Ratio law, California Dreamin' or nightmare?

Published

http://www.gazettes.com/grunionnurses03252004.html#top

Hospitals In Trouble On Ratios

By Harry Saltzgaver

Executive Editor

Hospitals in Long Beach are breaking state law virtually every minute of every day-and the state Department of Health Services have asked the hospital administrators to stop telling them about it.

Starting in January, California hospitals were required to comply with state-mandated nurse-patient ratios. The law, AB 394, actually was passed in 1999, but the health department and hospital representatives have been negotiating ways to meet the requirements.

The negotiations didn't work.

Under the current regulations, hospitals must be in compliance with nurse-patient ratios every minute of every day. That includes every department, from the emergency room to the intensive care unit.

Required ratios vary with the type of care being provided. In the general medical and surgical recovery wing, one nurse is expected to take care of six patients, while there is supposed to be one nurse for every two patients in the intensive care unit. The ratio is one to four in the emergency room.

While there is a general nursing shortage, hospitals typically can meet those targets at the beginning of a shift, according to Byron Schweigert, CEO of Long Beach Memorial Medical Center. It is the first time three patients come into the emergency room at the same time, or even when a nurse goes on break, that becomes the problem.

"We can try to anticipate the need, but if there is a significant spike in the patient load, there is no way we can stay in compliance," Schweigert said. "At the beginning of the year, we told the Department of Health Services we would self-report when we were out of compliance. After a month or so, they told us the didn't want them any more because they couldn't do anything with them.

Schweigert said he and other hospitals continue to keep track of the "violations," but are turning their attention to getting the regulations changed. He said that the vast majority of hospital staff have opted to do the best they can to serve patients and break the ratios when necessary.

Ray Jankowski, CEO at Community Hospital of Long Beach, said the added regulation is just putting another burden on struggling California hospitals. For newer, smaller operations such as Community who are having trouble attracting enough permanent nurses, there is a direct hit to the bottom line, Jankowski said.

"We're forced to bring in more and more outside people, registry nurses," Jankowski said. "In the first place, we need to bring them up to speed and there is a loss of continuity. Then there is the cost.

"I typical registered nurse will make in the low $30s (per hour). When you hire per diem nurses, they're in the high $30s. But when you have to go to the registry to meet the ratios, you're talking in the $60s and $70s an hour. Even without benefits, that's very costly.

"Add the fact that the Medicare reimbursement is essentially flat, and we're in trouble. California's hospitals are already over-regulated, and this regulation is not adding any value while it is adding costs.

If the state legislature doesn't act this year, the ratios are supposed to become even more stringent next year.

Schweigert and Jankowski have joined with the Hospital Association of Southern California in a lobbying effort to change the law, and has won the Long Beach Chamber of Commerce to its side. The Chamber's Government Affairs Committee has endorsed the effort to change the law.

In the meantime, Long Beach Memorial has taken steps to deal with the broader issue of nurse shortages. Another state ratio law, this one limiting one instructor to 12 nursing students, has caused a severe lack of space in nursing schools. Schweigert said that 432 candidates applied last year for the 72 available slots in the California State University, Long Beach, nursing program.

To ease that shortage, Memorial has partnered with CSULB to bring nursing education to the hospital campus. In a program first announced in January, Memorial is establishing a satellite nursing campus at its hospital complete with a simulator laboratory and clinical experience.

"We decided to work pro-actively," Schweigert said. "We provide the class space, the teachers.Š When we're done, we will have added another 108 students per year to the program, and we're setting it up with three semesters a year so the can get their bachelor of science in nursing in two years instead of the three it takes now.

"We're also making an offer to all the nurses in the program to pay for their education-tuition, books, fees, the whole thing-if they will in return agree to work here for two years. We think that will ultimately go a long way to resolve the shortage, at least in Long Beach."

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http://business.bostonherald.com/businessNews/view.bg?articleid=2121

Staffing law has nurses California dreaming

By Jennifer Heldt Powell

Monday, March 29, 2004

Patricia Healey, an intensive-care nurse at a major downtown teaching hospital, is envious of her colleagues in California, and not just because the weather is warmer there.

