State Senate Passes Amendment to Protect Patients by Establishing RN-to-Patient Ratios in Hospitals
Measure Calls for Ratios to be Phased into All Hospitals Over Three Years

[Actual amendment text]

CANTON, Mass.—In a major victory for the safety of hospital patients in the Commonwealth, the state Senate passed an amendment to the state budget last night that would require acute care hospitals to establish and maintain safe, flexible, minimum RN-to-patient ratios.

The Senate measure, championed by Senator Marc Pacheco (D-Taunton), provides for a pilot program that would phase in ratios in all Massachusetts hospitals over a three-year period; with 10 hospitals required to adopt the ratios in the first year, 15 more in the 2006, and the remainder in 2007. The measure would make Massachusetts the second state in the nation to adopt such legislation; a similar law has been implemented successfully in California.

"This legislation, which has won broad support and endorsement by more than 65 leading health care groups, marks an important step in the improvement of health care for all patients in Massachusetts hospitals," Sen. Pacheco said. The Taunton Democrat is chair of the Senate Post Audit and Oversight Committee, and former chair of the Joint Health Care Committee.

"We applaud Sen. Pacheco for his leadership and commitment to protect the patients of the Commonwealth, and we applaud the Senate for their recognition that the time has come to provide patients of the Commonwealth with a guarantee of quality nursing care through the implementation of RN-to-patient ratios, which is supported by eight out of 10 voters in the Commonwealth and nine out of 10 frontline nurses," said Karen Higgins, RN, president of the Massachusetts Nurses Association, a member of the Coalition to Protect Massachusetts Patients, and the organization that filed the original safe RN staffing legislation. "While we believe all hospitals and patients would benefit by introducing the ratios in all hospitals at once, this is a reasonable compromise that allows the process of protecting patients and improving care to begin, and ultimately, for all patients to be protected over time."

The MNA also praised Sen. Harriette Chandler (D-Worcester), former House chair of the Joint Committee on Health Care, for taking a strong leadership role in working with Sen. Pacheco to craft the compromise amendment and for promoting its passage among the membership in the Senate.

The legislation:

• Grants the Department of Public Health the authority to select hospitals to participate in the pilot program each year. In the first year, two hospitals will be selected from each of the state¹s health care regions, totaling 10 hospitals to include a sampling of teaching, community, and rural hospitals.
• Establishes a 17-member ³Patient Care and Nursing Staff Commission² to evaluate the Pilot Program and monitor its progress.
• Calls for an independent third party to verify the implementation cost of minimum RN-to-patient ratios in hospitals participating in the program.
• Allows a facility to apply to DPH for a waiver delaying participation in the program for one year if the cost of implementing the ratios is greater than 2% of net patient service revenue.
• Establishes minimum ratios for different types of units/departments in a hospital. The proposed law calls for one nurse for every four patients in medical/surgical units, where most patient care takes place. In emergency departments, the proposed regulations require between a 1-to-1 and a 1-to-3 ratio depending on the severity of the patient¹s conditions. Ratios are 1-to-1 in labor and 1-to-2 for intensive care units while other units range from 1-to-1 to 1-to-5 ratio.
• Provides flexibility in staffing and accounts for patients who require more care. The measure calls upon the commission to create an acuity-based patient classification system, which is a standardized formula for rating the illness level of patients. Based on the acuity of the patients assigned to a nurse, the ratio would be improved if those patients require more intensive care, meaning the nurse would be assigned fewer patients. This provision meets one of the key objections of the hospital industry, which has argued that by establishing minimum ratios without this acuity system, patients who need more care wouldn't receive it.
• Does not allow understaffing of other critical health care workers, including licensed practical nurses and unlicensed assistive personnel in meeting the RN-to-patient ratios.
• Establishes strong consumer protections for safe RN staffing, including a "prominent posting of the daily RN-to-patient ratios" on each unit.
• Requires each facility will provide each patient and/or family member with a toll-free hotline number for the Division of Health Care Quality at DPH, which may be used to report inadequate nurse staffing. Such a complaint shall cause investigation by DPH to determine whether any violation of law or regulation by the facility has occurred and, if so, to levy a fine for substantiated violations.
• Prohibits the practice of assigning nurses mandatory overtime as a means of meeting the ratios. Mandatory overtime has been used by hospitals as a means of staffing hospitals in lieu of recruiting enough nurses to provide safe care.
• Does not allow institutions to delegate to unlicensed personnel, duties which demand nursing expertise. Throughout the 1990s, the hospital industry attempted to cut costs by replacing nurses with unlicensed personnel, which led to deterioration in patient care and helped create the current shortage of nurses.

The results of an independent cost analysis of the impact of implementing staffing ratios in Massachusetts, provided to the Senate, showed the total cost of implementing these ratios in all hospitals to be just 1.8 percent of hospitals' net patient revenues. The study was commissioned by the MNA and is the only economic analysis to date based on actual Massachusetts staffing patterns.

The successful passage of the Safe Staffing amendment comes just 10 days after more than 1,000 nurses, patients and patient advocates rallied at the State House calling for passage of RN-to-patient ratio legislation. It was also given a boost by the release of a National Consumer League survey of hospital patients, which found that nearly half of recently hospitalized patients in hospitals reported their care was compromised by inadequate staffing. This study followed numerous studies published in the nation's most prestigious medial journals showing that RN staffing has direct impact on the safety of patient care and a DPH report of a 76 percent increase in injuries, medication errors and complaints by patients in Massachusetts hospitals due to poor nursing care over the last seven years.

"We have addressed every objection and concern about this bill with independent, factual information that supports our position," said Julie Pinkham, RN, MNA executive director. "If you look at this issue objectively, and in light of this compromise approach, there is no logical reason not to support the improvements this bill provides the citizens of the Commonwealth. Everybody wins here; hospitals, nurses, and most important of all, the patients."

The Safe Staffing measure is attached to the Senate¹s version of the state budget, but it is not included in the House version. To pass, the measure must be agreed upon by budget leaders from the House and Senate in a closed-door conference. The entire consensus budget is then voted up or down by the House of Representatives and the Senate.