Against the spirit of ratios

pickledpepperRN · Oct 19, 2003

Below is a cut and paste from the DHS link.

How do you interpret the first paragraph?

(from the revised Statement of Reasons)

http://www.applications.dhs.ca.gov/regulations/search.asp?REGID=R-37-01&advanced=yes&c2=@filewrite&o2=%3E&q1=&EMERGENCY=&submit1=Begin+Search

"In order to clarify that a hospital cannot reduce overall staffing by assigning licensed nurses to duties customarily and appropriately performed by unlicensed staff, it is stated that staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system. At 22 CCR 70053.2 and 70217(b), the PCS is defined as a system that is established to determine the amount of nursing care needed by each unit, on each shift, and for each level of licensed and unlicensed staff. Setting a minimum level of staffing for licensed nurses is not intended to alter the current requirement of the PCS to determine needed staffing levels for licensed and unlicensed staff. "

(1) Amend Section 70217 to read:

Section 70217. Nursing Service Staff.

(a) Hospitals shall provide staffing by licensed nurses, which includes registered nurses, licensed vocational nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a licensed psychiatric technician. Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system.

No hospital shall assign a licensed nurse to a nursing unit or clinical area unless that hospital determines that the licensed nurse has demonstrated current competence in providing care in that area, and has also received orientation to that hospital's clinical area sufficient to provide competent care to patients in that area. The policies and procedures of the hospital shall contain the hospital's criteria for making this determination.

Licensed nurse Nurse-to-patient ratios represent the maximum number of patients that shall be assigned to one licensed nurse during one shift at any one time. "Assigned" means the licensed nurse has responsibility for the provision of care to a particular patient within his/her scope of practice. There shall be no averaging of the number of patients and the total number of licensed nurses on the unit during any one shift nor over any period of time. Only licensed nurses providing direct patient care shall be included in the ratios.

Nurse Administrators, Nurse Supervisors, Nurse Managers, and Charge Nurses, and other licensed nurses not having a specific patient care assignment, shall not be included in the calculation of the licensed nurse-to-patient ratio only when those licensed nurses are engaged in providing direct patient care. When a Nurse Administrator, Nurse Supervisor, Nurse Manager, Charge Nurse or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the ratio. Nurse Administrators, Nurse Supervisors, Nurse Managers, and Charge Nurses who have demonstrated current competence to the hospital in providing care on a particular unit may relieve licensed nurses during breaks, meals, and other routine, expected absences from the unit.

Licensed vocational nurses may constitute up to 50 percent of the licensed nurses assigned to patient care on any unit, except where registered nurses are required pursuant to the patient classification system or this section. Only registered nurses shall be assigned to for Intensive Care Newborn Nursery Service Units, which specifically requires one registered nurse to two or fewer intensive care infants,. or where registered nurses are required pursuant to the patient classification system. In the Emergency Department, only registered nurses shall be assigned to triage patients and only registered nurses shall be assigned to critical trauma patients.

Nothing in this section shall prohibits a licensed nurse from assisting with specific tasks providing care within the scope of his or her practice to for a patient assigned to another nurse. "Assist" means that licensed nurses may provide patient care beyond their patient assignments if the tasks performed are specific and time-limited.

RNKPCE · Oct 19, 2003

I can see what is intended by that first paragraph, but I can see hospitals working around it saying the " primary care nursing is a type of nursing that has been around and ambulating, bathing, feeding patients is well within activities a licensed nurse can perform" I think it would be crossing the limits if they had us cleaning units after patients were discharged or other housekeeping duties.

I meant to include in my previous post that with the fairly good ratios we already have it includes one aid for every 8 patients or so. If that gets reduced then our staffing will be worse then before ratios were implemented.

