BILL ANALYSIS �
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 554
S
AUTHOR: Yee
B
AMENDED: As Introduced
HEARING DATE: April 27, 2011
5
CONSULTANT:
5
Hansel
4
SUBJECT
Health facilities: nurse-to-patient ratios
SUMMARY
Requires the Department of Public Health to inspect for
compliance with nurse-to-patient staffing ratios during
periodic inspections of hospitals. Requires DPH to inspect
hospitals that have been cited for deficiencies related to
nurse-to-patient staffing ratios for their compliance with
the plan of correction related to the deficiency, and
requires notices of deficiency and hospitals' plans of
correction to be posted in specified areas of the hospital.
Requires DPH to assess hospitals administrative penalties
for violations of nurse-to-patient staffing ratio
requirements and for the failure to comply with an approved
plan of correction related to nurse-to-patient staffing.
CHANGES TO EXISTING LAW
Existing law:
Provides for the licensing and regulation of health
facilities, including general acute care hospitals, acute
psychiatric hospitals, and special hospitals by the
Department of Public Health (DPH).
Requires DPH to inspect for compliance with state licensing
Continued---
STAFF ANALYSIS OF SENATE BILL 554 (Yee) Page
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requirements and regulation during periodic inspections of
health facilities.
Requires DPH to adopt regulations that establish 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.
Requires additional staff to be assigned in accordance with
a documented patient classification system for determining
nursing care requirements 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.
Prohibits a hospital from assigning a licensed nurse to a
nursing or clinical treatment unit unless the hospital
determines the nurse has demonstrated current competency in
providing care in that area and has received orientation to
the specific unit or clinical area.
Allows DPH to issue administrative penalties to hospitals
for licensing violations that constitute immediate jeopardy
to patients, defined as those in which the licensee's
noncompliance with one or more requirements of licensure
has caused, or is likely to cause, serious injury or death
to the patient.
Also allows DPH to impose administrative penalties for
violations that do not constitute immediate jeopardy to
patients, of up to $25,000 per violation. DPH must first
develop regulations to establish the criteria for such
penalties. In developing the regulations, DPH is directed
to consider several factors, including the probability and
severity of the risk that the violation presents to the
patient; the nature, scope, and severity of the violation;
the facility's history of compliance with related state and
federal statutes and regulations; factors beyond the
facility's control that restrict the facility's ability to
comply with the particular licensing requirement; the
demonstrated willfulness of the violation; and the extent
STAFF ANALYSIS OF SENATE BILL 554 (Yee) Page
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to which the facility detected the violation and took steps
to immediately correct the violation and prevent the
violation from recurring.
This bill:
Requires DPH to specifically inspect for compliance with
nurse-to-patient staffing ratios during periodic
inspections of hospitals.
Requires DPH to inspect hospitals that have been cited for
deficiencies related to nurse-to-patient staffing ratios
for their compliance with the plan of correction related to
the deficiency.
Requires notices of deficiency and hospitals' plans of
correction to be posted in the nurses' station or
designated area where the deficiency occurred until DPH
determines that the health facility has complied with the
plan of correction.
Requires DPH to assess hospitals an administrative penalty
of $10,000 for the fourth and each subsequent violation
within a six-month period of nurse-to-patient staffing
ratio requirements, and an administrative penalty of
$10,000 for the failure of the hospital to comply with an
approved plan of correction. Provides that moneys
collected by DPH from the penalties shall be deposited in
the Licensing and Certification Program Fund, and available
for expenditure upon appropriation by the Legislature.
FISCAL IMPACT
This bill has not been analyzed by a fiscal committee.
BACKGROUND AND DISCUSSION
According to the author, noncompliance with
nurse-to-patient staffing ratios in hospitals is a
prevalent and ongoing problem, and nurses are often
required to assume a patient load that exceeds the ratios
that are required by law. The author states that DPH has
issued deficiencies to approximately 40 percent of
hospitals for noncompliance with the ratios since 2004 and
STAFF ANALYSIS OF SENATE BILL 554 (Yee) Page
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suggests that rate of noncompliance may be higher due to
the fact that DPH inspects for compliance in response to
complaints and not during routine inspections of hospitals.
