HEALTH AND SENIOR SERVICES SENIOR …web.doh.state.nj.us/apps2/documents/bc/notice_adoption02.pdfThe compilation and reporting regulations would require extensive nursing time to complete

The official version of any departmental rulemaking activity (notices of proposal or adoption) are published in the New Jersey Register or New Jersey Administrative Code. Should there be any discrepancies between this document and the official version of the proposal or adoption, the official version will govern.

HEALTH AND SENIOR SERVICES

SENIOR SERVICES AND HEALTH SYSTEMS BRANCH

HEALTH FACILITIES EVALUATION AND LICENSING DIVISION

CERTIFICATE OF NEED AND HEALTHCARE FACILITY LICENSURE

PROGRAM

Hospital Licensing Standards

Mandatory Staff Level Posting and Reporting Standards; General

Provisions

Adopted New Rules: N.J.A.C. 8:43G-17A

Adopted Amendment: N.J.A.C. 8:43G-1.2

Proposed: April 16, 2007 at 39 N.J.R. 1363(a).

Adopted: , 2008 by __________________________,

Heather Howard, J.D., Commissioner, Department of Health

and Senior Services (with the approval of the Health Care

Administration Board and in consultation with the Quality

Improvement Advisory Committee).

Filed: , 2008, as R. 2008 d. , without changes.

Authority: N.J.S.A. 26:2H-1 et seq., specifically 26:2H-5h.

Effective Date: , 2008

Expiration Date: , 2010


2

Summary of Public Comments and Agency Responses:

The Department of Health and Senior Services (Department)

received written comments prior to the June 15, 2007 close of the 60-day

public comment period from the following:

1. Robyn Begley, RN, MSN CNAA, BC, President, ONE/NJ

(Organization of Nurse Executives), Princeton, NJ

2. Jean Bronock-Zaccone, RN, MPA, Vice President and Chief

Nursing Officer, St. Clare’s Health System, Dover, NJ

3. Edna Cadmus, PhD, RN, CNAA, Sr. VP, Patient Care Services,

Englewood Hospital and Medical Center, Englewood, NJ

4. Ann Campbell, Chief Nursing Officer, Virtua Health Inc., Marlton,

NJ

5. Charlotte Crowe, RN, no address

6. Dr. Dorothy J. DeMaio, Dean and University Professor Emerita,

Rutgers College of Nursing, Far Hills, NJ

7. Geri L. Dickson, PhD, RN, Bloomfield, NJ

8. Lois Dornan, MSN, RN, CPHQ, Director, Clinical Integration,

Robert Wood Johnson Health Network, New Brunswick, NJ

9. Linda Flynn, PhD, RN, Director of Research, New Jersey

Collaborating Center for Nursing and Assistant Professor, Rutgers College

of Nursing, Newark, NJ


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10. Joan Gavin, RN, MS, CNAA, BC, Vice President of Nursing

and CNO, Shore Memorial Hospital, Somers Point, NJ

11. Bernie Gerard, Jr., Vice President, Health Professionals and

Allied Employees, Emerson, NJ

12. Barbara Holfelner, RN, MSN, CNAA, Vice-President, Patient

Care Services and Risk Management, Our Lady of Lourdes Medical

Center, Camden, NJ

13. Aline M. Holmes, Sr. VP, Clinical Affairs and Karen S. Ali,

Acting General Counsel, New Jersey Hospital Association, Princeton, NJ

14. Kim A. Kelly, RN, MS, CNAA, BC, Vice President, Clinical

Services, CentraState Healthcare System, Freehold, NJ

15. Thomas H. Kenney, Executive Secretary-Treasurer, Essex-

West Hudson Labor Council AFL-CIO, Newark, NJ

16. Felissa R. Lashley, RN, PhD, ACRN, FAAN, FACMG, Dean

and Professor, Rutgers College of Nursing, Newark, NJ

17. Carmen Manibo, RN, Christ Hospital, Jersey City, NJ.

18. Nancy Miller, Retirees Staff Liaison and Robert J. Cawley,

Retirees Chair, New Jersey State AFL-CIO Community Services Agency,

Clifton, NJ

19. Stephanie Orrico, RN, BSN, Fair Lawn, NJ

20. Lisa Romano, RN, New Jersey Nurses Union, Livingston, NJ


4

21. Muriel M. Shore, EdD, RN, CNAA, Dean and Professor,

Division of Nursing and Health Management, Felician College, Lodi, NJ

22. Carolyn Torre, RN, MA, APN, C., Director of Practice, New

Jersey State Nurses Association, Trenton, NJ

23. Virginia C. Treacy, RN-Executive Director, District Council 1,

IUOE / AFL-CIO, New Brunswick, NJ

24. Susan Vilardi, RN, PHN, Bergenfield Health Department,

Bergenfield, NJ

25. Susanne Walther, APN, no address

26. David H. Weiner, President, Communications Workers of

America (CWA) Local 1081, Newark, NJ

27. Charles Wowkanech, President and Laurel Brennan, Secretary

and Treasurer, New Jersey State AFL-CIO, Trenton, NJ

Form Letters 28 through 38:

