CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)

8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)

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Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 10Mandatory Minimum Staffing

Ratios: Are They Working?


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Staffing Ratios

Economics: primary driver for changes in RN skill mix inhospitals

Trend over past decade: reduce RNs, replace with lessexpensive alternatives

Research shows number of RNs in staffing mix directlyimpacts uality of care, especially patient outcomes


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Staffing Ratios (cont d!

!ncreasing demand for ade uate staffing ratios of RNs inacute"care settings

National movement already begun to mandate minimumstaffing ratios


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Staffing Ratios and "atient #utcomes

#uggested link between increased RNs in staffing mix,improved patient outcomes

$ssociation between staffing levels and patient mortality,hospital outcome% relationship not causal

&ailure to find anticipated significant improvements in fallincidence, prevalence of hospital"ac uired pressure ulcers

after implementing mandated staffing ratios 'in ($% seeTable )*+)

#tudy by $iken et al+ as seminal work in support ofestablishing minimum staffing ratio legislation


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True or $a%se:

Research has demonstrated a direct causal link betweenstaffing levels and patient outcomes+


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Ans&er: $a%se

$lthough research has identified an associated linkbetween staffing levels and patient outcomes, this

relationship has not be identified as causal+


7/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

'eed for Mandatory Minimum StaffingRatios?

-roponents

. /andated minimum staffing ratios essential topromote patient safety, achieve outcomes

. #tandardi0ed ratios as more consistent approach

. $ppealing to nurses due to protection from

overburdening assignments



'eed for Mandatory Minimum StaffingRatios? (cont d!

(ritics

. 1verall cost of care increasing exponentially withmandated ratios nationally% no guarantee of ualityimprovement or positive outcomes

. 2ack of reimbursement for increased cost of moreRNs leading to unfunded mandates




(ritics 'cont3d

. -redetermined ratios overlook level ofexperience4knowledge of nurse

5ifficulty translating for medical4surgical units thanfor specialty units due to variability in patientpopulation

. No scientific evidence to support nurse"patient ratiosin all settings




(ritics 'cont3d

. (ost 'most often cited as deterrent % resources awayfrom patient care, into compliance

. 6ealth care professionals as best ualified todetermine staffing needs

. Reduction in hospital services, increased emergencyroom diversions, unit closures, expenses 'payment ofadditional labor costs for overtime, temporary agencynurses



Ca%ifornia as the "rototype

/inimum licensed nurse"to"patient ratio re uirement for!(7 and ((7 for over 8* yrs

(alifornia: )st state to implement mandatory minimumstaffing ratios

. /aximum number of patients RN could be assignedto care for under any circumstance



Ca%ifornia as the "rototype (cont d!

-rohibition of unlicensed personnel from performingprocedures

. /edication administration

. 9enipuncture

. -arenteral or tube feedings

. !nserting nasogastric tubes, catheters



Ca%ifornia as the "rototype (cont d!

-rohibition of unlicensed personnel from performingprocedures

. Tracheal suctioning

. $ssessment of patient conditions

. -atient education

. /oderately complex lab tests 'see Table )*+



Strugg%e to etermine Appropriate Ratios

2ack of readily accessible data about distribution of nursestaffing in (alifornia hospitals, number of hospitals likely

to be affected or expected costs Ratios to supplement valid, reliable patient classification

systems

. No standardi0ation, little guidance about what was

valid or what criteria to use !nitial costs unknown

-roposals suggest wide ranges of minimum ratios withdiffering cost estimates



True or $a%se:

(alifornia has had mandatory minimum staffing ratios forgeneral medical"surgical units for over three decades+



Ans&er: $a%se

(alifornia has had minimum nurse"to"patient ratios forintensive"care and coronary"care units for the past three

decades+. ;ut it wasn3t until )



e%ays in )mp%ementation: Cha%%enges

!nterpreting meaning, intent of language constituting =licensed nurse> ? RNs or 29Ns42-Ns meeting

re uirement. (ontroversy with labor unions for 29Ns

@uestions about hospitals eliminating4reducingnonlicensed staff to save costs

New legislation to delay implementation of ):A ratio

. ;ill failed



e%ays in )mp%ementation: Cha%%enges(cont d! Emergency regulation by Bovernor to overturn

emergency room ratios, improve med4surg ratios due tofinancial crisis

. Ruled illegal

$ccusations of hospitals undermining ratios% unionsthreatening to close down units



Strugg%e to )mp%ement the Ratios

#taffing mandate becoming effective Can ), **D

@uestion about hospitals being ready, willing toimplement changes

;igger hospitals ready to meet mandate% smallerhospitals seeking waivers due to existing budget deficits



*At+A%%+Times, C%ause

2egal clarification necessary after implementation relatedto ratio coverage =at all times>

#trict interpretation by (56# that ratios maintained at alltimes including breaks, lunches

2awsuit in **8 challenged ruling, argued =at all times>was impossible to implement

. Cudges ruled that not adhering to =at"all"times>clause would make ratios meaningless


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Assuring Comp%iance

(56# charged with compliance oversight of mandatoryminimum staffing ratios

-rocedures for

. (ompliance verification

. Responding to complaints

. $ddressing compliance violations


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True or $a%se

The =at"all"times> clause of (alifornia legislation did notapply to break and lunch times+


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Ans&er: $a%se

The =at"all"times> clause strictly interpreted re uiredinstitutions to maintain the staffing ratios at all times,

including breaks and mealtimes+


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Simi%ar )nitiati/es in #ther States

#everal attempts to address, enact hospital staffing laws

. None close to fruition

D (ode of &ederal Regulations for /edicare"certifiedhospitals


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Simi%ar )nitiati/es in #ther States (cont d!

-rediction: within A years, staffing legislation will havebeen at least introduced in all A* states

. ith significant number having passed some type

9arious states have passed safe nurse staffing orhospital"wide staffing plans legislation

-assage of =patient safety> bill


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#ther A%ternati/es

#taffing plans

No support by $N$ for legislated minimum staffing ratios

. $dvocating for workload system that takes intoaccount variables to ensure safe staffing

9iew that staffing ratios too inflexible, potentially

inefficient if calibrated incorrectly


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#ther A%ternati/es (cont d!

Coint (ommission: reluctant to endorse nationallymandated minimum staffing ratios

. $dvocating #taffing Effectiveness and (ontinuous@uality !mprovement

$nother alternative: market"based incentives to optimi0enurse staffing levels using revenue code data as

benchmark. $nd evaluate inpatient nursing care performance by

case mix across hospitals


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nd of "resentation

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CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)