BILL ANALYSIS
AB 822
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Date of Hearing: January 12, 2010
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
AB 822 (Fletcher) - As Amended: January 4, 2010
SUBJECT : Health facilities: program flexibility.
SUMMARY : Requires the California Department of Public Health
(DPH) to establish the Acuity-Adaptable Care Delivery Pilot
Program to allow at least two, but not more than 10, general
acute care hospitals to use licensed intensive care beds as
step-down and medical surgical beds interchangeably based on the
acuity of the patient. Specifically, this bill :
1)Requires, as of October 1, 2011, DPH to authorize at least
two, but not more than 10, general acute care hospitals to use
intensive care beds as step-down and medical surgical beds
interchangeably based on the acuity of the patient.
2)Requires DPH to identify the participating hospitals or
solicit and accept proposals from hospitals and requires at
least one participating hospital to be in San Diego County and
be associated with a two-hospital system operated by a
district.
3)Requires DPH to identify alternate technology, equipment,
procedures, techniques, and concepts and give special
consideration to use of acuity-adaptable nursing units and
beds that will promote innovation and improvement in service
and patient care.
4)Specifies standards for use of supporting technology,
procedures, techniques and equipment and requires such use to
be consistent with safe, therapeutic, and effective care that
promotes patient safety.
5)Specifies that deployment of technology shall not prevent a
health care provider from following accepted practice
standards.
6)Requires participating hospitals to comply with existing
statutory staffing requirements based on the acuity of the
patient and not the licensed bed category and physical
location of the patient.
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7)Authorizes DPH to charge participating hospitals an annual fee
not to exceed the costs of overseeing and evaluating the pilot
program.
8)Requires participating hospitals to consult with the Office of
Statewide Health Planning and Development (OSHPD) if the
physical buildings is involved.
9)Provides that a participating hospital may be required to
undergo an annual review of the outcome of the pilot program.
Authorizes DPH to require an independent evaluation annually
to evaluate clinical outcome in term of quality, patient
safety and worker safety.
10)Requires DPH, by January 1, 2015 to prepare and submit a
report to the legislature on the results of the pilot project
and the impact on quality of service and patient care.
EXISTING LAW :
1)Provides for the licensing and regulation of health
facilities, including general acute care hospitals, acute
psychiatric hospitals, and special hospitals by DPH.
2)Establishes minimum, specific, and numerical licensed
nurse-to-patient ratios, by licensed nurse classification and
by hospital unit, for hospitals, and provides that these
ratios shall constitute the minimum number of registered and
licensed nurses that must be allocated.
3)Requires additional staff to be assigned in accordance with a
documented patient classification system that includes 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.
4)Requires general acute care, acute psychiatric, and special
hospitals to adopt written policies and procedures for the
training and orientation of nursing staff, and further
provides that a registered nurse shall not be assigned to a
nursing unit or clinical area until they have received
orientation in that clinical area, and have demonstrated
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current competence in providing care in that area.
5)Requires that California Building Standards and DPH
regulations for adequacy, safety, sanitation, staffing, and
patient services permit program flexibility upon approval by
DPH or OSHPD. DPH is authorized to approve, modify, or reject
any application, but is also required to provide the applicant
hospital justification for any conditions or modifications
imposed.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the sponsor, the
California Hospital Association (CHA), due to outdated
regulations, California hospitals are not allowed to provide
patients with cutting-edge technology, equipment, procedures,
and care that is available elsewhere in the United States.
CHA notes that hospital licensing regulations were promulgated
in 1976, but while there have been limited revisions over the
years; the regulations have not kept pace with technological
and methodological advances in health care. According to CHA,
this bill is designed to provide hospitals with greater
flexibility in the use of modern technology, equipment,
procedures, and practices to reduce costs and/or provide
higher quality care for patients. CHA states that this bill
would require DPH to approve use of alternate concepts,
methods, procedures, techniques, or equipment whenever the
hospital demonstrates that the use meets or exceeds quality of
care and patient safety standards.
2)BACKGROUND . California hospital licensing provisions are
found in Division 5 of Title 22 of the California Code of
Regulations. The comprehensive regulations prescribe
standards for adequacy, safety, and sanitation of each
hospital's physical plant. The regulations specify
appropriate staffing by qualified personnel and define types
of health facilities and levels of service appropriate to
patients served in licensed health facilities. For instance,
under existing regulations the intensive care services
category is a nursing unit in that requires specially trained
nursing and supportive personnel and the necessary equipment
to provide specialized care to critically ill patients. The
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required ratio is one nurse to every two patients, or fewer,
depending on the acuity of the patient. The required ratio in
a medical-surgical unit is one to five.
Supporters of this bill are particularly interested in
permitting construction of "acuity-adaptable" patient units.
Acuity-adaptable units are hospital rooms that can accommodate
intensive care, intermediate care, or medical-surgical care
patients. The design of these units is such that patients can
be treated at these varied levels of care based on their
changing conditions without being moved to another unit to
receive specialized treatment. In a traditional hospital
design, patients are located in different units, typically on
different floors of the hospital, based on the level of care
they require. These proposed acuity-adaptable units minimize
movement of patients and permit hospitals to expand or reduce
types of beds based on the current census of the facility.