28. Carol Aiken, New Jersey Nurses Union, Livingston, NJ

29. Mary Barbes, New Jersey Nurses Union, Livingston, NJ

30. Anthony Caifano, Secretary-Treasurer, Amalgamated

Lithographers of America, New York, NY

31. Noel J. Christmas, President, Utility Workers Union of America

Local Number 601, Bloomfield, NJ

32. Chip Gerrity, President and Business Manager, International

Brotherhood of Electrical Workers Local Union 94, Hightstown, NJ


5

33. Laura Korkes, Wayne, NJ

34. Reynaldo Massa, President, CWA Local 1023, Cranford, NJ

35. Charles Mattson, President, Bergen County Central Trades &

Labor Council, AFL-CIO, Paramus, NJ

36. Hetty Rosenstein, President, CWA Local 1037, Newark, NJ

37. Bill Trulby, Business Manager, International Association of

Heat and Frost Insulators and Asbestos Workers, Newark, NJ

38. John R. Wende, Business Manager and Financial Sec-Treas,

Building and Construction and Metal Trades Divisions Pipefitters Local

274, Ridgefield, NJ

Form Letters 39 through 43:

39. Ponciana Javier, RN, no address

40. Maria, RN, no address

41. Illegible name, no address

42. Illegible name, LPN, no address

43. Illegible name, LPN, no address

A summary of the comments and the Department’s responses

follows. The number(s) in parentheses after each comment identifies the

respective commenter(s) listed above.

SECTION 1: General Comments

1. COMMENT: The commenter stated that the proposed

requirements would place an additional burden on its hospital and


6

estimated that it would need to add an additional two full time equivalent

positions. (10)

2. COMMENT: The commenter stated that, based on a study at

Lourdes, the proposed requirements would necessitate an estimated

minimum of 30 to 40 minutes of nursing time per day in 18 inpatient units.

The regulation would place additional demands on staff on the off-shift

and weekends when limited leadership is available. The commenter

states that it already incorporates nurse staffing levels in its performance

improvement and patient safety initiatives. (12)

3. COMMENT: The commenter stated that the onerous

regulations would require extensive “nursing/ancillary staff time” to

complete. A pilot study completed by the New Jersey Hospital

Association estimated that the cost to the commenter’s system would be

potentially $350,000 per year or more than one million dollars per year for

its four-hospital system. (2)

4. COMMENT: The commenter stated that the regulation’s burden

to the hospital far outweighs its benefits to the patients and families.

Currently, the facility posts staffing information on white boards on the

inpatient units and staff provides the information verbally when requested.

(3)

5. COMMENT: The commenter stated that its facility currently

posts staffing information at nursing stations and that the proposed


7

calculations are meaningless. The compilation and reporting regulations

would require extensive nursing time to complete. Pilot study results

indicated, conservatively, an hour a day to complete forms multiplied by

30 or more nursing units every day of the year, translated into 10,950

hours a year, or approximately an additional five full-time employees. “At

an average annual nursing salary of $70,000, the proposed posting

regulations could result in $350,000 a year in additional hospital

expenditures.” (13) Another commenter supported this position. (12)

6. COMMENT: The commenters stated that the burden of this

unfunded mandate to the hospitals far outweighs the benefits to the

patients and families. Nursing resources could be better and more

appropriately utilized in direct patient care. Currently, on virtually every

nursing unit, the facility posts staffing information at the nursing stations.

(1, 8, 14)

RESPONSE TO COMMENTS 1 THROUGH 6: As stated in the

Notice of Proposal published in the New Jersey Register on April 16, 2007

at 39 N.J.R. 1363(a), the Department promulgated the new rules at

N.J.A.C. 8:43G-17A to implement N.J.S.A. 26:2H-5f, 5g and 5h. N.J.S.A.

26:2H-5g requires general hospitals to compile, post, and report certain

staffing information and the Department is without authority to change the

requirements of a statute.


8

7. COMMENT: The commenter suggested reducing the inpatient

posting to one twenty-four hour posting, similar to the Post Anesthesia

Care Unit (PACU) and Emergency Department (ED) requirement. The

commenter also stated that a posting giving the actual staffing over a

period of time (week or month) would be more accurate and far less

cumbersome and costly for hospitals to provide. (10)

RESPONSE: As stated in response to the prior comments, the

proposed new rules implement N.J.S.A. 26:2H-5f, 5g and 5h, which

require “daily” posting of certain staffing information based on each “unit”

and “the end of the prevailing shift.” The Department is without authority

to make the revisions as suggested by the commenter because they

contradict the statute.

SECTION 2: Definitions

8. COMMENT: The commenter stated that in its definition, “direct

patient care” includes only registered nurses (RNs) and nursing

assistants. The commenter does not collect information about physical

therapists (PTs) or respiratory care practitioners (RCPs) within the

Department of Nursing. Because such caregivers float across the

institution and would be difficult to measure on a shift-by-shift basis, the

commenter recommended deleting physical therapists and respiratory

therapists from the definition and other sections of the regulation. (3)


9

9. COMMENT: The commenter recommended the deletion of the

terms PT and RCP in the definition of “direct patient care.” The

commenter also recommended the deletion of the proposed regulation,

which requires reporting of staffing for PTs and RCPs because these

individuals may be assigned to inpatient units or to outpatient areas and,

therefore, the posting of those ratios would be meaningless. (13) Another

commenter supported this position. (12)

10. COMMENT: The commenters recommended the deletion of

the terms PT and RCP in the definition of “direct patient care.” The

commenters also recommended the deletion of the proposed regulation,

which requires reporting of the staffing of PTs and RCPs. The commenter

noted that since PTs and RCPs may be assigned to inpatient units or to

outpatient areas, posting those assignment areas would be meaningless.

