventist Health
Alameda Hospital
Alexian Brothers Hospital
Alliance of Catholic Health Care Systems
Alta Bates Medical Center, Sutter Health
Affiliate
Alta Bellwood Hospitals, Inc.
American Medical Group Association
Anacapa Hospital
Anaheim General Hospital
Antelope Valley Hospital
Association of California Healthcare
Districts
Bakersfield Memorial Hospital, Catholic
Healthcare West (CHW)
Barlow Respiratory Hospital
Barstow Community Hospital
Bay Harbor Hospital
Bellwood General Hospital
Beverly Hospital
BHC Fremont Hospital
OPPOSE: California Association of Catholic Hospitals
(cont'd) California Association of Health Plans
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California Chamber of Commerce
California Healthcare Association
California Hospital Medical Center, CHW
California Pacific Medical Center
California Rehabilitation Association
Catholic Healthcare West - Central
California
Catholic Healthcare West North State Region
Catholic Healthcare West - Southern
California
Catholic Healthcare West Bay Area Region
Board of Directors
Public Policy Committee
Cedar Vista Hospital
Centinela Hospital Medical Center, Tenet
HealthSystem
Chapman Medical Center, Tenet California
HealthSystem
Charter Behavioral Health System of Southern
California /
Charter Oak
Charter Behavioral Health System of Southern
California / Corona
Charter Behavioral Health System of Southern
California / Palm
Springs
Children's Hospital and Health Center
Children's Hospital Los Angeles
Chinese Hospital
Chino Valley Medical Center
Colorado River Medical Center
Colusa Community Hospital
Community Health System
Community Hospital of San Bernardino
Community Hospital of the Monterey Peninsula
Corona Regional Medical Center
Dameron hospital
Daniel Freeman Marina Hospital / Daniel
Freeman Memorial
Hospital
Delano Regional Medical Center
Dominican Hospital
Downey Community Hospital
Eastern Plumas Health Care
Emanuel Medical Center
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Encino-Tarzana Regional Medical Center
Enloe Health System
Falbrook Hospital
Fairchild Medical Center
Fountain Valley Regional Hospital and
Medical Center
French Hospital Medical Center
The Fremont-Rideout Health Group
Garden Grove Hospital
General Hospital
Glendale Adventist Medical Center
Glenn Medical Center
Good Samaritan Hospital
Greater El Monte Community Hospital
Hazel Hawkins Memorial Hospital,
Convalescent Hospital and
Home
Health Agency
Healdsburg General Hospital
Holy Cross Health Systems
John Muir Medical Center
John C. Fremont Healthcare District
Kaiser Permanente
Kaiser Permanent Medical Care Program
Kenneth Norris Cancer Hospital
Kentfield Rehabilitation Hospital
Lakewood Regional Medical Center
La Palma Intercommunity Hospital, CHW
Lindsay District Hospital
Lodi Memorial Hospital
Loma Linda University Medical Center
Lompoc Hospital District
Long Beach Community Medical Center, CHW
Los Angeles County Board of Supervisors
Los Alamitos Medical Center
Los Robles Regional Medical Center
Mad River Community Hospital
Mammoth Hospital
Marian Medical Center
Marin General Hospital
Mark Twain St. Joseph's Hospital
Martin Luther Hospital Anaheim
Martin Luther King, Jr./Drew Medical Center
Mayers Memorial Hospital District
Mee Memorial Hospital
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Memorial Hospital at Exeter
Memorial Hospital of Gardena
Memorial Hospital Los Banos
Mercy
Mercy Healthcare Sacramento, CHW
Mercy Hospital & Health Services, CHW
Mercy Medical Center Mt. Shasta
Mercy Medical Center Redding
Mercy Southwest
Mercy Westside Hospitals
Methodist Hospital
Methodist Hospital of Sacramento
Mission Hospital Regional Medical Center
Natividad Medical Center
North Bay Healthcare System
North Coast Health Care Centers
Novato Community Hospital
O'Connor Hospital, CHW
Ojai Valley Community Hospital
Orange County Business Council
Oroville Hospital
Pacifica Hospital of the Valley
Pacific Alliance Medical Center
Pacific Hospital of Long Beach
Palo Verde Hospital
Paradise Valley Hospital
Parkview Community Hospital
Pioneers Memorial Healthcare District
Placentia Linda Hospital, Tenet California
HealthSystem
Pomona Valley Hospital Medical Center
Presbyterian Intercommunity Hospital
Providence Holy Cross Medical Center
Providence Saint Joseph Medical Center
Queen of the Valley Hospital
Rancho Springs Medical Center, Tenet
HealthSystem
Redbud Community Hospital
Redlands Community Hospital
Riverside Community Hospital
Robert H. Ballard Rehabilitation Hospital
Ross Hospital
Saint Agnes Medical Center
Saint Francis Medical Center Santa Barbara,
CHW
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San Benito Health Care District
San Clemente Hospital & Medical Center
San Dimas Community Hospital
San Gorgonio Memorial Hospital
San Joaquin General Hospital
San Joaquin Valley Rehabilitation Hospital
San Jose Medical Center
San Pedro Peninsula Hospital
Santa Paula Memorial Hospital
Selma District Hospital
Sharp Health Care-Sharp Memorial Hospital
Sharp Mesa Vista Hospital
Sharp Chula Vista Medical Center
Sierra Kings District Hospital
Sierra Vista Regional Medical Center
Sierra View District Hospital
Sisters of Mercy of the Americas / Hermanas
de la Misericordia
de las Americas
OPPOSE: Sonoma Valley Hospital
(cont'd) Southern Inyo County Local HealthCare
District
South Coast Medical Center, Adventist Health
St. Bernardine Medical Center, CHW
St. Dominic's Hospital, CHWl
St. Elizabeth Community Hospital, CHW
St. Francis Medical Center of Santa Barbara
St. John's Health Center Patient Care
Services
St. John's Pleasant Valley Hospital,
Camarillo
St. John's Regional Medical Center, Oxnard
St. Joseph Health System
St. Joseph Health System of Greater Sonoma
County
St. Joseph Health System, Southern
California Region
St. Joseph's Health System - Humboldt County
St. Joseph's Behavioral Health Center
St. Joseph's Medical Center, CHW
St. Joseph's Regional Health System
St. Jude Medical Center
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St. Luke Medical Center
St. Luke's Hospital
St. Mary's Medical Center, CHW
St. Mary Regional Medical Center
St. Rose Hospital
Suburban Medical Center, Tenet HealthSystem
Sutter Auburn Faith Hospital
Sutter Coast Hospital
Sutter Delta Medical Center
Sutter Lakeside Hospital
Sutter Solano Medical Center
Sutter Tracy Community Hospital
Sutterville Roseville Medical Center
Tahoe Forest Hospital
Tehachapi Valley Healthcare District
Temple Community Hospital
Trinity Hospital
Twin Cities Community Hospital
UCSF Stanford Health Care
Ukiah Valley Medical Center
United Hospital Association
VacaValley Hospital
Valley Children's Hospital
Vencor Hospital San Diego
Vencor Hospital San Leandro
The Fremont-Rideout Health Group
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OPPOSE: Verdugo Hills Hospital
(cont'd) Vista del Mar Hospital
Walnut Creek Hospital
Warrack Hospital
West Anaheim Medical Center
West Hills Hospital & Medical Center
Western Medical Center Santa Ana
White Memorial Medical Center, Adventist
Health
Whittier Hospital Medical Center
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