National Nurses United

DHS Staf���ng Study and Survey of Random Selected California Hospitals After the ratio law was passed, the California Department of Health Services (DHS) in 2000 began its research to help determine what the numerical ratios should be. First the DHS used data collected by the Of���ce of Statewide Health Planning and Development (OSHPD). This data on ���Productive Hours per Patient Day��� (PHPD) over 24 hours by employee classi���cation, cost center, number of beds, and number of admissions and discharges is collected every year from all acute-care hospitals in California. DHS identi���ed important limitations to the usefulness of the data for the purpose of developing staf���ng minimums. These were that PHPD includes hours not spent at the bedside, and measurement of census at midnight may leave out some patients who were admitted and discharged after midnight and before midnight the following day. The additional work required to admit and discharge patients is not captured although these activities increase staf���ng demands. DHS also stated that because all patient days are not alike, not all nurses are alike, and the PHPD re���ects average staf���ng over 24 hours and does not re���ect staf���ng variations at different times. CNA���s Campaign for Safe Staf���ng Ratios The safe staf���ng law did not come easily. It required massive lobbying and highly visible campaigns by the California Nurses Association and thousands of RNs across the state. In 1992 and 1993, the California Nurses Association sponsored with Jackie Speier AB 1445, the ���rst legislative attempt in the United States to establish nurse-to-patient ratios. The bill didn���t make it out of committee. In 1996 CNA sponsored Proposition 216, a patient protection ballot initiative that included the requirement that the Department of Health Services (DHS) set ratios in healthcare settings. RNs collected the required signatures. Although the proposition didn���t win, it was successful in raising awareness among RNs and the public of the need for safe staf���ng. In 1996 DHS added to Title 22 regulations requiring orientation, nursing in-service education, competency validation for the unit, and staf���ng by a validated acuity system. Unfortunately, most hospitals continued to staff by numbers/census rather than patient needs. In 1997 and 1998, CNA sponsored ratio bill AB 695. The bill passed the Legislature. Gov. Pete Wilson vetoed the bill after extensive lobbying by the hospital industry. In 1999 CNA sponsored AB 394, authored by Assemblywoman Sheila Kuehl. Nurses and patients wrote more than 14,000 letters in support and delivered them to lawmakers and the governor. CNA rallied tens of thousands of nurses at the Capitol in Sacramento and the governor���s Los Angeles of���ce. Gov. Gray Davis signed AB 394 on Oct. 10, 1999. California is the ���rst state in the U.S. to agree to safe RN staf���ng standards. This drew praise throughout the nation as well as internationally. NOVEMBER 2012 DHS then partnered with the University of California to gather in 2001 empirical real-world data about the acute-care workforce. DHS chose 17 experienced facility surveyor registered nurses who were in an enforcement role in the ���eld. These RNs received training on the purpose of the study and the process. They were provided with contact information when technical questions came up while doing the survey. All the visits were unannounced. The team studied a sample of the 495 hospitals in California. The sample visited included 10 academic medical centers, 10 Kaiser Permanente hospitals, 20 small and rural hospitals, 10 other public hospitals, 30 other private hospitals, and 10 state facilities for a total of 90 hospitals. Other DHS RN staff worked with the research team to develop a study tool to capture how hospital units were actually staffed. The forms sorted the hospital units into categories of unit types. A script was developed that was read to hospital administrators which included de���nitions of each unit type. A ���nurse staf���ng form��� was ���lled out on each unit for the current time, the previous 24 hours, and the preceding seven days. This included the number of patients, numbers of discharges and admissions, and the number of RNs, LVNs, and unlicensed staff on duty. In addition, the same data was requested for 10 speci���c dates during the ���rst three months of 2001. The study provided DHS with a portrait of nurse staf���ng as it was occurring in general acute-care hospital units. It provided retrospective data for the week before the study and the 10 randomly selected 24-hour periods over the ���rst three months of 2001. The numerical staf���ng ratios were ultimately predicated on an analysis of this staf���ng data. Mandated, Minimum, Numerical Nurse-to-Patient Ratios by Unit Type In California, DHS de���nes hospital units and appropriate patient population for the purposes of licensing and certi���cation of healthcare facilities and for monitoring compliance with existing public health and safety regulations. Because the literature describes the most common factor underlying preventable complications/failureto-rescue as ���triage error��� or admission to a unit other than one that provides the optimal and safe level of care required by the patient, it���s instructive to include a review of unit/patient population de���nitions upon which the California nurse-to-patient ratio law and staf���ng standards are predicated. Hospital Unit De���nition Hospital unit means a critical care unit, burn unit, labor and delivery room, post-anesthesia recovery service area, emergency department, operating room, pediatric unit, step-down/intermediate care unit, specialty care unit, telemetry unit, general medical care unit, sub-acute care unit, and transitional in-patient care unit. The regulation addressing the emergency department shall distinguish between regularly scheduled core staff licensed nurses and additional licensed nurses required to care for critical care patients in the emergency department. (Note: This home study incorporates excerpts of relevant ratio sections of AB 394 together with highlights from the ���nal Statement of Reasons (FSOR) submitted by the DHS. The FSOR can be downloaded in its entirety by accessing the web link listed in the bibliography.) 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 25

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