The author states that by clarifying the responsibility of
DPH to inspect for compliance with the ratios during
routine hospital surveys, and to reinspect hospitals that
have been cited for noncompliance, and authorizing it to
assess monetary penalties against hospitals that have
demonstrated a pattern of violating ratio requirements, SB
554 will give DPH the tools and impetus it needs to
properly enforce ratio laws. Further, the author states
that by requiring hospitals to post notice of deficiencies
in nurses' stations, the bill will aid nurses in keeping
hospitals accountable in meeting the nurse-to-patient
staffing requirements.
Relationship between hospital staffing and quality of care
A number of studies have found that higher levels of nurse
staffing in hospitals contribute to lower rates of adverse
outcomes in patients. A review of studies by the federal
Agency for Healthcare Research and Quality in 2004, for
example, found that higher staffing at all levels of
nursing was associated with a 2 to 25 percent reduction in
adverse outcomes such as urinary tract infections,
gastrointestinal bleeding, hospital-acquired pneumonia, and
shock or cardiac arrest. A study comparing patient
outcomes in California, Pennsylvania, and New Jersey found
that hospitals in New Jersey and Pennsylvania would
experience 14 percent and 11 percent fewer patient deaths,
respectively, if they met the 1 to5 staffing ratio in
surgical units that California hospitals must meet.
Current hospital nurse staffing requirements
In response to concerns about the increasing use of
unlicensed personnel and the decreasing use of appropriate
levels of nursing staff, AB 394 (Kuehl) was passed in 1999
to establish required nurse-to-patient staffing ratios in
general acute care hospitals, acute psychiatric hospitals,
and special hospitals, making California the first in the
nation to do so.
Pursuant to DPH regulations, a minimum ratio of one nurse
for every two units is required in critical care units,
such as intensive care units and burn centers, and labor
and delivery units. A minimum of one nurse for every four
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patients is required in postpartum care units, pediatric
care units, and basic and comprehensive emergency
departments. A minimum of one nurse for every five
patients in required in medical/surgical units, and a 1 to
6 ratio is required in psychiatric units. The regulations
provide that these minimum ratios must be met at all times.
DPH regulations also provide that nurse administrators,
supervisors, managers, and charge nurses can only be
counted towards the ratios when they are actually providing
direct care to patients. The regulations additionally
provide that licensed vocational nurses may constitute up
to 50 percent of the licensed nurses assigned to patient
care on any unit, with exceptions. Hospitals are required
to keep records of the actual assignments of registered
nurses, licensed vocational nurses, and licensed
psychiatric technicians to individual patients on a
day-to-day, shift-by-shift basis. Hospitals must also plan
for routine fluctuations in patient census. If a health
care emergency causes a change in the number of patients on
a unit, the hospital must demonstrate that prompt efforts
were made to maintain the required staffing levels. DPH
also has a process to consider requests from hospitals for
program flexibility to use alternative concepts and methods
of providing services. DPH also permits hospitals to shift
nurses in some cases, allow one nurse to temporarily cover
for another, or take actions to modify their patient census
in order to stay in compliance with the requirements.
DPH enforcement of nurse-to-patient staffing requirements
At an October 20 2010 hearing of the Senate Health
Committee on DPHs implementation of recent patient safety
legislation, DPH testified that it does not inspect for
compliance with nurse-to-patient staffing ratios in the
course of regular and periodic inspections of hospitals.
DPH stated that if it identifies quality of care problems
during routine inspections, survey staff may look at
nurse-to-patient staffing ratios to determine if the
hospitals' compliance with the ratios is a factor. DPH
also stated that it conducts large numbers of complaint
investigations alleging violations of nurse-to-patient
staffing ratios, and that it assigns these complaints a
higher priority for investigation because of the potential
for patients to be receiving inadequate care.
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According to DPH, it has issued 465 deficiencies since
January 2004 related to nurse-to-patient staffing ratios,
and has issued two hospitals penalties of $25,000 each for
staffing violations that it determined constituted
immediate jeopardy to patients, i.e. caused, or could have
cause injury or death to patients. DPH stated that it
conducts follow-up surveys of these deficiencies, on a case
by case basis, depending on the hospital's compliance
history and the extent of the impact on patient care of the
deficiencies, but does not routinely conduct follow-up
surveys to determine if hospitals are complying.