Already they are posting positions on all the med-surg units for an RN 7 days a week from 11a-7:30p to do admits and relieve people for breaks. I wasn't at the staff meeting so I am not sure what that all means. If you work on day shift and this nurse comes on at 11 and she has to relieve 7 RN's , that will take 2.5 hours, the last nurse going to lunch at 2p. That doesn't take into account the 2 15 minute breaks. Before long evening shift will be on and need all their breaks by the time she leaves at 7:30p. Somewhere in there she will need her 2 15min breaks and lunch

pickledpepperRN · Oct 19, 2003

I believe you have an in house union, KRONA, at Stanford. Find someone who was there in the early to mid 1980s. I have been told there was true'Primary Nursing" with an RN responsible for the care plan from admission to the unit to discharge. Med/surg nurses had only FOUR patients each.

"Total Patient Care" meant doing everything for your patients.

I think we are all in for a struggle. We are fortunate to have a union to work with us on this. The community needs to know why nursing care is inadequate. They can't cry "shortage' while hiring RNs and eliminating other caregivers.

They are not dumb. They just want to focus on a small part of the new law. Too bad they don't focus on the mission of their hospital.

RNKPCE · Oct 20, 2003

Thanks for the information. However I don't work at Stanford. I was just saying I think this is something that many of us are going to see come the new year!

pickledpepperRN · Oct 23, 2003

http://www.calnurse.org/102103/hospindustry.html

Hospital industry seminars advise administrators how to evade RN ratios

*'Close beds and cry wolf':

*Attacks on RN practice:

*Eroding the ratios at the bedside:

*Subverting the DHS:

*Cover your tracks:

California's hospital industry has been holding seminars across the state in recent weeks advising hospital administrators on how to undermine and avoid compliance with the new RN staffing ratios that go into effect on January 1, 2004.

While some hospitals are hiring hundreds of RNs to meet the ratios, and some are promising to fully cooperate in implementation, the seminars indicate that a number of industry executives are seeking to evade the regulations and overturn the law - regardless of the consequences for patient safety, and the likelihood of driving more RNs from the bedside.

The seminars are hosted by the California Healthcare Association, CHA, (the union for hospital officials) and the Association of California Nurse Leaders, ACNL (the nurse executive association, a CHA affiliate). Seminars have been held in Fresno, Chico, Fremont, Long Beach, Los Angeles, San Diego, and San Diego, attended by hundreds of nursing supervisors and other hospital officials.

Presenters have included top officials of the CHA, hospital management attorneys, and nurse executives, such as Carol Bradley, the new chief nursing officer for Tenet Healthcare Corporation and the former editor of NurseWeek.

Among the industry plans:

'Close beds and cry wolf'

*Voluntarily close or downsize beds or units, citing an inability to "find" sufficient RNs to meet the ratios. The goal is to fan hysteria in hopes of softening public support for the ratios, winning regulatory exemptions to compliance, and generating political support for legislation to repeal or suspend the ratios.

*Delay elective surgeries, declare healthcare "emergencies," both to force RNs on staff to work more hours and to engage in a PR war to subvert the ratios.

To ratchet up public pressure, some hospitals may close units or suspend operations every day, and will meet with legislators to place the blame on the ratio law. The officials concede that hospitals may in some cases have difficulty receiving permission to reopen beds or units that have been temporarily or permanently shut down.

Seminar packets provide:

1. Detailed information on temporary and permanent closures of units and suspensions of beds

2. Sample letter to DHS requesting bed suspension

3. Sample letter to employees and medical staff announcing unit closures

4. Sample press release for participants headlined "(Facility/System Name) Closes XXXX Unit Because of Lack of Nurses. Despite Recruitment Efforts, Hospital Unable to Hire Enough Nurses to Meet New State Law."

Hospital officials are told to view their PR department as their new best friend, and that the "CHA PR will help as well."

*Keep the doctors in line, on all the strategies, from avoiding the ratios to downsizing, closing units, and suspending surgeries. Physicians are also seen as vital in public and legislative campaigns to reverse the ratio law.

Attacks on RN practice

*Use LVNs to comprise up to 50% of the ratios, doubling the RN work load.

Hospital industry officials hope to distort the intent of the law by assigning patients directly to LVNs, rather than have LVNs be assistive to, and under the supervision of, the RN. Under the final AB 394 regulations, hospitals must use RNs because of scope of practice and patient acuity, based on a hospital's patient classification system.

