Do You Want Safe Staffing? Learn More About H.1186 Safe RN Staffing Legislation Frequently Asked Questions

1. What is the ratio bill?

House Bill 1186, the Quality Patient Care/Safe Staffing Bill, creates a commission of stakeholders in health care to work with the Department of Public Health in setting appropriate RN-to-patient ratios to ensure quality patient care. DPH would be responsible for establishing and regulating the RN-to-patient ratios in Massachusetts. The bill establishes a minimum level of RN staffing that every patient shall have a right to. In hospitals, different ratios will be developed for specific types of floors and units. In addition, the legislation calls for an acuity system that would allow for improvements in staffing ratios based on the needs of patients.

The Massachusetts Nurses Association has sponsored this legislation. The bill’s lead sponsors include Representative Christine Canavan and Senator Robert Creedon. The bill has also been endorsed by the Massachusetts Senior Action Council.



2. Why is HB 1186 significant, and why is the law needed?

Patients in Massachusetts’s hospitals today have to share their nurse with too many other patients.

This is dangerous to patients:

• Mistakes become more likely when nurses are asked to care for too many patients at once.

• Nurses on typical medical floors in Massachusetts are required to care for eight, ten or more patients at a time. Most health care professionals agree that nurses should not take care of more than four or five patients at once.

• Registered nurses are often required to work mandatory overtime, which forces tired nurses to work extra hours beyond their scheduled shifts–sometimes leading to nurses working for sixteen hours straight.

• In order to compensate for understaffing, nurses are often floated from one unit to another, which is often an area where they have no training or experience. This is similar to asking a math teacher to teach a French class, except that in a hospital people’s lives are at stake.

The public, and study after study agree, that nurses have the greatest impact on quality care. Study after study demonstrates a strong and consistent link between RN staffing and patient outcomes. The ratios are a direct response to the erosion of patient care standards in hospitals, and the exodus of nurses who will no longer work in unsafe hospitals.

The good news is that studies and surveys show that if staffing levels are improved, nurses will come back to the bedside. In Victoria, Australia, nurse to patient ratios were regulated. In less than six months after regulations were established, more than 2,300 nurses who had stopped practicing re-entered the profession to work under the safe conditions.




3. Do some hospitals have the staffing ratios that may be required with passage of HB 1186?

Some hospitals do have appropriate staffing ratios. Some in fact now meet the requirements of California’s recently announced ratios. Unfortunately, too many do not and this is dangerous to patients. Mistakes happen when a nurse is assigned too many patients.

For example, there are two teaching hospitals in Boston with the same patient population subject to the same reimbursement rates. A patient in an ambulance who is taken to one hospital and admitted to a medical surgical floor will share his nurse with only three other patients (a safe ratio). However, should that ambulance take the patient to the other hospital, the patient will share his nurse with eight other patients (an unsafe ratio). The patient’s needs are the same, and the cost of the patient’s care is the same, the only thing that will vary is the quality of his nursing care. Creating an appropriate minimum RN staffing level is critical to ensuring quality patient care for everyone.

Also, even if a hospital has a safe ratio today, there is no guarantee it will maintain that ratio tomorrow. Staffing now is totally in the hands of administrators, with no oversight or regulation by the Department of Public Health. Staffing should not be based on what an administrator decides is appropriate. It should be based on the standards of care and, most important of all, on the actual needs of the patient.




4. How will hospitals afford to hire additional nurses to meet the ratios?

Regulating nursing levels in hospitals will actually reduce health care costs. There will be less turnover among nurses, which will save money on training costs and the hiring of temporary nurses. Also, since patients will receive better care there will be fewer complications, which often result in extended, unnecessary and more costly hospital stays.

A number of Massachusetts hospitals already meet many of the new ratios, and will not incur added costs. But all hospitals stand to achieve cost savings that will accrue with safe ratios, including reduced expenditures on nursing registry, travel nurses, and overtime costs, reduced RN turnover, and improved patient outcomes. Here's how:

* $avings for hospitals in shorter patient lengths of stays (about one hour less per day in hospitals with more RNs).

A 2001 Harvard School of Public Health study for the U.S. Health Resources Services Administration cites a 3% to 6% shorter length of stay for patients in hospitals with a high percentage of RNs.

Other research studies also document a link between RN studies and lower costs. Johns Hopkins University researchers, for example, have found that patients with fewer RNs in intensive care units at night incurred a whopping 14% increase in hospital costs. A study in progress by James Bramble, PhD of Creighton University, presented publicly in June 2001 reports that higher levels of RN staffing are associated with significantly lower costs and shorter lengths of stay for patients at risk for pneumonia, urinary tract infections and venous thrombosis or pulmonary embolism.

* $avings on temporary RN staff.
Hospitals across the U.S. spent $7.2 billion last year for temporary employees. The projection for next year is $10.6 billion nationally. Most of that expenditure is for RNs. Hospital officials say they have to pay registry-recruited nurses about $10 more per hour than permanent employees. For travel nurses, hospitals must often provide travel costs, room and board, meal allowances, and other expenses, in addition to higher wages than are paid for permanent RNs. Travel nurse companies typically charge hospitals double or more the average pay rate for staff RNs.

