BILL ANALYSIS
AB 394
Page 1
Date of Hearing: April 6, 1999
ASSEMBLY COMMITTEE ON HEALTH
Martin Gallegos, Chair
AB 394 (Kuehl) - As Introduced: February 11,1999
SUBJECT : Health facilities: nursing staff.
SUMMARY : Establishes specified staffing ratios for nurses in
specified hospitals and limits the nursing-related duties that
may be performed by unlicensed personnel. Specifically, this
bill :
1)Finds and declares that the basic principles of staffing in an
acute care setting should be based on patient care needs, the
severity of condition, services needed, and the complexity
surrounding those services, and that to ensure adequate
protection of patients in acute care settings, it is essential
that qualified registered nurses (RNs) and other licensed
nurses be accessible and available.
2)Prohibits specified types of health facilities from assigning
unlicensed personnel to perform nursing functions in lieu of a
RN and from assigning unlicensed personnel, under the direct
clinical supervision of an RN, to perform functions, as
specified, which require scientific knowledge and technical
skills.
3)Requires a general acute care hospital, acute psychiatric
hospital, and a special hospital, as defined, to allocate
specified numbers of RNs so as to provide the following
nurse-to-patient ratios:
a) One RN to two patients in critical care units, burn
units, labor and delivery, postanesthesia units, and
critical patients in emergency departments requiring care
in an intensive care or critical care setting.
b) There must be sufficient nursing personnel so that one
RN is not serving as circulating assistant for more than
one operating room.
c) One licensed nurse to three patients to staff pediatric
and step-down/intermediate care units.
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d) One licensed nurse to four patients to staff specialty
care and telemetry.
e) One licensed nurse to six patients to staff general
medical care units that include subacute care and
transitional inpatient care units.
f) Provides that the above ratios constitute the minimum
number of registered and licensed nurses; requires
additional staffing to be assigned in accordance with a
documented patient classification system for determining
nursing care requirements, as specified.
4)Requires all acute care hospitals, acute psychiatric hospitals
and special hospitals, to adopt written policies and
procedures for training and orientation of nursing staff.
5)Prohibits the assignment of a RN to a nursing unit or a
clinical area until the nurse has received orientation and has
demonstrated competence in the area. Requires that the
written policies and procedures must require that all
temporary nursing staff receive the same amount and type of
orientation as provided to permanent staff.
6)Allows for a waiver of the nurse-to-patient ratio provisions
for rural general acute care hospitals, as long as the health,
safety and well-being of patients affected are not
jeopardized, and the hospital meets specified requirements.
7)Stipulates that this bill is not intended to preclude any
person from performing any function within their scope of
practice, and should any conflict occur between the provisions
of this bill and any provision or regulation defining the
scope of nursing practice, the scope of practice provisions
shall control.
EXISTING LAW:
1)Provides for the licensure and regulation of nurses by the
Board of Registered Nursing.
2)Provides for the licensure and regulation of health care
facilities by the Department of Health Services (DHS).
3)Establishes, pursuant to regulation, specific staffing ratios
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for nurses providing services in specified intensive care
settings.
4)Requires hospitals, pursuant to regulation, to implement a
"patient classification system" for determining nursing care
needs of individual patients that reflects the assessment made
by an RN, patient requirements, and provides for a
shift-by-shift staffing based on those requirements.
5)Requires, pursuant to regulation, the "patient classification
system" developed by hospitals to include
individual patient care requirements, the patient care delivery
system, and generally accepted standards of nursing practice.
6)Requires, pursuant to regulation, that a written staffing plan
be developed by the administrator of nursing service, or a
designee, based on patient care needs determined by the
"patient classification system." Requires the staffing plan
to be developed and implemented for each patient care unit, to
specify patient care requirements and to specify the staffing
levels for RNs and other licensed and unlicensed personnel, as
specified.
FISCAL EFFECT : Unknown
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author and sponsor,
the California Nurses Association (CNA), RNs are a critical
component in guaranteeing California's patients safety and the
highest quality of health care. CNA states that over the past
several years many hospitals in response to managed care
reimbursement contracts, have cut costs by reducing their
licensed nursing staff. In some of those hospitals, the ratio
of licensed nurses to patients requires nurses to perform at
unprofessional levels of care. Numerous studies have
documented that patients in hospitals today are sicker and
require more intensive nursing care than patients of several
years ago. In addition, numerous studies have also documented
a clear and direct relationship between low skill mix (i.e.,
less licensed nursing staff to higher numbers of patients) and
increased infections, higher mortality rates, increased
illness and errors. CNA states that hospitals are enjoying
their third straight year of record profits according to the
American Hospital Association yet they are still lacking
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adequate nursing staff.
CNA reports that it has received hundreds of letters from
nurses who point to poor and unsafe care due to too few nurses
assigned to acute care facilities.
