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