In response to concerns that it was not routinely
inspecting hospitals for compliance with patient safety
requirements, DPH in 2010 developed a Patient Safety
Licensing Survey, which it uses to assess hospitals'
compliance with the requirements of 11 patient safety
statutes enacted since 2006 during regular and periodic
inspections. Among the requirements that DPH surveys for
compliance on a regular basis are those pertaining to
hospital infection control procedures and practices and
discharge planning procedures. Compliance with hospital
nurse-to-patient staffing requirements is not part of the
patient safety survey.
Administrative penalties
SB 1312 (Alquist) of the 2005-06 Session and SB 541
(Alquist) of the 2007-08 Session give DPH authority to
issue administrative penalties to hospitals for licensing
violations that cause immediate jeopardy to patients, as
well as those that do not cause immediate jeopardy. DPH
must first establish regulations to implement the penalties
for non-immediate jeopardy violations, based on several
criteria, including the probability and severity of the
risk that the violation presents to the patient; the
nature, scope, and severity of the violation; the
facility's history of compliance with related state and
federal statutes and regulations; factors beyond the
facility's control that restrict the facility's ability to
comply with the particular licensing requirement; the
demonstrated willfulness of the violation; and the extent
to which the facility detected the violation and took steps
to immediately correct the violation and prevent the
violation from recurring.
DPH is currently developing regulations to implement
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administrative penalties for licensing violations that do
not constitute immediate jeopardy to patients. DPH has
indicated that it intends to submit draft regulations to
the Office of Administrative Law in late 2011, and after
public comment period, to promulgate regulations in late
2012.
Prior legislation
SB 541 (Alquist), Chapter 605, Statutes of 2008, increases
the level of administrative penalties DPH may assess
against hospitals, including for deficiencies that
constitute immediate jeopardy to the health or safety of
patients. Requires health care facilities to prevent
unlawful or unauthorized access to, use, or disclosure of,
patients' medical
information, and to establish safeguards to protect the
privacy of patients' medical information.
SB 1312 (Alquist), Chapter 895, Statutes of 2006,
authorizes DHS to assess administrative penalties on
hospitals for deficiencies constituting immediate jeopardy
to the health and safety of a patient and those that do not
constitute immediate jeopardy to patients.
SB 360 (Yee) of the 2009-10 Session would have required
each new direct care registered nursing hire to receive and
complete an orientation to the hospital and
patient care unit in which he or she will be working.
Nurses who have not completed this orientation would not be
allowed to be assigned to direct patient care or be counted
as staff in computing nurse-to-patient ratios. Held under
submission in Senate Appropriations Committee.
SB 1721 (Yee) of the 2007-2008 Session contained provisions
that were similar to the provisions of SB 360. Held in
Assembly Appropriations Committee.
SB 1760 (Kuehl), Chapter 148, Statutes of 2000, provided a
one-year extension for the adoption of regulations
establishing specified nurse-to-patient staff ratios in
health facilities.
AB 394 (Kuehl), Chapter 945, Statutes of 1999, requires DPH
to adopt regulations specifying nurse-to-patient ratios, by
unit, for general acute care hospitals, acute psychiatric
STAFF ANALYSIS OF SENATE BILL 554 (Yee) Page
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hospitals and special hospitals. Requires hospitals to
adopt written
policies and procedures for nursing staff training.
Provides that the ratios shall constitute the minimum
number of registered and licensed nurses that must be
provided; requires hospitals to assign additional staff in
accordance with a documented patient classification system.
Arguments in support
The California Nurses Association (CNA), the sponsor of SB
554, and other supporters state that noncompliance with
nurse-to-patient staffing ratios in hospitals is a
prevalent and ongoing problem. CNA and other supporters
further state that noncompliance with the ratios may be
higher than what is reported because DPH doesn't inspect
for compliance with the ratios during routine inspections
of hospitals; nor does it consistently reinspect for
compliance if a hospital has been cited for violating the
ratio laws and does not have authority to assess monetary
penalties for violations. CNA and other supporters state
that arguments that compliance with the law is too
challenging for hospitals miss the point that the law
requires the ratios to be complied with at all times.
The United Nurses Associations of California/Union of
Health Care Professionals (UNAC/UHCP) states that DPH has
lacked the ability and the tools to review staffing ratios
as part of routine inspections of hospitals, which SB 554
will give it. UNAC/UHCP further states that the posting
requirements in SB 554 will provide transparency and
accountability between hospitals and their nursing staffs
concerning staffing requirements and how hospitals are
meeting them.