Additionally, CNA states that the existing patient
classification system is incomprehensible and that DHS has a
difficult time reviewing these systems for noncompliance.
However, last year, DHS received very few complaints regarding
Intensive Care Unit (ICU) staff issues, because the statutory
licensed nurse numerical ratios required in these units are
very easy to evaluate - either they are staffed at appropriate
levels or they are not. The sponsor points out that this bill
will establish specific nurse-to-patient ratios, such as those
already established in law for ICUs, for other medical units
in health care facilities, such as Pediatric units, Labor and
Delivery units, Burn units and Medical/Surgery units. The
ratios established in this bill are based on the team model of
RNs, Licensed Vocational Nurses (LVNs) and Certified Nursing
Assistants. Numerous studies show that staffing nurses at
optimal levels is both cost effective and dramatically
improves patient outcomes. In addition, this bill will
prohibit hospitals from assigning to unlicensed assistive
personnel (UAPs) "nursing" functions that require a
substantial amount of scientific knowledge and technical
skill. CNA additionally points out that most UAPs do not want
to perform these functions, for which they are not licensed or
qualified.
2)SUPPORT . The California School Nurses Association (CSNA)
states that the extraordinary changes in medical care have
caused changes that are not always to the benefit of the
patient. The use of UAPs while necessary for certain duties
must be done with an understanding of their limited ability
and training. This bill will assure that registered nurses
are utilized when appropriate instead of UAPs.
The Consumer Attorneys of California (CAOC) states that this
bill is crucial to ensuring continued safe care for California
patients. Nurses are the professionals that patients rely on
most for day-to-day care and treatment. Further, nurses are
on the front line of detecting and evaluating changes in
patient conditions. Unfortunately, too many hospitals are
foregoing this crucial patient service in the name of cost
savings. The result of inadequate staffing can be horrendous.
CAOC cites the case of a young boy injured in an auto
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accident who is now in a persistent vegetative state as a
result of a negligently understaffed hospital facility.
3) OPPOSITION . The California Healthcare Association (CHA)
opposes the bill because it legislates nurse staffing levels
for hospitals based on ratios. CHA believes the public policy
of the state should be to require hospitals to base nurse
staffing levels on the specific care needs of the patients as
measured each shift for every unit, not on staffing ratios.
CHA states that hospitals across California are facing a
nursing shortage and that this bill will not remedy this
problem. Instead, CHA and CNA are trying to persuade the
legislature to do more about increasing the number of nurses
graduated. CHA states that passage of this bill will put
hospitals in the position of being non-compliant because they
will not be able to hire the nurses required.
Additionally, CHA states that the ratios in this bill have no
analytical basis, that staffing ratios will lead to
inefficiency, and that this bill could cost hundreds of
millions for hospitals with no reimbursement. Absent
additional revenue, CHA states that the overall level of
patient care could suffer because hospitals may decide to
limit the number of patients they admit in order to
accommodate the ratio requirements. If hospitals are able to
find nurses to hire and lay off aides and other personnel to
pay for the additional nurses, then there will be service
gaps. Given the salary differentials, the number of nurses
hired would have to be less than the number of aides and other
unlicensed staff laid off. Services now provided by
unlicensed staff could not be fully made up by the additional
nursing staff. Moreover, CHA states that this bill will
adversely affect many lower-income, unlicensed personnel who
are put at risk of a lay off.
The California Association of Health Plans (CAHP) states that
this issue has been debated before in the Legislature, at the
ballot box and in the regulatory process. These bills and
initiatives were defeated because the Legislature and the
voters recognize that inflexible staffing ratios did not make
sense in the ever changing health care environment, and would
increase costs without improving the quality of care.
Additionally, CAHP states that regulations were adopted in
December of 1996 after years of negotiations between the
hospital association, DHS, CNA and the Organization of Nurse
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Executives (ONE). These regulations, which require the use of
patient classification systems to determine staffing needs,
are being implemented. The regulations, which also require
competency standards for all health care personnel caring for
patients, set higher standards than this bill because the
regulations require hospitals to staff their units based on
the needs of the individual patients, not in accordance with
fixed, arbitrary ratios.
4)PREVIOUS LEGISLATION . AB 695 (Kuehl) and SB 1125 (Alpert)
from last session contained substantially similar provisions.
SB 1125 reached Governor Wilson's desk and was vetoed. The
veto message indicated that existing DHS regulations regarding
nursing services in health facilities were adequate to ensure
proper patient care and the bill was therefore unnecessary.
5) PROPOSITION 216 . Proposition 216, which appeared on the
November 1996 ballot, and was sponsored by the California
Nurses Association, would have required that DHS adopt
standards to determine the numbers and classifications of
licensed or certified direct caregivers necessary to ensure
safe and adequate staffing at all heath care facilities.