Hospitals hope to expand LVN scope of practice to permit direct assessment of patients. Some also project expansion of "team nursing" to sharply expand the role of LVNs from data collection and med administration to performing more nursing care functions. The hospital industry is meeting with the LVN Board on the issue of assessments, presumably to encourage ongoing efforts by the SEIU-dominated LVN Board to expand LVN scope in assessing patients.

Additionally, many hospitals project using LVNs for meal and break relief for RNs.

SEIU has also promoted 50% LVN ratios. Click here for more on SEIUs role

Eroding the ratios at the bedside

*Distort the use of acuity systems or other tools to reduce staffing. According to ACNL in one seminar, acuities are no longer a factor in staffing.

Some Tenet hospitals are employing a pilot staffing program borrowed from Tenet hospitals in Texas. The tool monitors labor efficiency in census driven units. In order to meet "production goals," managers can flex the number of hours of care to make staffing adjustments to meet budget targets. Managers are told to input acuity ratings to use the tool as a patient classification system to preclude the appearance of violating the staffing law.

*Manipulate triage and work flow in the Emergency Department.

One non-CNA hospital in Southern California uses "operational flow redesign" of patients presenting to the ED to reclassify some patients as "office level" so they will first be seen by a Physician Assistant rather than by an RN, along with the expanded use of an EMT to reduce the amount of triage performed by an RN.

*Quicker discharge of patients so staffing can be reduced.

*Layoff non-RN staff thereby increasing the RN work load and violating the intent of AB 394.

*Challenge or ignore ADOs and other RN efforts to monitor and protest violations.

The industry officials concede that ADOs are not illegal, but also tell the hospitals there are no legal regulations covering the use of ADOs. Hospital officials worry that ADOs and other reports by RNs to object to unsafe assignments and document unsafe staffing pose civil liabilities for hospitals that violate the law.

They advise managers to ignore or not respond to the reports, and recommend hospitals develop their own, in-house reporting tool, like an incident report, which staff are required to use, instead of forms developed by CNA.

Subverting the DHS

*Continue to use existing, even expired, "program flexibility" waivers from the Department of Health Services to avoid compliance with the ratios and hope that no one notices.

According to one seminar speaker, DHS has said it will not grant new waivers for the ratios, but if a hospital has an alternative method for meeting the "spirit" of the law, it will be reviewed. Seminar packets include program flexibility request forms. Hospitals are advised to carefully document the "need" for waivers.

*Pressure or cajole DHS to not enforce the law.

Seminar speakers note that DHS, already understaffed, is facing another 20% funding cut - and may face further cuts under Gov. Schwarzenegger. Hospital officials are also encouraged to cozy up to local DHS officers, and explain that the nursing supervisor is the expert for their unit. The officials are advised that they need to "educate" DHS.

Re-introducing anti-ratio legislation

*Reintroduce AB 847, the hospital industry bill CNA helped to defeat last year. The bill would have required indefinite delays in implementation of ratios until iron clad studies prove there are sufficient numbers of RNs and that ratios improve patient outcomes.

Cover your tracks

*RN supervisors and hospital administrators are advised to carefully record all their efforts to recruit RNs and comply with the law.

Industry officials advise hospitals to systematically keep track of all their efforts to find RNs to meet the ratios, from contacting all their own staff and registries to time and money spent on ads, travel and other recruitment efforts. The purpose: to have a record to justify decisions to close services and seek repeal or revisions in the law.

Hospitals are encouraged to "self-report" their violations of the law, because they can control what is reported rather than waiting for RNs or CNA to report the violation.

Seminar packets also include a sample "Documentation of Nursing Service Assignments" to demonstrate to the DHS or JCAHO the staffing plan on a day-to-day, shift-by-shift basis for every unit, and the specific number of RNs, LVNs, and PTs assigned.

RNKPCE · Oct 23, 2003

very interesting posting.

sharann, BSN, RN · Oct 24, 2003

SCARES the SH&T OUT OF ME.

Hellllllo Nurse, BSN, RN · Oct 24, 2003

Lord Almighty.