Arguments in opposition
The California Hospital Association (CHA) and other
hospital systems and individual hospitals state that
California's stringent nurse-to-patient staffing ratio law
requires hospitals to only staff with nurses who have
demonstrated competency and have been oriented to a
particular unit, which means they cannot easily transfer
nurses from one unit to another to stay in compliance with
the ratios. CHA and other opponents further state that the
ratios do not take into account situations that occur daily
when working with patients and employees, such as when a
STAFF ANALYSIS OF SENATE BILL 554 (Yee) Page
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nurse calls in sick at the last minute, or when an
emergency department is impacted by a major accident or
incident. Further, while hospitals often schedule coverage
for meal and rest periods, which they also face penalties
for not providing, the realities of patient care frequently
disrupt the schedule. As a result, a hospital may have to
decide between providing a much needed 10 minute rest
period and slipping out of compliance with the ratios for
those 10 minutes, or denying an employee a rest period to
stay in ratio.
CHA and other opponents also assert that the evidence is
inconclusive whether ratios improve care, but hospitals are
incurring an estimated $1 billion in costs to meet the "at
all time" staffing requirements of the regulations. SB 554
would create another opportunity to cite hospitals, thereby
increasing costs, for staffing issues that are frequently
out of their control. CHA argues that SB 554 is not
necessary because DPH currently has the ability to cite
hospitals for noncompliance with regulations, and that
additional fines will not improve compliance or improve
care.
COMMENTS
1. Bill singles out one type of licensing violation for
enhanced enforcement. Hospitals currently must comply with
a variety of licensing requirements that impact the safety
of patients, including infection control requirements,
reporting of medical errors, and meeting prescribed
staffing and building standards. Aside from licensing
violations that constitute immediate jeopardy to patients,
failure to file reports of adverse events, or whistleblower
protection violations, most violations do not carry
specific administrative penalties such as those proposed in
SB 554. In addition, in most cases DPH can take into
consideration the seriousness of the violation in
determining whether to conduct a follow-up inspection
following a licensing violation, in contrast to the
mandatory follow-up inspection required by SB 554.
DPH is developing regulations to establish criteria for
administrative penalties for licensing violations that do
not constitute immediate jeopardy to patients. These
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penalties will apply to violations of hospital nurse
staffing requirements. In deciding whether to assess
penalties, and the amount of the penalty, DPH is directed
to consider a number of factors, including the seriousness
of the violation, risk of harm to patients, the hospital's
licensing track record, the willfulness of the violation,
and whether the violation occurred due to factors beyond
the hospital's control, was willful, or was known to the
hospital but the hospital did not take steps to correct and
prevent the violation from recurring, in deciding whether
to levy a penalty, and the amount of the penalty. DPH
expects to promulgate these regulations by the end of 2012.
A suggested amendment would be require DPH to take into
consideration similar factors in considering whether to
impose an administrative penalty or conduct a follow-up
inspection of a nurse staffing violation, as well as the
level of the penalty. The purpose of this would be to
focus penalties and follow-up enforcement actions on
violations that are more systemic, recurring, and serious
in nature. The penalties could be varied based on the
frequency of violations. An additional suggested amendment
would be to phase out the penalties upon the adoption by
DPH of its general regulations containing criteria for
levying of administrative penalties for licensing
violations that do not constitute immediate jeopardy to
patients.
