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hospital-assigned DRG codes and patient severity of illness levels program. The total and ongoing cost of developing and maintaining the National Acuity Tool shall be the basis for the charge to every acute-care facility for use of the National Acuity Tool. The National Acuity Tool shall remain a publicly owned tool. The National Acuity Tool shall include, but is not limited to the following elements: (1) A method to predict nursing care requirements of individual patients as determined by direct-care registered nursing assessments of individual patients, including: ��� Severity of the patient���s illness including secondary diagnosis ��� The need for specialized equipment and technology ��� The complexity of clinical judgment needed to assess, plan, implement, and evaluate the patient care plan ��� The ability for self-care, including motor, sensory, and cognitive de���cits ��� The need for advocacy intervention ��� The licensure of the personnel required for care ��� The patient care delivery system ��� The unit���s geographic layout ��� Generally accepted standards of nursing practice, as well as elements re���ective of the unique nature of the acute-care hospital���s patient population. (2) A method that provides for suf���cient direct-care registered nursing staf���ng to ensure that all of the following elements of the nursing process are performed in the planning and delivery of care for each patient: assessment, nursing diagnosis, planning, intervention. (3) A method to ensure that the patient care needs of individual patients are the exclusive determinant of direct-care registered nursing staf���ng, and that ���scal and budget considerations are not used for and do not in���uence the prediction or determination of direct-care registered nursing staf���ng levels. (4) An established method by which the amount of nursing care needed for each category of patient is validated. (5) A mechanism by which the accuracy of the nursing care validation method can be tested. (6) A method for validation of the reliability of the National Acuity Tool. The National Acuity Tool shall be fully transparent in all respects, including disclosure of detailed documentation of the methodology used by the system to predict nursing staf���ng, each factor used in the methodology, each assumption and value used in the methodology with an explanation of the scienti���c and empirical basis for each such assumption and value, and certi���cation that the methods for testing and validating the accuracy and reliability of the system. Each hospital shall include an evaluation and report on at least an annual basis by a committee of direct-care registered nurses who have provided and provide direct patient care in the units covered by the patient classi���cation system. Review and Consideration for Healthy Public Policy The evidence evaluated here suggests that patient satisfaction, nurse satisfaction, and optimal patient outcomes are in���uenced by ensuring that there are an effective number of direct-care registered nurses to meet the needs of patients who require nursing care. Effective RN-to-patient ratios, not creative and illusory NOVEMBER 2012 staf���ng committee schemes, are required for prevention, care planning, initial and ongoing assessment and evaluation of the treatment plan, patient education, and restoration to the optimal level of health and well-being attainable in the exclusive interests of the patient. The social good and public bene���t of increasing RN-to-patient ratios compels nurses and other social advocates to demand healthy social policy and ���nancial accountability when it comes to solving our current crisis in healthcare. This is congruent with our vision of advocacy for an expanded and improved Medicare-for-all program, with a single standard of excellent care for all. State nursing practice acts and registered nursing board implementing regulations, practice standards, and professional license guidelines generally impose a ������duciary responsibility��� on registered nurses who accept assignment to a direct care RN-to-patient relationship in which nursing care is provided. The ���duciary obligation infers a duty of loyalty to the patient to provide care in the exclusive interests of the patient without compromise or surrender to interests of health facility employers, physician practice groups, healthcare systems, managed care organizations, or health insurers/ HMOs. The ���duciary relationship and related professional ���duciary duties of direct-care registered nurses to assigned patients are fundamental public health and safety regulations created to protect patient safety. The hospital industry and its political cronies have continued their dangerous agenda to control the availability, access, and quality of healthcare services for purposes of pro���t and surplus revenue generation against the interests of patients and healthcare consumers. However, it is the nation���s direct-care RNs who will continue to honor the public���s trust in them. Nurses recognize the importance of collective patient advocacy for maintaining the integrity of professional nursing standards of care. Selected Overview of the Scienti���c Evidence for Safe Staf���ng Ratios The Agency for Healthcare Research and Quality (AHRQ) is one of three organizational focuses for Department of Health and Human Services (HHS), along with the National Institutes of Health and the Centers for Disease Control. AHRQ���s mission is to improve the quality, safety, ef���ciency, and effectiveness of healthcare for Americans. AHRQ focuses on quality improvement and patient safety. In this capacity, AHRQ in October 2012 lauded the nurse-to-patient ratios in a ���policy innovation pro���le��� titled ���State-Mandated Nurse Staf���ng Levels Alleviate Workloads, Leading to Lower Patient Mortality and Higher Nurse Satisfaction.��� AHRQ is well respected and in���uential in shaping healthcare policy. Its praise regarding the effectiveness of the ratios is welcome news to RNs and patients across the country and will bolster efforts to establish federally mandated nurse-to-patient ratios. AHRQ de���ned the problem that ratios solved thus: Heavy patient workloads for nurses have been associated with poor patient outcomes and low job satisfaction. Yet few states require hospitals to maintain minimum nurse-to-patient ratios, leaving nurses to care for a signi���cant number of patients at a time. AHRQ categorically stated that the ratios have been a success: The legislation has increased staf���ng levels and created more reasonable workloads for nurses in California hospitals, leading to fewer patient deaths and higher levels of job satisfaction than in W W W. N AT I O N A L N U R S E S U N I T E D . O R G N AT I O N A L N U R S E 31