Three states, Ohio, Hawaii, and Indiana, now permit the
construction of acuity-adaptable beds, but California does not
recognize this category.
3)PILOT PROJECT AUTHORITY . Title 22 provides for program
flexibility by the use of alternative procedures, techniques,
equipment, and purchasing in accordance with existing law.
However, it does not allow any variation in supplemental
service or staffing requirements in a unit with intensive care
or critical care beds. On January 23, 2008, DPH informed
Palomar Pomerado Health (PPH) that "the identification of the
purposed pilot unit as an acuity-adaptable care unit would not
allow for a decrease of the required staffing for a critical
care unit" and therefore denied the request for a pilot
project.
4)EVIDENCE-BASED HOSPITAL DESIGN . According to a September 2007
report from the U.S. Department of Health and Human Services,
Agency for Healthcare Research and Quality (AHRQ),
"Transforming Hospitals: Designing for Safety and Quality,"
evidence based design is a term used to describe how the
physical design of health care environments affects patients
and staff. The report states that evidence based design
elements can help hospitals improve quality outcomes and
reduce costly and avoidable incidents of patient harm, such as
patient falls, hospital-acquired infections, and medication
errors. In addition, this report points out that design
elements can improve patient satisfaction, the overall care
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experience and reduce patient and family stress by providing
adequate space to interact with their families in single
patient rooms. According to the report, other key design
characteristics include noise-reducing construction materials,
distributed nursing stations and easily accessible
workstations. The report states that by reducing the need to
transfer patients around, acuity-adaptable rooms lessen the
communication burden on staff at a new location and results in
lower rate of medication errors. Acuity-adaptable rooms are
also cited as an example of ways to improve staff satisfaction
and reduce workforce injury by improving workflow and
increasing productivity. Staff injuries can be reduced by
designing beds to reduce back stress and improved layouts.
5)SUPPORT . CHA, in support, states that acuity-adaptable rooms
improve health care quality because they can adapt to a
person's necessary level of care without forcing the patient
to be wheeled around the hospital to different rooms as their
condition or necessary treatment changes and time is of the
essence.
The California Children's Hospital Association supports this
bill and states that it will help ensure that children receive
the best medical care while holding providers to the highest
standard of medical care.
PPH, in support, points out that there are many advantages of
eliminating the need for patient transfers. These include
reducing the costs of the transfer process that results from
time spent preparing for and actually moving the patients,
holding cost due to lack of available beds, and room turnover
costs. PPH also states that a growing body of evidence
suggests that an acuity-adaptable delivery model reduces
missed or delayed treatments and medication errors that occur
because of poor communication during the hand-off of patients.
In support, PPH cites the experience of Methodist Hospital in
Indianapolis that reported that use of the acuity-adaptable
delivery model with distributed nursing stations and
single-occupancy rooms resulted in a 70% reduction in medical
errors. PPH also points out that transfers from intensive
care to medical/surgical units can be traumatic and result in
confusion, stress, and fear and that this model improves
patient and care-giver satisfaction.
6)OPPOSITION . The Chair of the Professional Practice Committee
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at PPH opposes on behalf of the Committee and as a member of
the California Nurses Association (CNA), stating that forcing
the Registered Nurses and the patients to test an unproven,
potentially dangerous, model of nursing is totally
unacceptable. According to the chair, this committee meets
with PPH administrators regularly to create solutions to a
spectrum of issues including a number of those referenced by
the sponsor in background material. The chair maintains
however that the PPH administrations have never sought their
input on the controversial issue of acuity-adaptable rooms.
According to this opposition, there are a number of barriers.
First, they assert that there is little reason to believe that
it will improve the practice and nursing and will actually
work against it. For instance, the proposed system undermines
the healing effect of moving out of the Critical Care
environment and ignores the relevance and value of
specialization. Secondly, the existing registered nurses
union contract at PPH contains restriction on floating that
the members fought hard to achieve.
The Professional Performance Committee (PPC) of Children's
Hospital & Research Center at Oakland (CHRCO) writes in
opposition that hospitals already have the flexibility to
change a unit's designation. However, the units may not be
mixed. According to the PPC of CHRCO, the existing regulation
was developed specifically to prevent that which is proposed
in this bill; that is confusion about how patients are
classified, what the legal nurse to patient ratios are,
patient safety policies and protocols specific to critical
care, orientation and competencies of nursing staff,
supervision by a qualified nurse manager, and documentation of
these standards. The opposition also states that this bill
will create pressure from hospital administrators to cut costs
by down-grading the acuity of patients so that fewer nurses
would be required to meet the ratio.
CNA in opposition, states that this bill would create an
enforcement nightmare. DPH is already overwhelmed and tepid
in enforcing existing ratios and Title 22 regulations in
hospitals. Creating mixed acuity units will create a whole
new category of complex enforcement demands that the agency
would be able to handle.
