BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 455
AUTHOR: Hernandez
AMENDED: August 6, 2014
HEARING DATE: August 20, 2014
CONSULTANT: Marchand
PURSUANT TO SENATE RULE 29.10.
SUBJECT : General acute care hospitals: nurse to patient ratios.
SUMMARY : Codifies existing regulations requiring hospitals to
have a committee annually review the reliability of its patient
classification system, including regulations requiring at least
one-half of this committee be composed of registered nurses who
provide direct patient care. Requires the registered nurses
appointed to this committee to be selected by the collective
bargaining agent, if any. Requires the Department of Public
Health, during every periodic state inspection of a hospital, to
inspect for compliance with nurse-to-patient ratios, as
specified.
Existing law:
1.Licenses and regulates health facilities by the Department of
Public Health (DPH).
2.Requires DPH to inspect for compliance with state laws and
regulations during a state periodic inspection or at the same
time as a federal periodic inspection. Requires, for general
acute care hospitals, acute psychiatric hospitals, and special
hospitals, the inspection to be conducted no less than once
every three years.
3.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.
4.Requires the ratios adopted by regulation to 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, including: the
Continued---
SB 455 | Page 2
severity of the illness; need for specialized equipment and
technology; complexity of clinical judgment needed to design,
implement, and evaluate the patient care plan and the ability
for self-care, and licensure of the personnel required for
care.
Existing regulations:
1.Define "patient classification system," in part, as a method
for establishing staffing requirements by unit, patient, and
shift.
2.Require a hospital's administrator of nursing service to
develop a written staffing plan based on patient care needs
determined by the patient classification system.
3.Require the reliability of the patient classification system
for validating staffing requirements to be reviewed at least
annually by a committee appointed by the nursing administrator
to determine whether or not the system accurately measure
patient care needs, and requires at least half of the members
of the review committee to be registered nurses who provide
direct patient care.
This bill:
1.Requires a committee for each general acute care hospital, at
least annually, to review the reliability of the patient
classification system, as specified, for validating staffing
requirements to determine whether or not the system accurately
measures patient care needs.
2.Requires at least one-half of the membership of the patient
classification system review committee to be composed of
registered nurses who provide direct patient care, and
requires these registered nurses to be appointed by the
bargaining agent of the registered nurses, if any, and in the
absence of a bargaining agent, to be appointed by the nursing
administrator. Requires the remaining members of the review
committee to be appointed by the nursing administrator of the
hospital.
3.Requires DPH, during every periodic state inspection of a
general acute care hospital, to inspect for compliance with
the nurse-to-patient ratios established pursuant to specified
provisions of existing law.
4.States the intent of the Legislature that the provisions of
SB 455 | Page
3
this bill specified in 1) and 2) above, relating to the
patient classification system review committee, are to
supersede similar provisions in the California Code of
Regulations, and are not intended to affect any other law.
FISCAL EFFECT : According to the Assembly Appropriations
Committee, minor costs to DPH's Licensing and Certification Fund
to modify regulations that conflict with this bill's provisions.
COMMENTS :
1.Author's statement. This bill codifies an existing regulation
that requires a committee composed of at least 50 percent
registered nurses to annually review the reliability of a
hospital's patient classification system. This bill makes one
change to this requirement by specifying that if a hospital's
nurses are represented by a collective bargaining agent, then
the collective bargaining agent can select the nurses that are
appointed to the committee. Additionally, this bill requires
that hospitals are surveyed for compliance with nurse staffing
requirements as part of the existing inspection that the
department is required to complete for each hospital every
three years.
2.Nurse to patient ratios and patient classification systems.
In 2004, regulations implementing nurse-to-patient ratios in
California hospitals pursuant to AB 394 (Kuehl), Chapter 945,
Statutes of 1999, went into effect. However, long before
California had specific nurse-to-patient ratios, hospitals
were required by regulation to establish a patient
classification system. This patient classification system is a
method by which hospitals establish staffing requirements by
unit, patient, and shift, and includes a method by which the
amount of nursing care needed for each category of patient is
validated for each unit.
The regulations implementing the AB 394 nurse-to-patient ratios
law set the minimum ratio of nurses to patient by unit,
including one-to-one in operating rooms, one-to-two in
intensive care units, and one-to-five in general
medical-surgical units. These regulations also incorporated
the patient classification system requirement. In essence, the
specific nurse-to-patient ratios establish the minimum number
of nurses by unit, while the patient classification system
determines whether there needs to be a higher level of
staffing beyond the minimum ratio after taking into
SB 455 | Page 4
consideration factors such as the severity of the illness, the
need for specialized equipment and technology, and the
complexity of clinical judgment needed to evaluate the patient
care plan, among other factors. The nurse-to-patient ratio
regulations require that the minimum ratios must be met at all
times.