The commenter stated that although such caregivers provide direct patient

care, they are not included in the direct care hours as calculated by all

hospitals in New Jersey and the gathering of such information would

require additional resources. (1, 8, 14)

11. COMMENT: The commenter, although not explicitly referring

to the definition of “direct patient care,” stated that it operates nursing units

with a nurse director, assistant manager, advanced practice nurse,

physicians, advanced nurse practitioners, and physician assistants, many

of whom aren’t captured by the regulations. (4)


10

RESPONSE TO COMMENTS 8 THROUGH 11: The Department

acknowledges that several commenters recommended the deletion of PT

and RCP from the definition of “direct patient care” for one or more of the

following reasons: (1) such caregivers float across the institution and

would be difficult to measure on a shift by shift basis, (2) these individuals

may be assigned to inpatient or to outpatient areas and, therefore, the

posting of those ratios would be meaningless, and (3) they are not

included in the direct care hours as calculated by all hospitals in New

Jersey and the gathering of such information would require additional

resources. As noted previously, the proposed new rules implement

N.J.S.A. 26:2H-5f, 5g and 5h. More specifically, N.J.S.A. 26:2H-5g(a)4

requires “information detailing for each unit and for the end of the

prevailing shift, as appropriate. . .the number of other licensed or

registered health care professionals meeting State staffing

requirements….” Such health care professionals include PTs and RCPs,

both of which are appropriately included in the definition of “direct patient

care” in the rules. As the Department noted in the New Jersey Register of

Monday, April 16, 2007 (39 N.J.R. 1363(a)), “‘Other licensed health care

professionals’ means 1. ‘Physical therapist,’ which shall have the meaning

set forth in N.J.S.A. 45:9-37.13, and 2. ‘Respiratory care practitioner,’

which shall have the meaning set forth in N.J.S.A. 45:14E-3.” The

Department is without authority to make the revisions as suggested by the


11

commenters because they contradict the statute. Therefore, the

Department declines to make any changes to the rules at N.J.A.C. 8:43G-

17A that would remove the requirements for the reporting of staffing for

PTs and RCPs. Furthermore, under the rules at N.J.A.C. 8:43G-17A.2

advanced practice nurses would be included in the definition of “direct

patient care” because they would be registered professional nurses, a

group about which the statute requires information. However, physicians

and physician assistants would not be included in the definition of “direct

patient care” because the statute does not require information about these

health care providers. Administrative nurses, such as nurse directors and

assistant managers, would be counted in the definition because they are

registered professional nurses, but only if they are functioning as direct

care providers rather than as administrators.

12. COMMENT: The commenter indicated her support for the

regulations, but stated that the reporting should be simplified to include

strictly full-time equivalents (FTEs) because the reporting of partial shift

workers would be confusing and might lead to inaccurate accounting of

ratios of staff to patients. (25)

13. COMMENT: The commenter recommended identifying the

number of staff on a shift and not including the actual hours. The

commenter added that calculating actual hours goes beyond the required

law and would create additional workload. (3)


12

RESPONSE TO COMMENTS 12 AND 13: The Department

acknowledges the concerns of these commenters regarding the

methodology to be used for counting staff. The Department is required by

law to consult with the Quality Improvement Advisory Committee (QIAC) in

developing the rules at N.J.A.C. 8:43G-17A and held a number of

meetings with this broad-based stakeholder group. The QIAC was deeply

divided between union and hospital representatives on whether to use

FTEs or to count the actual number of staff. Although the law does not

specify one method or the other, the Department believes that using

methods for counting staff that are not standard could confuse the

consumer, defeating the purpose of the legislation. While recognizing the

potential additional burden of calculating FTEs, the Department has

concluded that this method is in keeping with the intent of the legislation at

N.J.S.A. 26:2H-5f through h to provide the public with clear and concise

numbers that can be compared across facilities. The term FTEs includes

“partial shift workers” and the Department believes that inclusion is

appropriate. Equally important, as noted by other commenters, numerous

employers, governments, research institutions, and professional

organizations around the world have adopted the use of FTEs for staffing

calculations.

14. COMMENT: The commenter stated that the process does not

account for the direct patient care provided by centralized care providers


13

such as an “IV team” or wound care team. The commenter also stated

that although shifts end at a predictable time, true nursing hours are not as

predictable. Some nursing staff may stay beyond their shift and these

hours would not be captured in the posting. (10)

15. COMMENT: The commenter stated that the definition of “shift”

does not take into account the many and varied shifts its health system

uses. (2)

16. COMMENT: The commenter stated that it has numerous

facilities, each of which uses a variety of “shifts, ” including nine-hour

shifts, which comprise float nurses, rapid emit nurses, rapid response

nurses, nurse managers, on-call nurses, and Code Blue teams. The

commenter suggested that the Department should revise the definition of

“shift” to more accurately reflect these variations and to allow hospitals to

provide accurate data. (4)


definition of “shift” “does not take into account the variety of shifts currently

being offered in hospitals. . .It also does not address the times when,

because of patient census, transfers in or out, or patient acuity, additional

staff such as advanced practice nurses, nurse managers, or members of

rapid response teams are deployed to help out for a short period of time.

