BILL ANALYSIS �
-----------------------------------------------------------------
|SENATE RULES COMMITTEE | SB 455|
|Office of Senate Floor Analyses | |
|1020 N Street, Suite 524 | |
|(916) 651-1520 Fax: (916) | |
|327-4478 | |
-----------------------------------------------------------------
UNFINISHED BUSINESS
Bill No: SB 455
Author: Hernandez (D)
Amended: 8/6/14
Vote: 21
SENATE HEALTH COMMITTEE : 7-1, 4/10/13
AYES: Hernandez, Anderson, Beall, De Le�n, DeSaulnier, Monning,
Pavley
NOES: Nielsen
NO VOTE RECORDED: Wolk
SENATE APPROPRIATIONS COMMITTEE : 5-2, 4/29/13
AYES: De Le�n, Hill, Lara, Padilla, Steinberg
NOES: Walters, Gaines
SENATE FLOOR : 23-10, 5/13/13
AYES: Anderson, Beall, Block, Corbett, De Le�n, DeSaulnier,
Evans, Galgiani, Hancock, Hernandez, Hill, Hueso, Jackson,
Leno, Lieu, Liu, Monning, Padilla, Pavley, Roth, Steinberg,
Wolk, Yee
NOES: Berryhill, Cannella, Correa, Emmerson, Fuller, Huff,
Knight, Nielsen, Wright, Wyland
NO VOTE RECORDED: Calderon, Gaines, Lara, Price, Walters,
Vacancy, Vacancy
SENATE HEALTH COMMITTEE : 5-3, 8/20/14 (Pursuant to Senate Rule
29.10)
AYES: Hernandez, Beall, De Le�n, DeSaulnier, Monning
NOES: Morrell, Evans, Nielsen
NO VOTE RECORDED: Wolk
ASSEMBLY FLOOR : 49-22, 8/19/14 - See last page for vote
CONTINUED
SB 455
Page
2
SUBJECT : General acute care hospitals: nurse-to-patient
ratios
SOURCE : AFSCME, AFL-CIO
United Nurses Associations of California/Union of
Health Care Professionals
DIGEST : This bill 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 (RNs) who provide direct patient care. This
bill requires the RNs appointed to this committee to be selected
by the collective bargaining agent, if any. This bill requires
the Department of Public Health (DPH), during every periodic
state inspection of a hospital, to inspect for compliance with
nurse-to-patient ratios, as specified.
Assembly Amendments specify requirements for patient
classification review committees, require periodic inspection of
acute care hospitals for compliance with minimum
nurse-to-patient ratios, add legislative intent, and make other
changes.
ANALYSIS :
Existing law:
1.Licenses and regulates health facilities by 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
CONTINUED
SB 455
Page
3
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
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 RNs 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 RNs
who provide direct patient care, and requires these RNs to be
appointed by the bargaining agent of the RNs, if any, and in
the absence of a bargaining agent, to be appointed by the
CONTINUED
SB 455
Page
4
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
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.
Comments
According to the author's office, this bill codifies an existing
regulation that requires a committee composed of at least 50%
RNs 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.
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
CONTINUED
SB 455
Page
5
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 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 RNs who provide direct patient
care.
Prior Legislation
SB 1246 (Hernandez, 2012) contained very similar provisions to
this bill, among several other provisions. In addition to the
provisions that are similar to this bill, the bill 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. The bill 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.
CONTINUED
SB 455
Page
6
FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: Yes
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.
SUPPORT : (Verified 8/20/14)
AFSCME, AFL-CIO (co-source)
United Nurses Associations of California/Union of Health Care
Professionals (co-source)
American Nurses Association\California
SEIU California
OPPOSITION : (Verified 8/20/14)
Association of California Healthcare Districts
California Hospital Association
California Nurses Association
Department of Finance
Hospital Corporation of America
ARGUMENTS IN SUPPORT : This bill is co-sponsored by the United
Nurses Associations of California/Union of Health Care
Professionals (UNAC/UHCP), and 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
Classification System into statute; and (3) requiring that the
collective bargaining agent, if any, has the opportunity to
appoint the RNs 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.
ARGUMENTS IN OPPOSITION : The California Hospital Association
(CHA) is opposed to this bill unless amended to remove the
CONTINUED
SB 455
Page
7
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. 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 RN staffing by not taking into
account, for staffing purposes, (1) 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.
ASSEMBLY FLOOR : 49-22, 8/19/14
AYES: Alejo, Bocanegra, Bonilla, Bonta, Bradford, Brown,
Buchanan, Ian Calderon, Campos, Chau, Chesbro, Cooley,
Dababneh, Daly, Eggman, Fong, Fox, Frazier, Garcia, Gatto,
Gonzalez, Gordon, Gray, Hall, Roger Hern�ndez, Holden,
Jones-Sawyer, Levine, Linder, Lowenthal, Maienschein, Medina,
Mullin, Muratsuchi, Nazarian, Pan, Perea, John A. P�rez, V.
Manuel P�rez, Quirk-Silva, Rendon, Ridley-Thomas, Rodriguez,
Salas, Stone, Ting, Weber, Williams, Atkins
NOES: Achadjian, Allen, Bigelow, Ch�vez, Conway, Dahle,
CONTINUED
SB 455
Page
8
Donnelly, Beth Gaines, Gorell, Grove, Hagman, Harkey, Jones,
Logue, Mansoor, Melendez, Nestande, Olsen, Patterson, Wagner,
Waldron, Wilk
NO VOTE RECORDED: Ammiano, Bloom, Dickinson, Gomez, Quirk,
Skinner, Wieckowski, Yamada, Vacancy
JL/RM:k 8/20/14 Senate Floor Analyses
SUPPORT/OPPOSITION: SEE ABOVE
**** END ****
CONTINUED