News & Events

Bill to Protect Patients by Establishing RN-to-Patient Ratios in Hospitals Is Approved by Health Care Committee, Clearing Major Hurdle on Path to Passage

Reports of Rise in Hospital Injuries and Recent Research Studies Give Boost to Bill

BOSTON — Responding to mounting evidence that inadequate RN staffing in hospitals threatens patient safety, the state’s Joint Committee on Health Care today favorably reported out legislation to better protect patients by regulating RN-to-patient ratios in Massachusetts hospitals.

The legislation has won broad public support and the endorsement of 64 of the state’s most influential health care and consumer advocacy groups, including the American Cancer Society, American Heart Association, American Lung Association, Health Care for All, League of Women Voters, Massachusetts Senior Action Council, and the Massachusetts Nurses Association. Similar bills have been brought before the legislature in past sessions, but never made it out of the Health Care Committee. It has gained ground in the legislature following the release of numerous scientific studies and prestigious reports that clearly demonstrate the link between poor staffing and harm to patients—including a shocking report from the Massachusetts Department of Public Health that said errors in Massachusetts hospitals had increased by one-third in the last three years and were up 76 percent from 1996.

Calling this "a great day for Massachusetts patients," Rep. Peter J. Koutoujian (D-Waltham), House Chair of the Health Care Committee said, "This legislation will not only protect patients and save lives, it will also save money—as dollars will no longer need to be added to the cost of healthcare each year because of deaths, complications, and medical errors caused by nurses having too many patients to care for at once." Rep. Koutoujian cited a report by Joint Commission on Accreditation of Healthcare Organizations that found "positive impacts on quality, costs and health outcomes when nurse staffing levels are optimized—fewer complications, fewer adverse events, shorter lengths of stay, lower mortality."

The bill’s sponsor, Rep. Christine Canavan, (D-Brockton), Vice Chair of the Committee and herself a registered nurse, said the legislation had been, "Carefully crafted to provide the maximum degree of flexibility in patient care. We took into account the criticism of previous bills and struck a balance between the needs of patients and the realities of today’s health care system."

The bill, H.1282 An Act Ensuring Quality Patient Care and Safe RN Staffing, would protect Massachusetts patients by ensuring that they receive nursing care appropriate to the severity of their medical conditions. To ensure maximum flexibility, the bill also requires that the Department of Public Health develop an objective system for monitoring patient medical conditions so that staffing levels can be adjusted and improved to meet patient needs. The bill would set minimum staffing standards specific to every unit and department in a hospital to ensure that major disparities in care levels do not exist in the commonwealth’s hospitals, and specifically provides that nothing in the bill "shall be deemed to preclude any facility from increasing the number of direct-care registered nurses."

Currently there are no standards in existence for nurse staffing in Massachusetts hospitals, and no requirements for hospitals to provide an adequate level of nursing care. RN-to-patient ratios, which have been linked to a variety of patient complications and mortality in hospitals, can vary widely from facility to facility. It is not uncommon for nurses in Massachusetts to have 7, 8 or even 10 patients at a time, when a safe ratio would be no more than four patients for a nurse on a typical hospital floor.

As a result of the Health Care Committee’s favorable report, the bill now moves to the House Ways and Means Committee and could arrive on the floor for a vote sometime next year. If passed, Massachusetts would become the second state to regulate RN-to-patient ratios in the nation. A similar bill was passed in California and will go into effect on January 1, 2004.

"The Quality Patient Care/Safe Staffing bill will have a profound impact on the safety and quality of care provided to patients," said Isaac BenEzra, president of the Massachusetts Senior Action Council and a member of the Coalition to Protect Massachusetts Patients—an alliance of organizations that is promoting passage of the bill. "This initiative will enhance the efforts of our organization by ensuring that seniors who are admitted to the hospital have access to the safest, most high-quality nursing care available. As an on-going commitment to our mission, the Massachusetts Senior Action Council proudly supports this important patient-safety initiative."