Although these healthcare professionals are providing direct patient care,


14

this information will not be captured through the proposed allocation of

shifts.” (13) Another commenter supported this position. (12)

18. COMMENT: The commenters stated that mandating the

reporting of these shifts into an arbitrary eight- or 12-hour period does not

reflect what is in fact occurring on the nursing unit. The commenters said

that today’s hospitals may have two-, four-, six-, or ten-hour shifts in an

attempt to be flexible in meeting patient needs and to address high acuity

and high census fluctuations while meeting the needs of their nursing

staffs. The commenter added that “the proposed reporting system would

not accurately reflect the dynamic composition of the nursing unit due to

the fluctuation in the patient census (patient transfers in and out of the

unit), patient acuity, additional staff such as advanced-practice nurses,

nurse managers or members of rapid-response teams who are deployed

to assist anywhere in the hospital for periods of time when emergent

situations occur.” The commenters stated that such variables will not be

captured through the proposed allocation of shifts, which may not be

reflective of the actual care provided. (1, 8, 14)

RESPONSE TO COMMENTS 14 THROUGH 18: The proposed

new rules at N.J.A.C. 8:43G-17A, which implement N.J.S.A. 26:2H-5f, 5g

and 5h, require that nursing hours be measured in shifts. The Department

is aware of the many and varied shifts currently being offered in hospitals

and, therefore, suggested eight- and 12-hour shifts in order to achieve


15

standardization and to make the staff posting process more efficient for

both hospitals and Department staff. The Department decided to use

these two standardized shifts in order to provide understandable data for

the public and comparable data across all hospitals. Furthermore, as

noted in the response to comment numbers 8 through 11, the Department

would include advanced practice nurses in the definition of “direct patient

care” because they would be registered professional nurses, a group

about which the statute requires information. Similarly, the Department

would include centralized care providers, float nurses, rapid emit nurses,

rapid response nurses, on-call nurses, and Code Blue teams in the

definition of “direct patient care” whenever such providers are included in

one of the groups for which the statute requires information.

Administrative nurses, such as nurse directors and assistant managers,

would be counted in the definition because they are registered

professional nurses, but only if they are functioning as direct care

providers rather than as administrators. However, physicians and

physician assistants would not be included in the definition of “direct

patient care” because the statute does not require information about these

health care providers.

SECTION 3: Information Required to be Posted; Retention

19. COMMENT: The commenter stated “posting data one hour

before the end of or one hour after the beginning of the next shift only


16

provides historic information, and not current staffing levels.” The

commenter added that such data would not provide any useful information

to patients and their families. (2)

20. COMMENT: The commenter stated that the “form is required

at the busiest time, change of shift, when the one nursing supervisor on

duty for evenings, nights, weekends and holidays is ensuring that changes

in staffing needs are addressed.” The commenter also said, “to implement

this for every unit would require either the hospital to hire additional staff

or more likely assign this task to the charge nurse on each unit thereby

detracting from patient care.” Finally, the commenter added that “time

could be better spent focusing on patient needs” during change of shifts.

(3)

21. COMMENT: The commenters stated that collecting data “one

hour before the end of the shift” diverts nursing resources and attention

from the priorities of “safe patient handoffs” and “communication” at the

change of shifts. The commenter recommended posting the staffing

numbers after the beginning of the shift, so that patients and visitors could

view what the current status is for the current shift. (1, 8, 14)


new rules at N.J.A.C. 8:43G-17A implement N.J.S.A. 26:2H-5f, 5g and 5h

which require, in part, that a general hospital licensed pursuant to P.L.

1971, c.136 (N.J.S.A. 26:2H-1 et seq.) must compile and post daily. .


17

.information detailing for each unit and for the end of the prevailing shift.

While the Department acknowledges that the form is required at change of

shift, the busiest time on hospital units, the Department believes, following

extensive consideration, that the intent of the law is that staff shall post

staffing information at the end of each shift. The Department trusts that

hospital staff will first focus nursing resources and attention on “safe

patient handoffs” and secondly on the completion of the staff posting

forms. Finally, the Department acknowledges that posting information at

the end of the shift will not allow patients and visitors to view the current

status for the current shift. However, as noted above, the Department has

determined that the law intends and mandates that staff shall post staffing

information at the end of each shift and therefore, the Department makes

no change on adoption.

22. COMMENT: The commenter stated that the counting of

patients in the ED is an irrelevant function since the data is retrospective.