Why are these people just soooooo evil?

NursePaula · Dec 21, 2003

At the hospital that I work for we will have 2-3 aides on days, 1-2 aides on pm's and usually 1 and maybe 2 aides on nocs. all this for about 35-40 pts. And let me tell you several of the aides are worthlesss! They might take some of the vitals but not all, or the in's and out's one noc and not the next, and God forbid that you ask them to answer a call light during report! I have literally been in a new CVA pt room that has diarrhea and insists on using bedside commode (with it already everywhere inthe bed) for the first 1.5 hours of my shift. My other 5 pts that I had that NOC pretty much were on their own for a while...I did end up in the Managers office but all that got me was 30 minutes less sleep in the morning! And to be honest I love this hospital...it is the best that I have worked at so far! Oh, did I mention that we also have "split halls" on a regular basis meaning that 2 of your pts could be on one hall and the other 3 on the hall around the corner (and no the call system does not go around the corner) so if your other nurse is around the corner with the other pts you also get to answer her call lights! Sorry about the unload here but I think that in the end these ratios may not be all that great. We'll see. :eek:

pickledpepperRN · Dec 21, 2003

Well at our hospital we have units with strong united nursing staff who will not work in unsafe conditions!

Other units have "martyrs" who are well meaning but accepr poor staffing. In the long run those are the units where nurses transfer to OUR unit, quit, or hurt their back. The hospital constantly has to hire new staff. There is always an orientee who will probably be gone soon.

Go up the chain of command with your concerns,

Document everything, and enlist risk management.

Use an incident report each time you have to care for patients on different halls, each time the ratios are not met (or the patients need more care than the minimum allows),. Fill out an incident report if meds, including PRNs are not given on time.

Try to have a petition with nursing staff, RN, LVN, CNA, clerk, and anyone else who agrees the staffing is not safe.

I think that just like the motorcycle helmet law this will not be followed by magic on New Years Day.

NURSES can make it work!

pickledpepperRN · Dec 23, 2003

http://www.consumerwatchdog.org/arnoldwatch/blogs/blog-pol_reform_12-16-03.html

ArnoldWatch.Org

Doctoring The Nurse-Patient-Ratios

by Jerry Flanagan and Carmen Balber

December 16, 2003 - 12:05 PM

Tipsters tell ArnoldWatch that lobbyists for the state hospital association were livid when they realized that Arnold's freeze of all pending state regulations was too late to put a stop to newly minted rules for adequate nurse-to-patient ratios. The regulations require a standardized ratio of nurses-to-patients in health care facilities and is loathed by the state's hospital lobby.

Hospital executives, hopeful for a second bite at the apple, may have hit upon a workable strategy: Take advantage of the state's health care crisis. Word is hospitals will soon call for the declaration of a state of health care emergency - using the flu epidemic and lack of available hospital space in ERs and ICUs as their excuse - to suspend the finalized regulations. The Administrative Procedures Act, which governs regulatory matters, allows its operations to be suspended only after a state of emergency has been declared. Then Schwarzenegger can rewrite the rules more to the health care industry's liking.

An intercepted internal Schwarzenegger Administration memo from the press office seems to back the theory. It discusses hot topics and what the official line is on them. It says, "Regulations: The nurse-patient ratio is going into effect on Jan 1. We are telling reporters this along with giving them a little background about the process DHS would go through to change them once they are implemented (which is the regular process any reg would go through)." Regs typically are not changed the day after implementation.

ArnoldWatch also received word that the hospital lobby has been taking Schwarzenegger staffers on private hospital tours in their attempt to dump the nurse ratios as unworkable. Adding hard cash to political prodding, Arnold pocketed $21,200 from Steven Francis, the CEO of AMN Healthcare which specializes in recruiting RNs and less-qualified healthcare professionals.

As the Southern California hospital association's top exec Jim Lott recently told radio listeners on Warren Olney's "Which Way L.A." show:

"The Administration controls the regulatory process and they are the ones who actually came up with most of these ratios that we are going to be confronted with, so the Administration giveth, they can take it away. "

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