"This is a major hurdle in a long overdue fight to protect patients from what have become unsafe and even life-threatening staffing conditions in Massachusetts hospitals," said Karen Higgins, RN and president of the Massachusetts Nurses Association, the organization that filed the bill. "We applaud the Health Care Committee for its understanding of this issue and its commitment to guarantee every patient in every Massachusetts hospital the right to quality nursing care."

"We are delighted to see this important patient-safety initiative move forward," said Carlos Alverez, executive director of the American Lung Association of Massachusetts. "Our organization works tirelessly to educate and inform citizens about a variety of lung-related diseases and their causes, and we work even harder at finding disease-prevention techniques and treatments. But if patients are not getting the appropriate nursing care when they’re in the hospital, then our work is truly diminished."

As the Legislature was preparing to recess for the holidays, pressure to move the bill intensified from nurses and the general public. The bill was given a boost in recent weeks by the release of some influential reports underscoring its need.

The Massachusetts Department of Public Health reported two weeks ago that medical errors and patient complaints for the commonwealth’s hospitals jumped 32 percent in the last three years; 76 percent over the last seven. At nearly the same time, the prestigious Institute of Medicine of the National Academies joined the chorus of medical researchers who have found that "there is a clear relationship between staffing levels and patient safety."

A survey in October by Opinion Dynamics (ODC) found that 60 percent of Massachusetts voters attributed deterioration in the quality of hospital care to nurses having to care for too many patients and 76 percent of registered voters support legislation to regulate RN-to-patient ratios. A separate June ODC survey of Massachusetts RNs found that 87 percent of nurses report having too many patients to care for, and that the results are devastating to patients: nearly one in three nurses (29 percent) report patient deaths directly attributable to having too many patients to care for, and two-thirds report instances of patient complications or substandard care because of understaffing.

These studies followed earlier reports in some of the nation’s most prestigious medical and nursing journals, including the New England Journal of Medicine, The Journal of the American Medical Association, the Joint Commission on Accreditation of Healthcare Organizations, and other prestigious researcher journals revealing that the more patients a registered nurse cares for, the higher the risk of injury, illness and mortality to those patients.

"The scientific evidence is clear and overwhelming: when nurses have too many patients, patients’ lives are in jeopardy. The evidence also makes clear that poor staffing conditions in Massachusetts hospitals have caused and continue to exacerbate a growing shortage of nurses who are willing to work in hospitals," said Higgins, RN. "Passage of this legislation is the key to improving care to our patients and to creating conditions that will retain and recruit the nurses we need to provide safe patient care."

Fact Sheet on H. 1282

What the Bill Does
Currently, there are no legal or regulatory mandates—or even voluntary industry guidelines—to ensure that patients receive a level of nursing care that is based on accepted standards of nursing practice or on their actual need for care. Nor is there any requirement for hospitals to disclose their staffing levels to the public. Instead, nurse staffing is left to individual facilities to determine and, too often, those staffing decisions are primarily driven by financial and budgetary factors. As the health care system has moved to a deregulated, free market system, where competition and cost drive the industry, the pressures to cut nurse staffing and the resources allocated to nursing have escalated. This has resulted in dramatic cuts in nurse staffing levels and an increase in the number of patients each nurse is expected to care for.

This legislation attempts to reverse these trends by mandating nurse staffing that is sufficient to care for the planned and unplanned needs of patients. It is based upon significant nursing research and experience. The major provisions of the legislation include:

  • To provide flexibility in staffing and to account for patients who require more care, the bill calls upon DPH to create an acuity-based patient classification system, which is a standardized formula for rating the illness level of patients (a tool to measure how sick the patients are on a particular unit). 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), meant that patients who need more care wouldn’t receive it.
  • Minimum ratios are established 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 patient’s 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.
  • All acute care hospitals would be required to adhere to these ratios and the DPH acuity scale as a condition of state licensure.
  • Strong consumer protections for safe RN staffing would be put in place, including a "prominent posting of the daily RN-to-patient ratios" on each unit.
  • 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.
  • The bill 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.
  • Clear language related to the role of the licensed nurse and the inability for 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.