The commenter suggested posting the numbers of RNs and nurses aides

only and eliminating the number of patients on the form, and providing

patient census on a 24-hour basis. (3)

23. COMMENT: The commenter stated that the ED information to

be reported would not assist the general public in making informed

decisions. The commenter added that reporting such aggregate numbers

would not take into “account the acuity of the patients being treated” and


18

various components of direct patient care. Therefore, the commenter

suggested that the Department delete the proposed reporting requirement

for EDs. (4)

24. COMMENT: The commenters stated that the reporting of the

total number of patients seen in the ED for the shift and the number of

staff is relatively useless information to the public. Such information does

not take into account the various shifts used in EDs to accommodate

swings in census during the day, the ability to open up prompt or urgent

care centers to respond to increased volume, and the utilization of rapid

response and admission teams to assist with patients when needed. The

commenter recommended that the Department delete the proposed

reporting requirement for EDs. (1, 8, 13, 14) Another commenter

supported this position. (12)


new rules at N.J.A.C. 8:43G-17A implement N.J.S.A. 26:2H-5f, 5g and 5h,

which require “daily” posting of certain staffing information based on each

“unit” and “the end of the prevailing shift.” The Department, with input

from the QIAC, agreed to consider the ED a “unit” and, as defined in the

law, staffing information, including the number of patients, must be posted

at “the end of the prevailing shift.” The Department acknowledges that ED

data is retrospective and that aggregate numbers do not take into account

“the acuity of the patients being treated.” Nevertheless, the Department is


19

without authority to make the revisions as suggested by the commenter

because the Department believes those revisions are contrary to the intent

of the statute. Finally, as noted earlier, health care providers on rapid

response teams, admission teams, various shifts, and in urgent care

centers would be counted in the definition of “direct patient care”

whenever such providers are included in one of the groups for which the

statute requires information.

25. COMMENT: The commenter stated that the counting of

patients in the PACU is an irrelevant function since the data is

retrospective. The commenter suggested posting the numbers of RNs

and nurses aides only and eliminating the number of patients on the form,

and providing patient census on a 24-hour basis. (3)

26. COMMENT: The commenter stated that the proposed post-

anesthesia care unit regulation is duplicative as current Department

regulations require specific staffing ratios for PACU units throughout the

state. In addition, the commenter saw no reason to gather and post such

data, which would not impact patient care or consumer education.

Therefore, the commenter recommended that the Department delete the

proposed PACU regulation. (4)

27. COMMENT: The commenter stated that calculations for the

PACU are unnecessary given that current Department regulations require

specific staffing ratios for that department. The commenter added that


20

N.J.A.C. 8:43G-35.3(b) states: “There shall be a ratio of at least one

registered professional nurse for every three patients in the post-

anesthesia care unit.” The commenter suggested that the Department

delete the provision regarding the PACU. (1, 8,13, 14) Another

commenter supported this position. (12)



which require “daily” posting of certain staffing information based on each

“unit” and “the end of the prevailing shift.” The Department considers the

post-anesthesia care unit as a “unit” and, as defined in the law, staffing

information, including the number of patients, must be posted at “the end

of the prevailing shift.” The Department acknowledges that PACU data is

retrospective and that existing Department rules require specific staffing

ratios for PACUs. However, the Department believes the required

reporting for PACUs meets the intent of the statute to provide as much

staffing information as possible to the public. The Department believes

the commenter’s proposed revisions are contrary to the intent of the

statute and therefore declines to make any change on adoption.

28. COMMENT: The commenter stated that if members of the

public are requesting staffing information, they should obtain quarterly

information from the Department or utilize the Department’s complaint line,

which is already available to the public. The commenter added that the


21

hospitals would not be able to provide information to the public due to

limited resources. (3)

29. COMMENT: The commenter stated that the provision of a

copy of daily postings at no charge and at any time to any member of the

public upon request would be onerous and would require additional

funding in order for hospitals to comply. The commenter recommended

that one copy of the daily posting be made available to patients and

families through normal record copying procedures in every healthcare

organization. “All other requests by individuals or entities. . .should be

directed to the. . . Department and addressed through their normal record

request procedures.” (13) Another commenter supported this position.

(12)

30. COMMENT: The commenters stated that compliance with the

mandate that “all general hospitals shall establish procedures to provide a

copy of the daily postings at no charge to any member of the public upon

request” would have significant adverse impact upon the resources of all

institutions. The commenters recommended that all such requests should

be funneled through the Department. (1, 8, 14)



which require a general hospital to “provide upon request to a member of

the public, information detailing for each unit and for the end of the


22

prevailing shift. . . .” Although the statute did not provide any funding, the

law requires compliance from facilities regarding the provision of

information upon request. In addition, hospitals would submit information

to the Department monthly and the Department would develop quarterly

numbers, which the public could easily retrieve from the Department

website. Hospitals may customize their procedures to allow sufficient time

for retrieval and copying.

31. COMMENT: The commenter stated that since reports will be

submitted to the Department on a “to-be-developed” web-based interface,

the most efficient and expeditious method of three-year storage would be

at the State level in an electronic archiving system, which the Department

should develop. (2)

32. COMMENT: The commenter stated that the three-year storage

of daily postings would involve a tremendous amount of paper, “3

sheets/day x 365 days/unit,” as well as the non-productive time of

retrieving the form each shift from every unit. The commenter

recommended that the Department develop an electronic form to enter

and aggregate data in an efficient manner. (3)