* $avings in reduced RN turnover.
For every nurse that leaves, hospitals incur significant costs to recruit replacements. This includes costs for advertising, travel, bonuses, training and orientation.



5. If this bill passes, will hospitals close because of the added cost?

No. (see answer # 4 above) The statistics speak for themselves. More nurses at the bedside will ultimately result in more cost-effective care. Studies show that better nurse to patient ratios result in fewer complications, which prevent unnecessary and costly hospital stays; as well as decreases in costly re-admissions for patients who must come back to the hospital for a second time because of inadequate care during their initial visit. With proper staffing, there is significantly less turnover of nursing personnel, which results in significant savings in personnel recruitment costs, as well as in the high costs of using temporary help.

This same argument was made by the hospital industry in California back in 1976 when they first established mandatory nurse to patient ratios for intensive care units. In fact, after the law was implemented, hospitals made more money than ever before.

Federal reimbursement for hospitals is predicated on the premise that Medicaid and Medicare dollars are spent on direct patient care. Unfortunately, many hospitals have chosen to use those dollars inappropriately, such as for paying exorbitant CEO salaries, hiring consultants, or on other unnecessary items that have on impact on patient care. This bill would require hospitals to refocus their spending priorities; specifically, on the quality of patient care.

Finally, a number of hospitals already have appropriate ratios in place and are doing fine financially because they are investing their resources where it really counts – at the bedside.



6. Will ratios lead to improved patient care?

Yes. Research over three decades documents a direct correlation between safe RNs staffing and positive patient outcomes. Among the most recent:

* A U.S. Department of Health and Human Services study released in April 2001, based on five million patient discharges from 799 hospitals in 11 states, found a strong and consistent relationship between nurse staffing and patient outcomes in medical patients -- urinary tract infection, pneumonia, shock, upper gastrointestinal bleeding, and length-of-stay. In surgical patients, the study found a strong link between nurse staffing and the failure to revive a patient. A higher number of RNs was associated with a 3% to 12% reduction in the rates of adverse outcomes, while higher staffing levels for all types of nurses was associated with a decrease in adverse outcomes from 2% to 25%.

* A study reported in the November 2001 issue of the American Journal of Critical Care found that fewer RNs in the ICU at night translated to more patient complications and higher costs. Johns Hopkins University researchers collected data on 569 patients who were in various hospital ICUs after undergoing hepatic resection. Patients who shared their RN with too many other patients were at increased risk for reintubation. The study found that intensive care units having ratios of one nurse for every three patients, rather than one or two, have significantly higher rates of post-surgical complications.

* A study released in early January, 2002, found that infants treated in neonatal intensive care units in British hospitals with poor nurse-to-infant staffing and heavier nurse workloads were up to 50% more likely to die than babies in units with safer staffing.

* One extra hour of RN care per surgical patient per day cuts a patient's risk of contracting a urinary tract infection by nearly 10% and the risk of pneumonia by 8% according to the findings of December 1998 study by the Agency for Health Care Policy and Research, an arm of the U.S. Health and Human Services Department. The researchers looked at 506 hospitals in 10 states, including California, using American Hospital Association data.



7. Wouldn’t this approach introduce rigidity into the health care system at a time when more “flexibility” is needed?

No. The law would provide a minimum standard of care for every patient with the flexibility to increase nurse staffing when patients’ needs dictate that more care is necessary. The problem now is there is no standard of nursing care patients can expect. Worse still, staffing decisions and patients’ access to registered nurses are now driven by financial concerns, not by what is in the best interests of the patient.




8. Each hospital has different floors, units that serve different types of patients. It's not practical.

The legislation recognizes and accounts for these differences. First of all, the bill would establish different ratios for different floors. Nurses working in an intensive care unit would have fewer patients than nurses on a medical floor. Because of the high penetration of managed care, and the small number of insurers controlling admissions criteria for patients, there is little difference between patients in a specialty unit in one hospital and those in the same type of unit in another hospital. We would acknowledge variation between tertiary teaching hospitals, community hospitals and rural hospitals, and the ratios and regulation can address this.

California, the largest and most diverse state in the nation, with hundreds of hospitals and a rate of managed care penetration similar to Massachusetts, has recently implemented a nurse to patient ratio law. Victoria, Australia has also passed such a law. The ratios for both are very similar. This is not rocket science, it is very practical, and it has already been done.




9. Don’t we have a nursing shortage – there just are not enough nurses out there?

Massachusetts has more RNs per capita than any other state in the country. Presently, just ¼ are choosing to work at the bedside. In large part, this is because of high patient assignments and unsafe staffing. Ironically, California, which has passed an RN-to-patient ratio law, is 49th in the country in RNs per capita.

Hospitals have tried a variety of gimmicks to attract nurses such as huge signing bonuses. These are band-aid approaches. RN turnover rates, the highest in decades, demonstrate nurses will not remain in unsafe hospitals.

The fact that nurses are overworked is causing them to leave the profession, but nearly 90% of nurses say that better staffing ratios would improve recruitment and retention of nurses. They want to practice, but they want to practice safely.