A California law that went into effect in January mandates minimum staffing levels, ensuring that there are enough nurses per patient, advocates say.

That's a dream Bay State nurses hope to one day realize, Healey said.

It's frustrating and stressful to have to leave a patient in need to admit another patient or run to another part of the hospital to help with an emergency, she said.

``It makes me feel like I'm a bad nurse because I can't keep up,'' she said. ``You start blaming yourself.''

Many nurses don't want to work in hospitals, citing pressure, and that contributes to a growing nursing shortage, nurses say.

``They know they'll have to race around trying to get everything done,'' Healey said. ``It's incredible pressure to know that you've played a role in not helping patients get better.''

But the California law has gotten mixed reviews from hospital administrators. And while nurses here hold it it up as an example to be emulated, local hospital leaders say it confirms their misgivings.

Staffing mandates handcuff hospitals, forcing them to have staff that may not be needed at a given time.

``It just doesn't make sense to have fixed ratios that are the same across all hospitals,'' said Karen Moore, president of the Massachusetts Organization of Nurse Executives. ``And it doesn't address the issues of work force supply.''

It will force hospitals to hire more nurses without necessarily improving quality, she said.

Mandated levels could add as much as half a billion dollars a year to the cost of health care in Massachusetts, according to one estimate.

The nursing shortage is expected to grow as baby boomers retire, creating a greater demand on the hospital system as more nurses retire.

According to the U.S. Department of Labor, 1 million replacement nurses will be needed by 2012.

In California, the new law is boosting the number of nurses available to work in hospitals, advocates there say. Some of them are nurses returning to the field in the hopes that conditions have improved, said Chuck Idelson, spokesman for the California Nurses Association.

In a recent survey by the group, 70 percent of nurses said they've seen an improvement in staffing since the law went into effect nearly four months ago.

``That's quite significant, because there is an enormous benefit for the patient when staffing is improved,'' he said.

In addition, vacancy rates have dropped in hospitals that are in compliance with the law, Idelson said.

The change started soon after the law was signed, he said. The number of nurses coming into the work force grew by 10,000 last year, he said.

But California hospital executives paint a grimmer picture. Nurses are coming from out of state exacerbating shortages there, they said.

In addition, the rules are so restrictive, they must often hire more staff than necessary, creating financial hardships.

``The nursing shortage isn't being solved, and now we have this new problem,'' said Jan Emerson, spokeswoman for the California Health Care Association.

According to the group's weekly survey, about nine out of 10 hospitals aren't meeting the mandate because they can't find enough people.

In Massachusetts, nurses are pushing hard for the safe staffing bill, bringing it up at hearings about state budgets, holding rallies and meeting with lawmakers.

The issue is also coming up in contract talks.

But others are pushing for more moderate measures that would emphasize voluntary staffing levels and efforts to boost the nurse supply.

``Even enactment of (the mandated-staffing bill) is no guarantee of a safer system,'' said Sen. Richard T. Moore (D-Uxbridge), who offered an alternative plan.

His bill calls for staffing studies and scholarships to draw more students into nursing. It would also create a collaborative to find ways to address the nursing shortage.

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thanks for the info - it is an interesting debate. i had never looked at the other side of the coin. i still think nursing ratios are a good idea, they should not be thrown out.

i'm trying to figure out how to get in that program - all expenses paid - to work in long beach? that i can do! :D

topcat

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Thanks for the articles and links to the CNA. They helped me to answer a question I had about charge nurses under the ratio. (Unfortunately, the answer favors management more than nursing.) I will pass the info on to my co-workers.

The problem with the ratio law will come within two years. Not when the legislature overturns the law -- it would be too unpopular to do that -- but when the government ignores it. Hospitals have already started bending the edges of the law. If government agencies don't bust their chops for breaking the law, as the Long Beach article suggests, there's no point in having it. Like having great laws against murder but never sending out a cop when a body is found. Gov. Cyborg wants to be "business friendly" after all, and hospitals are businesses...

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bukko,

It won't be the government enforcing the ratio laws that get the hospitals to comply - it'll be the lawsuits.