33. COMMENT: The commenter stated that the requirement to

have hospitals maintain data separately is superfluous because hospitals

must send the data to the Department’s web-based reporting system. The

commenter added that maintaining thousands of essentially duplicate


23

reports would be an expense to its non-profit organization. The

commenter recommended that because the Department will store data on

an electronic database, the Department should require hospitals to

maintain the “shift/daily” specific reports only until they submit that data

electronically to the Department website in the monthly reports. (4)


regulation seems to mandate “a redundancy in effort and a very expensive

one, in terms of paper, storage costs and manpower time” since the

Department will include the same data on a monthly basis on a web-based

system, which will be available to the public. The commenter, therefore,

recommended that the Department delete the proposed regulation

regarding three-year storage of daily postings. (13) Another commenter


35. COMMENT: The commenters stated that a 15-unit hospital

would generate an additional 49,275 reports for a three-year period. The

commenters recommended that the Department develop and test an

electronic archiving system prior to implementation of posting and

reporting rules. (1, 8, 14)



which states that hospital patients “are entitled to have access to the

information that is required to be posted. . . .” While the Department


24

acknowledges that hospitals find data retention burdensome and

superfluous, the Department has determined that the intent of the law is

that hospitals should maintain and have available for a reasonable amount

of time, such as the required three-year period, the daily staff posting

information to which patients, their families, and the public are entitled.

Furthermore, hospitals would be responsible for keeping daily shift

reports, paper or computerized copies, for three years in case of audits or

the need for verification. In addition, the Department would give hospitals

an Excel spreadsheet to aggregate information in an efficient manner.

The hospitals would input all the data from their calculations and give the

Department only aggregate information monthly. The Department would

archive monthly reports and make public quarterly reports. The

Department does not believe it is necessary for the Department to develop

an electronic archiving system and declines to make any changes on

adoption.

SECTION 4: Posting Locations

36. COMMENT: The commenter stated that there is an

inconsistent standard for posting. The commenter recommended that all

information be posted on the unit in a visible location or all posted in

waiting rooms. (3)

37. COMMENT: The commenters stated that based on their

recommendation to delete proposed regulations regarding the collection of


25

staff information in the ED and PACU, the Department should delete the

regulation about posting in the ED and PACU waiting areas. (1, 4, 8,13,

14) Another commenter supported this position. (12)

RESPONSE TO COMMENTS 36 AND 37: The proposed new

rules at N.J.A.C. 8:43G-17A implement N.J.S.A. 26:2H-5f, 5g and 5h,

which require general hospitals to “post daily. . .information detailing for

each unit. . . .” As noted previously under “Response to Comments 22

through 24 and 25 through 27,” the Department believes the commenter’s

proposed revisions to delete the rule about posting in the ED and PACU

waiting areas are contrary to the intent of the statute and therefore

declines to make any change on adoption. Posting is required by law and

the posting areas stated in the rule vary due to the different types of units

and factors such as accessibility and infection control.

SECTION 5: Reporting Requirements


reporting requirements would be costly and an undue burden to the

hospital. The commenter recommended that the Department should

develop and test an electronic tool, which the Department could make

available to each institution. Such a tool should automatically aggregate

the daily shift information. (3)

RESPONSE: The proposed new rules at N.J.A.C. 8:43G-17A

implement N.J.S.A. 26:2H-5f, 5g and 5h, which require general hospitals


26

to “report the information compiled to the commissioner on a monthly

basis.” The Department acknowledges that this reporting requirement

may be costly and burdensome to hospitals. As a result, the Department

is working to develop a web-based monthly reporting submission tool.

After considering issues of compatibility that may exist at some hospitals,

the Department will provide all hospitals with a basic Excel spreadsheet to

assist hospital staff with preliminary calculations. Although this tool will

not automatically aggregate information, it will assist hospitals in

complying with the statute and the rules without incurring undue cost and

burden.

39. COMMENT: The commenter stated that the hospitals should

validate the Department’s information for accuracy before the Department

releases such information to the public. The commenter added that

hospitals currently perform such validation regarding other data they

submit to the Department. (3)

40. COMMENT: The commenter recommended that staffing

information should not be publicly reported until validated by the individual

facility. (1, 8, 14)

RESPONSE TO COMMENTS 39 AND 40: The Department does

not have the staff or funds for independent validation of data. Therefore,

just as hospitals validate other data, they should also verify their staffing

information prior to submitting such data to the Department. In addition,


27

the Department will give hospitals the opportunity to review reports before

releasing them to the public.

SECTION 6: Penalty

41. COMMENT: The commenter recommended “that a one-year

time period should be given to work out any issues of data collection or

accuracy before fines are instituted since this model has not been tested.”

(3)

42. COMMENT: The commenters recommended that no fines be

issued until the system is fully implemented and tested. (1, 8, 14)

RESPONSE TO COMMENTS 41 AND 42: N.J.S.A. 8:43G-17A will

become effective upon publication of the Notice of Adoption in the New

Jersey Register. However, the Department will consider allowing a period

without instituting fines, as the model for staff posting and reporting is

new.

APPENDIX A

43. COMMENT: The commenter recommended the elimination of

all areas “already regulated for staffing such as the ICUs, PACU, NICU

and Mother/Baby.” The commenter added that the Department already

has the ability to monitor these areas or address concerns. (3)

44. COMMENT: The commenters stated that the “unit type”

section on the form includes many units for which there are already State

staffing guidelines and so the collection of additional data in these areas


28

would be redundant. Also, because Virtua utilizes mixed units, the results

could be misleading. The commenter recommended (1) that the draft

proposed forms should be eliminated for the units already covered by the

State guidelines; (2) that only medical surgical units should report data

regarding their direct patient caregivers; and (3) that hospitals should be

able to label the units more accurately on the forms. (1, 4, 8, 14)

45. COMMENT: The commenter stated that the Department

currently has staffing requirements in place for “adult intensive care unit /

critical care unit, normal newborn nursery, neonatal intensive and neonatal

intermediate bassinets, pediatric intensive care unit, and psychiatric

services.” The commenter added that since the Department has the

ability to monitor staffing in said units, the collection of additional staffing

information would not be useful. (13) Another commenter supported this

position. (12)



which does not allow for the exclusion of units based on current staffing

requirements. Therefore, the Department does not have the authority to

eliminate units and will not make any changes regarding the proposed

form and unit types on adoption.