Finally, the regulations require the reliability of the patient
classification system for validating staffing requirements to
be reviewed at least annually by a committee appointed by the
nursing administrator to determine whether the system
accurately measures patient care needs. At least half of the
members of this committee are required to be registered nurses
who provide direct patient care.
3.Prior legislation. SB 1246 (Hernandez) of 2012, contained very
similar provisions to this bill, among several other
provisions. In addition to the provisions that are similar to
this bill, SB 1246 also would have required periodic
inspections by DPH to include a review of compliance with
nurse staffing ratios and patient classification systems, and
eliminated a requirement that DPH promulgate regulations
further defining the criteria for assessing administrative
penalties, thereby allowing existing fine authority to go into
effect. SB 1246 was vetoed by Governor Brown.
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 hospitals
and special hospitals. Additionally, requires hospitals to
adopt written policies and procedures for nursing staff
training. Provided 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.
4.Support. This bill is co-sponsored by the United Nurses
Associations of California/Union of Health Care Professionals
(UNAC/UHCP), and the American Federation of State, County and
Municipal Employees (AFSCME) which state that this bill is
designed to improve compliance with existing law covering
nurse-to-patient staffing in hospitals. This bill does this by
implementing the following three changes: 1) adding compliance
with nurse-to-patient ratios to the periodic inspections that
hospitals are required to have every three years; 2) putting
regulations that require hospitals to have a Patient
SB 455 | Page
5
Classification System into statute; and 3) requiring that the
collective bargaining agent, if any, has the opportunity to
appoint the registered nurses to the committee that reviews
the Patient Classification System. UNAC/UHCP and AFSCME state
that nurse staffing ratios are academically proven to save
lives, yet existing laws requiring hospitals to comply with
these ratios are oftentimes ignored. By increasing enforcement
of these ratios, this bill will help ensure patients are
receiving adequate critical care.
5.Opposition. The California Hospital Association (CHA) is
opposed to this bill unless amended to remove the provision
giving a third-party labor union the right to appoint specific
members to the patient classification review committee,
arguing that this is an inappropriate infringement on the
hospital's ultimate responsibility for patient care. Under
current regulations, CHA states that the members of the
patient classification committee are appointed by the hospital
nursing administrator, and this bill would change that
process. CHA states that the hospital has ultimate
responsibility for ensuring quality patient care, and given
this responsibility, it is inappropriate to delegate a major
component of its assessment tool to a third party. For
example, CHA states that the hospital may want to have
particular units represented on the committee, while the union
may appoint individuals based on their own priorities such as
leadership development or other factors. Further, CHA states
that the hospital must maintain the prerogative to appoint
staff in good standing who are eligible and qualified to
perform the duties vested in the review committee. The
bargaining agent is not a hospital representative and cannot
determine performance eligibility requirements. With regard to
the recent amendments requiring DPH to inspect for compliance
with the nurse-to-patient ratios, CHA states that this
requirement is redundant and unnecessary as DPH already
routinely inspects all aspects of patient care delivery during
their periodic inspections.
The California Nurses Association (CNA) is also opposed to this
bill, stating that recently added language creates a fa�ade
that appears to increase enforcement of nurse-to-patient
ratios but actually does nothing to increase overall hospital
staffing compliance. CNA states that this bill, if enacted
into law, would undermine hard-won gains in registered nurse
staffing by not taking into account, for staffing purposes, 1)
SB 455 | Page 6
the severity of the illness; 2) the complexity of clinical
judgment involved in the patient's care; and, 3) the licensure
of the personnel required to provide that care.
The Department of Finance states in opposition that it is
unnecessary, as nearly identical regulations currently exist,
and that control over the appointment process to the patient
classification review committee would be more appropriately
reached through contract negotiations between the hospitals
and the unions.
SUPPORT AND OPPOSITION :
Support: United Nurses Associations of California/Union of
Health Care Professionals (sponsor)
American Federation of State, County and Municipal
Employees, AFL-CIO (cosponsor)
American Nurses Association\California
SEIU California
Oppose: Association of California Healthcare Districts
California Hospital Association
California Nurses Association
Department of Finance
Hospital Corporation of America