POSITIONS
Support: California Nurses Association (sponsor)
California Labor Federation
Consumer Attorneys of California
National Lawyers Guild Labor & Employment
Committee
Professionals
SEIU Nurse Alliance of California
United Nurses Association of California/Union of
Health Care
Oppose: Alhambra Hospital Medical Center
Alliance of Catholic Health Care
Alvarado Parkway Institute
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Antelope Valley Hospital
Arroyo Grande Community Hospital
Association of California Healthcare Districts
Bakersfield Heart Hospital
Bakersfield Memorial Hospital
Banner Lassen Medical Center
Barlow Respiratory Hospital
Beverly Hospital
BHC Alhambra Hospital
Biggs-Gridley Memorial Hospital
California Association of Public Hospitals and
Health Systems
California Children's Hospital Association
California Hospital Association
California Hospital Medical Center
California Pacific Medical Center
Casa Colina Hospital for Rehabilitation
Catholic Healthcare West
Cedars-Sinai Health System
Centinela Hospital Medical Center
Children's Hospital Central California
Chinese Hospital
Citrus Valley Health Partners
Coalinga Regional Medical Center
Coastal Communities Hospital
Colusa Regional Medical Center
Community Hospital of San Bernardino
Community Medical Centers
Community Memorial Health System
Contra Costa Health Services
Cottage Health System
Dameron Hospital
Delano Regional Medical Center
Desert Regional Medical Center
Desert Valley Hospital
Doctors Hospital of Manteca
Doctors Medical Center of Modesto
Doctors Medical Center - San Pablo
Dominican Hospital
Eisenhower Medical Center
Emanuel Medical Center
Enloe Medical Center
Fairchild Medical Center
Fountain Valley Regional Hospital & Medical
Center
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Fremont-Rideout Health Group
French Hospital Medical Center
Garden Grove Hospital & Medical Center
Garfield Medical Center
Gateways Hospital and Mental Health Center
Glendale Adventist Medical Center
Glendale Memorial Hospital and Health Center
Hemet Valley Medical Center
Henry Mayo Newhall Memorial Hospital
Hollywood Presbyterian Medical Center
Huntington Beach Hospital
JFK Memorial Hospital
John C. Fremont Healthcare District
John Muir Health
Kern Valley Healthcare District
Kindred
La Palma Intercommunity Hospital
Lakewood Regional Medical Center
Lodi Memorial Hospital
Lompoc Valley Medical Center
Long Beach Memorial Medical Center
Los Alamitos Medical Center
Los Robles Hospital Medical Center
Lucile Packard Children's Hospital
Madera Community Hospital
Marian Medical Center
Mark Twain St. Joseph's Hospital
Marshall Medical Center
Mayers Memorial Hospital District
Mee Memorial Hospital
MemorialCare Health System
Mercy General Hospital
Mercy Hospital of Bakersfield
Mercy Hospital of Folsom
Mercy Medical Center - Merced, CA
Mercy Medical Center Mt. Shasta
Mercy Medical Center Redding
Mercy San Juan Medical Center
Methodist Hospital of Southern California
Miller Children's Hospital
Mission Hospital
Mission Hospital Laguna Beach
Modoc Medical Center
Montclair Hospital Medical Center
Monterey Park Hospital, AHMC
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Mountains Community Hospital
NorthBay Healthcare
Northridge Hospital Medical Center
Novato Community Hospital
Oak Valley Hospital
Olympia Medical Center
Orange Coast Memorial Medical Center
Pacific Hospital of Long Beach
Palm Drive Hospital
Palomar Pomerado Health
Pioneers Memorial Healthcare District
Placentia-Linda Hospital
Pomona Valley Hospital Medical Center
Prime Healthcare Services
Providence Health & Services California
Queen of the Valley Medical Center
Redlands Community Hospital
Riverside Community Hospital
Saddleback Memorial Medical Center
Saint Agnes Medical Center
Saint Francis Memorial Hospital
San Antonio Community Hospital
San Dimas Community Hospital
San Gorgonio Memorial Hospital
San Joaquin Community Hospital
San Ramon Regional Medical Center
Scripps Health
Scripps Memorial Hospital La Jolla
Sequoia Hospital
Sharp Chula Vista Medical Center
Sharp HealthCare
Shasta Regional Medical Center
Sherman Oaks Hospital
Sierra Nevada Memorial Hospital
Sierra Vista Regional Medical Center
Simi Valley Hospital
Sonora Regional Medical Center
Southwest Healthcare System
St. Bernardine Medical Center
St. Elizabeth Community Hospital
St. John's Pleasant Valley Hospital
St. Joseph Health System - Humboldt County
St. Joseph Health System - Sonoma County
St. Joseph Hospital
St. Joseph's Behavioral Health Center
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St. Joseph's Medical Center
St. Jude Hospital
St. Mary Medical Center
St. Mary's Medical Center, CHW
St. Vincent Medical Center
Surprise Valley Health Care District
Sutter Auburn Faith Hospital
Sutter Delta Medical Center
Sutter Lakeside Hospitals
Sutter Medical Center of Santa Rosa
Sutter Solano Medical Center
Sutter Tracy Community Hospital
Tri-City Medical Center
Trinity Hospital
Twin Cities Community Hospital
Ukiah Valley Medical Center
Victor Valley Community Hospital
West Anaheim Medical Center
West Hills Hospital & Medical Center
White Memorial Medical Center
Woodland Healthcare
Eight individuals
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