46. COMMENT: The commenter stated “actual hours worked”

should be eliminated because this requirement appears to go beyond the


29

intent of the law. According to the commenter, calculating actual worked

hours would require the charge nurse to add or subtract hours depending

on whether the nurse took her or his meal time and breaks. The

commenter recommended that the Department only require hospitals to

calculate the number of nurses. (1, 3, 8, 14)

47. COMMENT: The commenter stated that given contractual

language regarding staff pay for eight hours, including time for meals, the

Department’s use of the phrase “actual hours worked” might result in

confusion and result in inaccurate reporting. (13) Another commenter


RESPONSE TO COMMENTS 46 AND 47: The national standard

for calculating worked hours is “hours worked per patient day.” In the

absence of consensus from the QIAC, the Department relies on its

interpretation of the intent of the legislation (N.J.S.A. 26:2H-5f, 5g and 5h)

and will consider “actual hours worked” rather than counting staff at the

end of the shift. The Department would not count lunchtime, but would

count breaks.

48. COMMENT: The commenters recommended the elimination of

the proposed reporting forms. The commenters suggested that the

posting of staffing information should be required only on medical surgical

units and that the Department should use data it currently collects on the

cost reports to determine actual hours worked per patient day. Other


30

commenters stated that an electronic system for reporting staffing

information to the Department should be developed and tested prior to full

implementation of the regulations. (1,8,13,14) Alternatively, NJHA stated

that it is prepared to work with hospitals to develop a system similar to that

developed in Massachusetts which requires publicly reported staffing

plans and an update, reflecting actual hours worked, on an annual basis.

(13) Another commenter supported this position. (12)

RESPONSE: The rules at N.J.A.C. 8:43G-17A do not include a

“reporting form.” The Department includes a “daily posting form” to

capture the staffing information required by N.J.S.A. 26:2H-5f, 5g and 5h.

The Department will develop a web-based system for monthly reporting by

the hospitals. Although the Department appreciates NJHA’s willingness to

work with hospitals to develop a system similar to that used in

Massachusetts, the Department believes the Massachusetts system is not

in keeping with New Jersey law because the reporting requirements are

different.

SUPPORTIVE COMMENTS

49. COMMENT: The commenters “strongly” supported the

Department’s proposal and methodology for determining nurse staffing

calculations based on worked hours. They stated, “giving the public the

right to know staffing levels at hospitals provides our patients, their

families, and our communities with some of the information they want and


31

deserve when they are making critical health care decisions and facing

frightening health crises.” The commenters stated that federal regulations

recently went into effect requiring staff posting in nursing homes and

added that access to staffing information will also benefit hospitalized

patients and their families. They added that the regulations “will enable

the public to make more informed choices when selecting a health care

facility and will enable the Department to evaluate staffing in relationship

to other quality indicators.” (28 through 43)

50. COMMENT: The comments stated that as nurses in a

subacute and long-term care facility, they need to enforce safe nurse to

patient ratios. The commenters added that their patients are “medically

fragile and require more than custodial care.” Finally, they stated,

“Facilities are for profit, we need to make sure at least adequate care is

given.” (39 through 43).”

51. COMMENT: The commenter stated support for the proposed

regulations and noted, “in addition to public protection, these new rules will

be consistent with the requirements of the Joint Commission on

Accreditation of Healthcare Organizations (JCAHO) Staffing Effectiveness

Standards that should streamline the data collection and reporting

requirements of hospitals.” (21)

52. COMMENT: The commenter stated that since nurses provide

the majority of care to patients in acute care hospitals, they “support the


32

proposal and method chosen by the Department of Health and Human

[Senior] Services in determining nurse staffing calculations based on

worked hours.” The commenter stated that the proposed regulations will

help patients and their families make decisions, enhance safe and

effective patient care, and improve the Department’s ability to evaluate

and manage staffing levels. (18)

53. COMMENT: The commenter stated that the Department’s

choice “for using a standardized method of calculation of the number of

worked hours to determine staffing is strongly supported. Without a

standard, the information reported to the public and the Department of

Health would have no consistency and defeat the purpose of comparison.”

The commenter added, “these provisions will enable the public to make

more informed choices when selecting a health care facility and will

enable the Department to evaluate staffing in relationship to other quality

indicators.” (15)

54. COMMENT: The commenter stated that this public disclosure

“will enable the patients and their families to choose the healthcare facility

with the sufficient numbers of staff who can provide them better care. . .”

and will motivate facilities “to improve and implement a safe staffing ratio.”