Whether or not the state takes a "wink wink, nudge nudge" attitude, I flat-out guarantee that the first time some hospital loses a patient, and they aren't in compliance with the ratios, some lawyer is going to take them for more money than it would have cost to staff the hospital properly. That's going to be the real power of the law - it'll make killing a patient more expensive than keeping him alive.

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bukko,

It won't be the government enforcing the ratio laws that get the hospitals to comply - it'll be the lawsuits.

Whether or not the state takes a "wink wink, nudge nudge" attitude, I flat-out guarantee that the first time some hospital loses a patient, and they aren't in compliance with the ratios, some lawyer is going to take them for more money than it would have cost to staff the hospital properly. That's going to be the real power of the law - it'll make killing a patient more expensive than keeping him alive.

Sad but true, Fins. What a shame when we have to rely on trial lawyers to step in to protect us when the government won't. Maybe that's why a certain faction in the government wants to do some tortie twisting on said attorneys...

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http://www.calnurse.org/112103alert/deannletter2.html

This letter was published in the Long Beach Gazette on April 1, 2004

Nurses' Concern

To The Editor,

Hospital CEOs have "had it their way" for long enough with "flexible" staffing that "flexes" registered nurses away from the bedside and out of our hospitals. The plight of King-Drew illustrates how deadly medication and treatment delays can result from inadequate RN staffing levels and scofflaw management practices.

Nurses and patients have been on the receiving end of the corporate mergers and consolidations to increase market share coupled with low public investment and state tax and budget policies disinvesting in a public health care system. This is not the result of staffing standards; staffing standards are part of the solution.

I am a Registered Nurse and I have witnessed the heartbreaking effects of managed care. Patients and their families have suffered because of industry downsizing; nurses were laid off and many left hospital nursing because of unsafe workloads. Time after time, I have seen patients admitted to the ICU who survive the most critical illness and trauma; and then after transfer to Medical-Surgical ward the patient develops a preventable, often tragic complication. Recent studies validate that increased RN staffing reduces these complications.

The purpose of nurse-to-patient ratios is to improve patient care and patient outcomes and prevent errors in hospitals. The RN-to-patient ratio law passed the legislature in 1999 and became effective on Jan. 1, 2004, after providing hospitals four years to prepare. Today, California has six times more than the number of additional RNs the state health department said were needed to accommodate the safe staffing law.

Let's not to turn our back on patients, our most vulnerable citizens, those who are sick and in the hospital. Let's maintain ethical, safe work environments for nurses and safe care environments for patients.

DeAnn McEwen, B.S., R.N.

Chair Joint Nursing Practice California Nurses Association

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Perhaps Karen can post the editorial by Bill Cruice the PASNAP director. It has a heading that says, "California Hospitals Adapting Well to Staffing Ratio's". Magazine just arrived in last couple of days.

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http://www.pasadenastarnews.com/Stories/0,1413,206~11851~2062629,00.html

Article Published: Sunday, April 04, 2004 - 8:21:28 AM PST

Pasadena Star-News

Nursing crisis appears averted

Sunday, April 04, 2004 - ALL the cries of doom that would befall hospitals due to the newly enacted nurse-patient ratios has subsided as hospitals quietly fill slots left vacant throughout much of the '90s.

Widespread reports of a nurse shortage also have proved a cry-wolf tactic. San Gabriel Valley Medical Center, for example, was able to fill 63 out of 67 registered nurse positions since Jan. 1 when the ratio became law. The excuse that the new law was too expensive to implement also ought not stand in the way of hospitals meeting the ratio. The state has put $60 million at the hospitals' disposal to aid compliance.

We sat down with representatives of the California Nurses Association last week, who reported that most area hospitals have met or are meeting the Safe Staffing Law easily. Ratios that range from one nurse for every two patients in acute care to 1-to-6 in medical-surgical wards are reasonable and, health advocates claim, lifesaving.

Seventy percent of hospitals across the state have met the mandate. Kaiser Permanente has hired more than 3,000 RNs to comply with the law in its 28 hospitals statewide. It seems the task has not been as difficult as advertised.

What happened to the nurse shortage? According to CNA's representatives, many nurses were driven from the profession in the '90s through reduced staffing that led to forced overtime and care spread too thin as floor nurses tried to handle up to 10 patients each. The artificial shortage was created by the layoff of about 20,000 nurses to improve hospital profits.

