8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
1/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 10Mandatory Minimum Staffing
Ratios: Are They Working?
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
2/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
3/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Staffing Ratios (cont d!
!ncreasing demand for ade uate staffing ratios of RNs inacute"care settings
National movement already begun to mandate minimumstaffing ratios
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
4/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
5/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
True or $a%se:
Research has demonstrated a direct causal link betweenstaffing levels and patient outcomes+
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
6/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Ans&er: $a%se
$lthough research has identified an associated linkbetween staffing levels and patient outcomes, this
relationship has not be identified as causal+
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
8/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
'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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
9/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
'eed for Mandatory Minimum StaffingRatios? (cont d!
(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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
10/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
'eed for Mandatory Minimum StaffingRatios? (cont d!
(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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
11/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
12/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Ca%ifornia as the "rototype (cont d!
-rohibition of unlicensed personnel from performingprocedures
. /edication administration
. 9enipuncture
. -arenteral or tube feedings
. !nserting nasogastric tubes, catheters
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
13/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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 )*+
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
14/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
15/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
True or $a%se:
(alifornia has had mandatory minimum staffing ratios forgeneral medical"surgical units for over three decades+
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
16/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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 )
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
17/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
18/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
19/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
20/29Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
*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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
21/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assuring Comp%iance
(56# charged with compliance oversight of mandatoryminimum staffing ratios
-rocedures for
. (ompliance verification
. Responding to complaints
. $ddressing compliance violations
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
22/29
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
23/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
True or $a%se
The =at"all"times> clause of (alifornia legislation did notapply to break and lunch times+
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
24/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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+
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
25/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
26/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
27/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
#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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
28/29
Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
#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
8/10/2019 CH10- Mandatory Minimum Nursing Ratios- Are They Working(1)
29/29
nd of "resentation
Recommended