(17)

55. COMMENT: The commenter stated its organization’s strong

support for “the proposed methodology for determining nurse staffing


33

calculations based on worked hours.” The commenter added that the

proposed rules will help the Department “evaluate existing staffing levels

in our facilities in an accurate and objective manner. A myriad of

reputable national organizations support or have adopted the same

concept.” (23)

56. COMMENT: The commenter stated support for the

Department’s position that nurse staffing calculations per unit per shift

would be calculated based on “the total actual hours of staff providing

direct care worked during the shift.” The FTE methodology “indicated in

the proposed rules is universally recognized as the ‘standard’ for staffing

calculation by many groups and disciplines.” (16)

57. COMMENT: The commenter stated its wholehearted

concurrence with “the Department’s proposal to utilize the accepted

standard of Full-Time Equivalents (FTEs) as a means of reporting staffing

information.” (27)

58. COMMENT: The commenter “finds the rule clear and believes it

achieves the intent of the statute.” In addition, the commenter agrees with

the Department that the methodology employed for counting the number

of staff will provide a calculation that can be used for “inter-hospital

comparison of data.” (22)

59. COMMENT: The commenter stated that the FTE methodology

indicated in the proposed rules is universally recognized as the “standard”


34

for staffing calculations across occupational groups because it “accurately

quantifies actual time worked; facilitates comparisons between units and

organizations; and is easy to calculate.” The commenter added that the

methodology has been adopted by employers, governments, research

institutions, and professional organizations worldwide. The commenter

also noted that “recognizing the importance of having an accurate and

standard methodology for calculating nurse staffing, the Center for

Medicare and Medicaid Services require that Skilled Nursing Facilities

report staffing levels of Registered Nurses, Licensed Practical Nurses, and

Certified Nursing Assistants in Full-Time Equivalents (FTEs), based on

actual hours worked.” (9)

60. COMMENT: The commenter stated that the proposed new

rules requiring hospitals and nursing homes to provide staffing information

to the public are similar to their examples of New Jersey hospitals

reporting infection rates to the public. The commenter added that its

“Union members and their family members frequent the Skilled Nursing

Facilities and Nursing Facilities and they would find significant succor

were staffing information regarding these facilities made public.” Finally,

the commenter “fervently supports the regulations as proposed.” (26)

61. COMMENT: The commenter stated that nurse staffing

calculations based on worked hours will enable inter-hospital comparisons

of data and may provide a means for researchers to develop methods of


35

analysis of staffing data to develop indicators of “safe / quality care.” In

addition, the numbers can be studied in relation to such variables as nurse

satisfaction, burn out, and intent-to-leave, thus benefiting patients, nurses,

and institutions alike. (7)

62. COMMENT: The commenter stated that the proposed rules will

improve the Department’s ability to asses the existing staffing levels and

measure the facilities’ attempts to provide safe staffing. In addition, the

commenter stated that staff posting would help patients and their families

to make informed decisions regarding their health care choices. The

commenter also strongly supports the Department’s “methodology for

determining nurse staffing calculations based on actual hours worked.”

(5)

63. COMMENT: The commenter stated that the proposed staff

posting regulations are a beginning. With over 40 years experience

ranging from a practicing RN to Dean of Rutgers College of Nursing, the

commenter had a recent hospital stay and wrote from the perspective of

both professional and patient. She noted that the primary reason for

nursing shortages is the shortage of decent working conditions for nurses.

She added that the Institute of Medicine has consistently reported that

one’s life depends upon the hospital they select—and the two main criteria

are the number of Board Certified Physicians and the number of

Registered Nurses. She also quoted the January / February 2006 issue of


36

the Journal of Health Affairs as follows: “Increasing the number of RNs

and the number of hours of care RNs devote to patients would save 6,700

lives and four million days of patient care in hospitals each year.” (6)

64. COMMENT: The commenters stated that the proposed rules

will improve the Department’s ability “to evaluate existing staffing levels in

our health care facilities, as well as the measures hospitals use to provide

safe staffing.” The commenters added that the provisions will enable the

Department to evaluate staffing in relationship to other quality indicators.

The commenters also stated their strong support of the Department’s “way

of determining nurse staffing calculations based on actually worked

hours.” (19, 24)

65. COMMENT: The commenters stated their strong support for

the proposed regulations and agree that staffing levels should be

calculated using FTEs. The commenters also stated that a number of

nationally recognized organizations support this concept as well. Finally,

the commenters support these regulations, which will help provide the

public with the number of caregivers per patient in a clear and concise

manner that could be compared across facilities. (11, 20)

RESPONSE TO COMMENTS 49 THROUGH 65: The Department

appreciates the support of the above commenters and thanks them for

their informative and insightful comments. The Department also

appreciates comments, which stated, “Union members and their family


37

members frequent the Skilled Nursing Facilities and Nursing Facilities and

they would find significant succor were staffing information regarding

these facilities made public.” The Department reminds the commenters

that the rules at N.J.A.C. 8:43G-17A apply to general hospitals. As the

Department stated in the Notice of Proposal at 39 N.J.R. 1363(a), “the

Department anticipates future rulemaking to fulfill the statutory

requirement for licensed nursing homes.”

Documents

HEALTH AND SENIOR SERVICES SENIOR …web.doh.state.nj.us/apps2/documents/bc/notice_adoption02.pdfThe compilation and reporting regulations would require extensive nursing time to complete