BILL ANALYSIS
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|Hearing Date:July 12, 1999 | Bill No:AB 394|
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SENATE COMMITTEE ON BUSINESS AND PROFESSIONS
Senator Liz Figueroa, Chair
Bill No: AB 394Author:Kuehl
As Amended:July 6, 1999 Fiscal: Yes
SUBJECT: Health facilities: nursing staff
SUMMARY: Establishes presumptive nurse to patient staffing
ratios in specified health facilities and limits the
nursing-related duties that can be performed by unlicensed
assistive personnel.
Existing law:
1)Provides for the licensing and regulation of nurses by the
Board of Registered Nursing (Board), 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 (Title 22), specified health
facilities to implement a "patient classification system"
(PCS) for determining patient nursing care needs that reflects
an assessment made by registered nurses, patient requirements,
the patient care delivery system, and generally accepted
standards of nursing practice; and 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
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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 specified functions that require scientific
knowledge and technical skills.
3)Requires, by March 1, 2000, acute care hospitals to 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.
These ratios are to ensure safe and adequate patient
care that permit assessment, nursing diagnosis, planning,
intervention, evaluation and, when justified, patient
advocacy.
5)Establishes rebuttable presumptions for the minimum ratios in
different units, as follows: a) 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 this staff, b) one
nurse to three patients for pediatric/step-down and
intermediate care patients, c) one nurse to four patients for
specialty and telemetry units, and d) One nurse to six
patients in general medicine.
6)Provides that DHS may adopt reduced ratios if its finds that
lower ratios allow for all elements of nursing care to be
provided, that each ratio provides safe and adequate care, and
that ratios do not include unlicensed personnel. If DHS fails
to produce ratios by March 2000 the standard shall default to
those ratios described here.
7)Allows for a waiver of the nurse to patient ratio provisions
for rural general acute care hospitals pursuant to specified
criteria.
8)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.
9)Requires orientation and demonstrated competence, as
specified, before assigning a nurse or other direct patient
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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.
10)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, scope of practice
provisions shall prevail.
FISCAL EFFECT: Potentially significant annual General Fund
costs to the Medi-Cal program, due to increased reimbursement
rates for hospital inpatient services.
COMMENTS:
1.Purpose. The author introduced this bill in response to
the decrease in the quality of care patients are
receiving in hospitals. Specifically, the author is
concerned with the increasing use of unlicensed personnel
and the decreasing use of appropriate levels of nursing
staff. These trends are adversely affecting the quality
of care provided in many acute care hospitals.
2.Cost-cutting Measures Have Reduced Staffing. According
to the author and sponsor, the California Nurses
Association (CNA), registered nurses are a critical
component in guaranteeing patient safety and the highest
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. One aspect of
managed care has been that patients are not being
admitted to hospitals as easily as in the past. It is
not therefore surprising that 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.
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3.Hospitals Are Profitable, But Still Have Low Staffing
Ratios. CNA points to studies, including a study by the
American Hospital Association, that show hospitals are
enjoying their third straight year of record profits.
Despite this financial health, hospitals still lack
adequate nursing staff. (California hospitals suggest
that this national profitability report may not be true
for California hospitals. However, they have not
provided a California-specific alternative financial
report.)
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 (see #3 under
Existing law). In contrast, last year DHS received very
few complaints regarding Intensive Care Unit staffing
issues (where numerical ratios are already required)
because staffing in those units is very easy to implement
and evaluate in the sense that they either are staffed at
appropriate levels or are not.
4.Is the Existing Staffing Criteria Comprehensible,
Enforceable? In 1998, the DHS surveyed over 160 acute
care hospitals during the Consolidated Accreditation and
Licensing Survey and found extremely high levels of
non-compliance with Title 22 patient classification
requirements (over 100 citations were issued). According
to CNA, 87% of hospitals were deficient in the specific
sections that require the facility to establish a PCS and
to staff based on the patient needs. CNA points out that
hospitals generally support the Title 22 regulatory
scheme for staffing exactly because it is difficult to
implement and enforce, and argue that it renders this
bill unnecessary. However, the nurses argue that many,
if not most, facilities are not complying with Title 22
(and probably will not face enforcement for
non-compliance).
5.Hospitals Argue Ratios Not The Answer. Hospitals argue
that strict 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
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substantial new costs on hospitals. Opponents 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 this bill.
6.Hospitals Argue Title 22 Is Adequate. Hospitals, in
opposition, note that the issue of adequate nursing staff in
hospitals was addressed in 1997 when DHS promulgated
regulations requiring nursing staff to adjust in relation to
the amount and type of nursing care needed by particular
patients on a given unit. The regulations require the
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.
Opponents note that the DHS, prior to adopting the current Title
22 regulations, considered regulations requiring staffing
ratios for registered nurses. However, upon closer
consideration the Department under the previous Administration
abandoned ratios and embraced the current regulatory approach.
Whether this approach is workable, or a failure, remains
subject to disagreement among the parties.
7.Hospitals Argue That Proponents Have Not Shown Patient Care Is
Suffering. The sponsors of this bill 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 care 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.
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However, it should also be noted that hospitals have discussed
the revenue pinch that managed care has placed on them, and
indirectly acknowledged that they cannot always afford to
staff at levels they may prefer.
8.Business and Professions Issues. The Senate Health and Human
Services Committee (HHS), with jurisdiction over health
facilities such as acute care hospitals, passed this bill last
week. In addition, the bill addresses scope of practice
issues by limiting the ability of these hospitals to hire
unlicensed personnel to perform functions that are within
nurses' scope of practice as contained in the Business and
professions Code. It may be appropriate for this Committee to
defer to the HHS except in relation to issues affecting the
scope of nursing practice.
Although it is not the primary focus of the bill, the scope of
practice issue has generated controversy in the recent past.
The Board was poised to adopt regulations that would delineate
a "scope of practice" for unlicensed assistive personnel
(UAP), including a role for nurses supervising these
personnel. However, when the new Administration assumed
office, and after concerns expressed by Legislators were
conveyed to the Board, those regulations were withdrawn. The
Business and Professions Committee is planning to hold interim
hearings on the extent to which UAPs are used in hospitals for
tasks that should be performed by nurses, and what tasks can
be appropriately performed by these employees.
9.Related Legislation. AB 675 (Thomson) is before the HHS. AB
675 is intended to improve compliance with the Title 22
patient classification. The proponents of AB 394 and the
proponents of AB 675 have argued that the two measures are
compatible and not alternatives.
SUPPORT AND OPPOSITION:
Support:California Nurses Association
American Nurses Association
AIDS Community Research Consortium
Board of Registered Nursing
California Advocates for Nursing Home Reform
California Applicants' Attorneys Association
California Society for Oriental Medicine
Congress of California Seniors
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Consumer Attorneys of California
County of San Francisco
Emergency Nurses Association
Gray Panthers
Marin Healthcare District
Neighbor to Neighbor
OlderWomen's League
Planned Parenthood
United Nurses Association
Numerous individual nurses, other health
professionals, and individuals
Opposition:American Medical Group Association
Association of California Healthcare Districts
California Association of Health Plans
California Chamber of Commerce
California Healthcare Association
California Rehabilitation Association
Catholic Healthcare West
County of Los Angeles
A number of individual hospitals
Consultant:Mark Rakich