Proposition 216 failed passage.
REGISTERED SUPPORT / OPPOSITION :
Support
California Nurses Association (sponsor)
California School Nurses Organization
Consumer Attorneys of California
United Nurses Association of California
Opposition
Alameda Hospital
Alexian Brothers Hospital
Alliance of Catholic Health Care Systems
Alta Bellwood Hospitals, Inc.
Anacapa Hospital
Antelope Valley Hospital
Association of California Healthcare Districts
Bakersfield Memorial Hospital, Catholic Healthcare West (CHW)
Barstow Community Hospital
Beverly Hospital
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BHC Fremont Hospital
California Association of Catholic Hospitals
California Association of Health Plans
California Healthcare Association
California Rehabilitation Association
Catholic Healthcare West
Catholic Healthcare West - Southern California
Catholic Healthcare West Bay Area Region Board of Directors
Public Policy Committee
Cedar Vista Hospital
Charter Behavioral Health System of Southern California /
Charter Oak
Charter Behavioral Health System of Southern California / Corona
Charter Behavioral Health System of Southern California / Palm
Springs
Children's Hospital and Health Center
Chino Valley Medical Center
Colorado River Medical Center
Colusa Community Hospital
Community Health System
Community Hospital of San Bernardino
Community Hospital of the Monterey Peninsula
Corona Regional Medical Center
Daniel Freeman Marina Hospital / Daniel Freeman Memorial
Hospital
Delano Regional Medical Center
Downey Community Hospital
Emanuel Medical Center
Enloe Health System
Fremont-Rideout Health Group
General Hospital
Glenn Medical Center
Good Samaritan Hospital
Greater El Monte Community Hospital
Hazel Hawkins Memorial Hospital, Convalescent Hospital and Home
Health Agency
Healdsburg General Hospital
Holy Cross Health Systems
John Muir Medical Center
Kaiser Permanente
Kentfield Rehabilitation Hospital
La Palma Intercommunity Hospital, CHW
Lodi Memorial Hospital
Lompoc Hospital District
Long Beach Community Medical Center, CHW
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Mammoth Hospital
Marian Medical Center, Santa Maria
Mark Twain St. Joseph's Hospital, CHW
Martin Luther Hospital Anaheim, CHW
Mee Memorial Hospital
Memorial Hospital at Exeter
Memorial Hospital Los Banos
Mercy
Mercy Healthcare Sacramento, CHW
Mercy Hospital & Health Services, CHW
Mercy Medical Center Mt. Shasta
Mercy Medical Center Redding
Mercy Southwest
Mercy Westside Hospitals
Methodist Hospital
Methodist Hospital of Sacramento
Mission Hospital Regional Medical Center
Natividad Medical Center
North Bay Healthcare System
North Coast Health Care Centers
Novato Community Hospital
O'Connor Hospital, CHW
Ojai Valley Community Hospital
Pacifica Hospital of the Valley
Palo Verde Hospital
Pioneers Memorial Healthcare District
Providence Holy Cross Medical Center
Queen of the Valley Hospital
Redlands Community Hospital
Robert H. Ballard Rehabilitation Hospital
Ross Hospital
Saint Agnes Medical Center
Saint Francis Medical Center Santa Barbara, CHW
San Benito Health Care District
San Joaquin Valley Rehabilitation Hospital
San Jose Medical Center
Santa Paula Memorial Hospital
Sharp Chula Vista Medical Center
Sierra Vista Regional Medical Center
Sisters of Mercy of the Americas / Hermanas de la Misericordia
de las Americas
Sonoma Valley Hospital
St Joseph's Medical Center, CHW
St. Bernardine Medical Center, CHW
St. Dominic's Hospital
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St. Elizabeth Community Hospital, CHW
St. Elizabeth Community Hospital, CHW
St. John's Pleasant Valley Hospital, Camarillo
St. John's Regional Medical Center, Oxnard
St. Joseph Health System
St. Joseph's Behavioral Health Center
St. Joseph's Health System - Humboldt County
St. Joseph's Regional Health System
St. Jude Medical Center
St. Luke Medical Center
St. Luke's Hospital
Sutter Auburn Faith Hospital
Sutter Delta Medical Center
Sutter Lakeside Hospital
Sutter Solano Medical Center
Sutter Tracy Community Hospital
Sutterville Roseville Medical Center
Tehachapi Valley Healthcare District
The Fremont-Rideout Health Group
Trinity Hospital
UCSF Stanford Health Care
VacaValley Hospital
Valley Children's Hospital
Vencor Hospital San Diego
Vencor Hospital San Leandro
Warrack Hospital
West Anaheim Medical Center
West Hills Hospital & Medical Center
Western Medical Center Santa Ana
Analysis Prepared by : Ellen McCormick / HEALTH / (916) 319-2097