BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 57
A
AUTHOR: Price
B
AMENDED: As Introduced
HEARING DATE: June 25, 2009
5
CONSULTANT:
7
Hansel/sh
SUBJECT
University of California hospitals: staffing
SUMMARY
Requires the Department of Public Health (DPH) to establish
a procedure for collecting and reviewing written staffing
plans developed by the University of California (UC)
hospitals. Requires DPH to review documentation from each
hospital concerning several aspects of its patient
classification plan, as specified.
CHANGES TO EXISTING LAW
Existing law:
Provides for the inspection and licensure of health
facilities, including hospitals, by the Department of
Public Health.
Requires DPH to adopt regulations that establish minimum,
specific, and numerical nurse-to-patient ratios, by
licensed nurse classification and by hospital unit, for
general acute care, acute psychiatric, and specialty
hospitals. Existing law requires the ratios to constitute
the minimum number of registered and licensed nurses that
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must be allocated, and 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, the ability
for self-care, and the licensure of the personnel required
for care.
Authorizes the Director of DPH to assess administrative
penalties against general acute care, acute psychiatric,
and specialty hospitals for licensing deficiencies and
violations, including violations of staffing requirements,
as specified. In particular, the director is authorized to
assess the licensee of specified health facilities an
administrative penalty in an amount not to exceed $25,000
per violation, if a licensee receives a notice of
deficiency constituting an immediate jeopardy to the health
or safety of a patient, as defined, and is required to
submit a plan of correction.
Existing regulations:
Requires the administrator of nursing services for each
hospital, or their designee, to develop a written staffing
plan for each patient care unit, based on patient care
needs as determined by the hospital's patient
classification system.
Requires a staffing plan to be developed and implemented
for each patient care unit, which must specify patient care
requirements, and the staffing levels for registered nurses
and other licensed and unlicensed personnel.
Requires hospitals to develop and document a process by
which all interested staff may provide input on the patient
classification system.
This bill:
Requires DPH to establish a procedure for collecting and
reviewing the written staffing plans developed by UC
general acute care hospitals, acute psychiatric hospitals,
and special hospitals.
Requires DPH, as part of its procedure, to collect and
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review documentation from each hospital relating to all of
the following:
The hospital's annual review of the reliability of its
patient classification system;
The hospital's adjustments to its patient classification
system, based on the annual review of the patient
classification system; and,
The hospital's process for accepting staff input about
the patient classification system, the system's required
revisions, and the overall staffing plan.
Requires DPH to exclude from its review issues related to
registered nurse staffing.
Allows DPH, if it deems it necessary, to reduce the volume
of information collected and reviewed, to identify specific
time frames for which the information is to be collected,
and to review that information as a representative sample.
Requires a UC general acute care hospital, acute
psychiatric hospital, and special hospital to cooperate
with DPH in providing the required information.
Makes various findings and declarations including that
inadequate staffing is a matter of statewide concern, and
that this bill is intended to provide DPH and the public
with access to the written staffing plans and actual
staffing levels of the only general purpose health care
system owned and operated by a state entity.
The bill would sunset its provisions on July 1, 2013.
FISCAL IMPACT
According the Assembly Appropriations Committee analysis of
AB 57:
Fee-supported special fund costs of approximately
$10,000 for DPH to review staffing plans submitted by
the five University of California Medical Centers.
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Unknown, likely absorbable, staffing costs to the
UC to provide DPH with staffing reports and evidence
of patient classification methodologies.
BACKGROUND AND DISCUSSION
According to the author, the intent of AB 57 is to better
ensure safe hospital staffing at UC medical centers by
requiring DPH to collect and review the medical centers'
written staffing plans and related documentation. The
author states that recruitment and retention of key
employees is a challenge at UC medical centers, and that UC
has acknowledged that it faces a shortage of key personnel
in its 2007-08 budget request. The author cites a 2007
analysis that found that one in four patient care workers
at the UC medical centers has two years or less experience
and states that for many critical patient care positions,
turnover is high. The author states that the measure will
also provide a factual basis upon which the Legislature and
DPH can evaluate the need for minimum staffing requirements
in professional and technical classifications other than
nursing. The author states that closer oversight of
staffing in the medical centers is appropriate, given that
the medical centers constitute the only general purpose
health care system owned and operated by a state entity.
Current hospital staffing requirements
Current regulations require hospitals to develop a written
staffing plan for registered nurses and other licensed and
unlicensed personnel that reflects patient care needs based
on a patient classification system. Hospitals use various
types of non-nursing professional and technical staff to
provide direct patient care, including respiratory
therapists, phlebotomists, radiology technicians, lab
technicians, pharmacy technicians, emergency room and
surgical technicians, and nursing assistants. According to
DPH, hospitals may use non-nursing staff to meet patient
care needs, if they are otherwise allowed to provide those
services. For instance, respiratory care services could be
provided by a nurse or respiratory therapist, or blood
draws could be done by a nurse or phlebotomist. DPH also
indicates that while it does not review the methods or
procedures that hospitals use to determine non-nursing
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professional and technical staffing levels, it would
investigate a complaint that is received related to
staffing, including non-nurse personnel, in a hospital, and
the investigation would involve examining the hospital's
patient classification system and staffing plans. If a
patient suffered harm and understaffing was determined to
be a contributing causative factor, DPH would issue a
deficiency notice.