7)OPPOSE UNLESS AMENDED . The Service Employees International
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Union (SEIU) is opposed unless this bill is amended to include
a meaningful standard for review and suggests the following
outcomes measures:
a) Reduction in hospital acquired infections;
b) Reduction in re-admissions;
c) Reductions in adverse events;
d) Reductions in mortality; and,
e) Reductions in workplace injuries.
In addition SEIU requests amendments to require on-site
inspection, independent evaluation by experts, and involvement
of OSHPD, and a public oversight process to ensure that the
workers, including their recognized collective bargaining
agents, the community and the public are informed and have the
ability to comment.
8)POLICY CONCERNS .
a) Pilot Project vs. Regulatory Pre-emption. This bill
requires DPH to establish a pilot project of up to 10
general acute care hospitals to allow use of licensed
intensive care beds as step-down and medical surgical
interchangeably. However, this bill does not include a
termination date or a sunset. There are also no specific
outcome measures and no point at which the results are
evaluated in order to extend or end the pilot. In the
absence of traditional elements of a pilot project, this
bill appears to be a permanent legislative override of
regulatory requirements, rather than a true pilot project.
b) Report to the Legislature. This bill requires a report
on the results of the pilot and the impact upon quality of
service and patient care. In order to determine the impact
a base line must be established. For instance, the
Methodist Hospital in Indianapolis, Indiana referred to by
the supporters used a pre-post test design that compared
baseline data captured two years prior to the opening of
the Cardiac Comprehensive Critical Care unit and compared
it to data collected three years after the opening. The
author may want to amend the bill to include specific
outcome measures and a sunset so that the Legislature may
properly evaluate the efficacy of continuing the pilot.
The author may also wish to limit the scope of the pilot to
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cardiac care for instance, in order to develop a more
controlled study.
c) Annual Review and Independent Evaluation. The pilot
project applies to critically ill patients in acute care
hospitals. With patient and worker safety at stake,
shouldn't the annual review and independent evaluation be
mandatory rather than discretionary?
d) Need for Pilot Project. The AHRQ, September 2007
report, relied on by the supporters, describes acuity
adaptable rooms as one example of a design element that
improves quality outcomes. The report lists additional
design features that achieve this goal. These include
single-bed rooms; decentralized nurses stations; multiple
wash stations; well-illuminated, quiet private spaces that
allow pharmacists to fill prescriptions without
distraction; limited overhead announcements; increased
sunlight in patient rooms; and, views of nature, artwork,
and music. It is not clear that the goal of improved
patient care would not be equally accomplished by use of
these other recommended strategies that are already
permissible under current law and regulation.
e) Variance from Title 22 Requirements. In addition to the
prohibited deviation from existing requirements for a
critical care unit, the January 23, 2008 letter from DPH
denying the pilot project request raises concerns with the
architectural designs. Specifically, DPH states that PPH
did not provide a plan that demonstrates how the hospital
will ensure maximum patient observation when there is an
acuity requiring one to one for some patients and one to
two for the remaining. It is also not clear if the intent
is to allow deviation from the required staff ratios. The
proposed configuration may make it difficult for DPH to
determine compliance when there are mixed ratio
requirements in the same space.
f) Identification of Pilots. This bill requires DPH to
identify the hospitals that are authorized to use licensed
intensive care beds interchangeably as step-down and
medical surgical. However, this bill does not include a
criteria or process for this selection. This bill also
requires DPH to identify alternate technologies, giving
special consideration to the use of acuity-adaptable
nursing units and beds, but does not define
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"acuity-adaptable" or the role of alternate technologies.
The author may wish to amend the bill to require DPH to
establish a public selection process with opportunity for
public input and to establish guidelines for selection.
g) Staff Challenges. The supporters acknowledge that there
are many challenges this model. For instance, the
supporters cite the inability to cross-train staff to all
levels of acuity and maintain their competencies, lack of
collaboration, peer support, and mentoring that is
necessary in a high-acuity intensive care unit. Also cited
is physician dissatisfaction with not having all critically
ill patients co-horted in one area and physician
perceptions of the competency and familiarity with the
nurses throughout the hospital as opposed to one or two
specialty units.
h) Role of OSHPD. This bill requires participating
hospitals to consult with OSHPD if the physical building is
involved, but fails to specify to what end. The author may
wish to clarify this.
REGISTERED SUPPORT / OPPOSITION :
Support
California Hospital Association (sponsor)
Adventist Health
Association of California Healthcare Districts
California Children's Hospital Association
California Emergency Physicians Medical Group
California Hospital Association
Community Medical Centers
El Centro Regional Medical Center
Little Company of Mary San Pedro Hospital
Palomar Pomerado Health
Numerous individuals
Oppose Unless Amended
Service Employees International Union
Opposition
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American Federation of State, County and Municipal Employees,
AFL-CIO
California Nurses Association
Professional Performance Committee, Children's Hospital &
Research Center at Oakland
Professional Practice Committee, Palomar Medical Center
United Nurses Associations of California/Union of Health Care
Professionals (UNAC/UHCP)
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097