Now, however, with the workload reduced and patient care better assured, many former nurses are returning to the profession. Encouraged by a new respect for the critical role nurses play in patient recovery, many young people are choosing nursing as a career.

We think the California Healthcare Association (CHA) should drop its nuisance lawsuit that is trying to overturn a part of the law that exempts the ratio during lunch and breaks. Silly, and again, dangerous to patient health.

When it comes to Assemblyman Tom Harman's bill to delay implementation of a 1-5 ratio, we're of two minds. AB 2963 requires the Department of Health to evaluate the nurse-patient regulations with an eye toward the number of nurses available and nursing vacancy rates. Part of that evaluation will be the effect nurse-to-patient ratios have had on hospitals.

Fortunately, the more important question also must be answered, i.e., how has the increased staffing affected patient care? The answer, we believe, will be fewer deaths and medical mishaps, lower infection rates and better patient outcomes.

Those factors will necessarily lead to fewer malpractice lawsuits and shorter hospital stays, thereby improving not only patient health, but hospitals' bottom lines as they are able to increase volume and profits.

To the extent that the legislation forces accountability from all concerned, we're for it. However, in no way do we want this to be the first step in dismantling the hard-won and much-needed current ratios.

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That business about suits about lunch and break relief is interesting. Most nurses in US would say, "what lunch, what break??"

http://www.pasadenastarnews.com/Stories/0,1413,206~11851~2062629,00.html

Article Published: Sunday, April 04, 2004 - 8:21:28 AM PST

Pasadena Star-News

Nursing crisis appears averted

Sunday, April 04, 2004 - ALL the cries of doom that would befall hospitals due to the newly enacted nurse-patient ratios has subsided as hospitals quietly fill slots left vacant throughout much of the '90s.

Widespread reports of a nurse shortage also have proved a cry-wolf tactic. San Gabriel Valley Medical Center, for example, was able to fill 63 out of 67 registered nurse positions since Jan. 1 when the ratio became law. The excuse that the new law was too expensive to implement also ought not stand in the way of hospitals meeting the ratio. The state has put $60 million at the hospitals' disposal to aid compliance.

We sat down with representatives of the California Nurses Association last week, who reported that most area hospitals have met or are meeting the Safe Staffing Law easily. Ratios that range from one nurse for every two patients in acute care to 1-to-6 in medical-surgical wards are reasonable and, health advocates claim, lifesaving.

Seventy percent of hospitals across the state have met the mandate. Kaiser Permanente has hired more than 3,000 RNs to comply with the law in its 28 hospitals statewide. It seems the task has not been as difficult as advertised.

What happened to the nurse shortage? According to CNA's representatives, many nurses were driven from the profession in the '90s through reduced staffing that led to forced overtime and care spread too thin as floor nurses tried to handle up to 10 patients each. The artificial shortage was created by the layoff of about 20,000 nurses to improve hospital profits.

Now, however, with the workload reduced and patient care better assured, many former nurses are returning to the profession. Encouraged by a new respect for the critical role nurses play in patient recovery, many young people are choosing nursing as a career.

We think the California Healthcare Association (CHA) should drop its nuisance lawsuit that is trying to overturn a part of the law that exempts the ratio during lunch and breaks. Silly, and again, dangerous to patient health.

When it comes to Assemblyman Tom Harman's bill to delay implementation of a 1-5 ratio, we're of two minds. AB 2963 requires the Department of Health to evaluate the nurse-patient regulations with an eye toward the number of nurses available and nursing vacancy rates. Part of that evaluation will be the effect nurse-to-patient ratios have had on hospitals.

Fortunately, the more important question also must be answered, i.e., how has the increased staffing affected patient care? The answer, we believe, will be fewer deaths and medical mishaps, lower infection rates and better patient outcomes.

Those factors will necessarily lead to fewer malpractice lawsuits and shorter hospital stays, thereby improving not only patient health, but hospitals' bottom lines as they are able to increase volume and profits.

To the extent that the legislation forces accountability from all concerned, we're for it. However, in no way do we want this to be the first step in dismantling the hard-won and much-needed current ratios.

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