UC medical centers
According to UC, the five medical centers operated by UC
(Davis, Irvine, Los Angeles, San Diego, and San Francisco)
support the clinical teaching programs of UC's medical and
health sciences schools and receive more than 138,000
inpatient discharges, 261,000 emergency room visits, and
more than 3.6 million outpatient visits each year. The UC
medical centers provide a full range of health care
services in their communities and are sites for the
development and testing of new diagnostic and therapeutic
techniques. Collectively, the UC medical centers comprise
one of the largest health care systems in California and
constitute one of the two largest Medi-Cal providers in the
state.
UC indicates that all UC medical centers currently have
systems in place to determine staffing needs, measure
turnover rates, and assess staffing effectiveness, based on
each individual hospital's facility details, patient acuity
levels, and employee needs. A 2007 report for the UC Davis
Health System indicated that some of the most difficult to
recruit positions in 2006-07 included clinical laboratory
scientists, physical/occupational therapists, respiratory
therapists, magnetic resonance imaging technologists, and
radiological technologists. The report noted that to
attract applicants to positions that are difficult to fill,
the UC Davis Medical Center has offered signing bonuses,
participated in employee referral programs, partnered with
other hospitals to offer training programs, and recruited
at employment and career fairs.
Prior legislation
AB 2244 (Price) of 2008 contained provisions substantially
similar to this bill. AB 2244 was vetoed by Governor
Schwarzenegger, who stated in his veto message that current
law already requires hospitals to have written staffing
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plans for nursing staff and that hospitals must determine
the staffing needs for "non-licensed" classifications using
the hospital's individual patient care requirements and
their system of delivering care.
AB 13 (Brownley) of 2007 would have required specified
hospitals to adopt a plan or procedure for determining
staffing of non-nurse professionals and technical
classifications, as specified. Would have directed DPH to
review hospitals' compliance with their plans, and allowed
the director to levy administrative penalties for failure
to comply with the bill's provisions. AB 13 is pending on
the Senate Floor.
AB 520 (Brownley) of 2007 was substantially similar to AB
13. AB 520 was held in the Assembly Appropriations
Committee.
AB 2754 (Chan) of 2006 was substantially similar to AB 13.
AB 2754 failed passage on the Senate Floor.
AB 761 (Jones) of 2005 would have required hospitals to
consider staffing guidelines developed by relevant
professional associations and worker and patient injury
rates in determining non-nurse staffing levels in
hospitals. AB 761 failed passage on the Senate Floor.
AB 2300 (Dymally) of 2004 would have required hospitals to
develop a staffing plan for professional, technical, and
support staffing. AB 2300 failed passage in the Assembly
Health Committee.
AB 1927 (Dymally) of 2004 would have required general acute
care hospitals, acute psychiatric hospitals, and special
hospitals to at least annually, review the use of, and
consult with, professional, technical, and support staff,
as specified. AB 1927 failed passage on the Assembly
Floor.
Arguments in support
The American Federation of State, County, and Municipal
Employees (AFSCME) states that the UC hospitals comprise a
crucial component of the state's health care system. As
such, it is necessary to ensure that these hospitals
maintain adequate staffing levels. The expanded oversight
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and review provided by AB 57 will provide assurances that
patients are receiving appropriate and quality care in
these facilities.
Arguments in opposition
DPH states that AB 57 will result in the redirection of DPH
staff from other mandated activities. Since non-nurse
staff, such as respiratory therapists, phlebotomists, and
radiology technicians, are not required to be included in
each hospital's patient classification system and written
staffing plan, DPH does not believe a review of the
staffing plans will yield the information related to
adequacy of staffing of non-nurse personnel. DPH also
estimates the bill would require surveyors to spend an
additional 150 hours per annual hospital inspection to
review UC hospital staffing plans, and divert them from
other state-mandated activities.
PRIOR ACTIONS
Assembly Floor: 48-31
Assembly Appropriations: 10-5
Assembly Higher Education:6-3
Assembly Health: 13-6
COMMENTS
1. Bill limited to UC hospitals. The committee has heard
a number of bills that would require hospitals
generally to document the systems they use for making
staffing decisions involving non-nurse personnel. This
bill, by contrast, would require DPH to review the
methods and systems by which UC hospitals make staffing
decisions involving non-nurse personnel. It is not clear
that issues involving staffing of non-nurse personnel are
any more or less prevalent at UC hospitals versus other
hospitals.
POSITIONS
Support: American Federation of State, County and
Municipal Employees (sponsor)
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American Federation of State, County and Municipal
Employees, Local 3299
United Nurses of California/Union of Health Care
Professionals
(UNAC/UHCP)
Oppose: Department of Public Health
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