2nd Annual Becker College Nursing Symposium An Analysis of House Bill 2663 and Senate Bill 1260 as R

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2nd Annual Becker College Nursing Symposium
An Analysis of House Bill 2663 and Senate Bill
1260as Related to Nurse StaffingPresented by
Debra Hurwitz, RN, BSN, MBA UMass Center for
Health Policy and Research Director, State
Health Policy Analysis UnitOctober 28th, 2005
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Background and Context (I)

• Nationally
• Nursing shortage
• Aging nurse workforce
• Higher inpatient acuity
• Concerns about patient safety quality of care
• California Assembly Bill 394 first mandatory
  nurse staffing ratio law in nation

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Background and Context (II)

• Here in Massachusetts
• Two alternative bills before the state
  legislature
• House Bill 2663
• Senate Bill 1260
• Both have a common mission to improve nurse
  staffing and patient safety.
• However, the bills have proposed different
  approaches to achieve these ends.

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Presentation Overview
Review of the Literature on Nurse Staffing
Quality of Care

• Review of Other Technical Reports Data Sources
• The California Experience
• The MA Nursing Labor Market
• Nursing Education

Comparison of Nursing Bills HB 2663 SB 1260

• Potential Costs to
• Hospitals
• Public Agencies

Conclusions
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Methodology for Literature Review

• Searched for articles in peer-reviewed medical
  and health services research journals
• PubMed search engine
• Focused on work by top researchers in nursing,
  patient safety, quality of care, and workforce
  issues
• Also searched for technical reports and primary
  data sources on nursing workforce, education
  system

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Review of the LiteratureNurse Staffing
Quality of Care

• Studies of quality measures and patient outcomes
  can be broadly grouped as follows mortality,
  length of stay, adverse events, and medical
  errors.
• Research studies vary with regard to questions
  they were designed to answer and research methods
  used.
• Literature points out that a variety of factors
  in addition to nurse staffing levels impact
  patient safety and quality of care patient
  acuity, nursing skill mix, work environment, etc.

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Research StudiesNurse Staffing Quality of
Care
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Review of the LiteratureNurse Staffing
Quality of Care

• Research does suggest that higher nurse staffing
  is associated with improvement in some patient
  outcomes.
• Limited number of unit types analyzed
• Lack of analysis of staffing needs by shift
• Studies also find that longer work hours and more
  patients per nurse are associated with nurse job
  dissatisfaction and burnout, and with increased
  self-reports of medical errors.
• However, there are no empirical studies that
  support specific nurse-to-patient ratios or
  benchmarks for each type of patient care unit.

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Presentation Overview
Review of the Literature on Nurse Staffing
Quality of Care

• Review of Other Technical Reports Data Sources
• The California Experience
• The MA Nursing Labor Market
• Nursing Education

Comparison of Nursing Bills HB 2663 SB 1260

• Potential Costs to
• Hospitals
• Public Agencies

Conclusions
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Review of Other Technical Reports Data
Sources The California Experience

• California's AB 394 passed in 1999 and
  implemented in 2004
• Projected cost estimates from California research
  on proposed nurse-patient ratios in med/surg
  units ranged from 800,000 to 2.3 million per
  hospital.
• There is concern that mandated ratios, combined
  with nursing shortages, could lead to hospitals
  reducing their bed capacity.
• It is too soon to determine the actual financial
  impact of Californias mandated nurse ratios on
  hospitals.
• Stay tuned

Sources Spetz J et al. Minimum Nurse Staffing
Ratios in California Acute Care Hospitals, Center
for the Health Professions, University of
California, San Francisco, December 2000
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Review of Other Technical Reports Data
Sources The MA Nursing Labor Market

• Massachusetts RN vacancy rate estimated at 7 for
  2005.
• RN vacancies in MA predicted to rise to 9,096 in
  2010 from 4,820 in 2005.
• Average age of RNs in MA is 48 years old, 3 years
  higher than national average.
• In 2000 just 9.1 of RN workforce was under 30,
  compared with 25.1 in 1980.

Sources U.S. DHHS, HRSA, Bureau of Health
Professions, July 2002 Center for Health
Professions at Worcester State College, 2001
Massachusetts Nurse Workforce Survey Spratley E,
et al., The Registered Nurse Population Findings
from the National Sample Survey of Registered
Nurses. HRSA, Bureau of Health Professions,
Division of Nursing, March 2000.
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Review of Other Technical Reports Data
Sources Nursing Education (I)
Source Massachusetts Board of Registration in
Nursing
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Review of Other Technical Reports Data
SourcesNursing Education (II)

• MA has 40 programs offering RN or higher degrees.
• 78 of MA RN programs reported that a total of
  1,814 qualified applicants were turned away in
  2004.
• Over 20 of RN programs listed faculty vacancies
  as the primary reason for turning away
  candidates.
• MA nurse faculty vacancy rate is expected to
  reach 8 for 2005-06 academic year similar to
  national average.

Sources Massachusetts Board of Registration in
Nursing Massachusetts Association of Colleges of
Nursing, Ensuring Educated Nursing Workforce for
the Commonwealth, July 2005.
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Presentation Overview
Review of the Literature on Nurse Staffing
Quality of Care

• Review of Other Technical Reports Data Sources
• The California Experience
• The MA Nursing Labor Market
• Nursing Education

Comparison of Nursing Bills HB 2663 SB 1260

• Potential Costs to
• Hospitals
• Public Agencies

Conclusions
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Facilities Affected by the Bills

• HB 2663
• Any licensed private or state-owned and operated
  general acute care hospital
• Any acute care unit within a state-operated
  hospital
• Any acute psychiatric or specialty hospital
• The teaching hospital of the UMass Medical School
• SB 1260
• General acute care hospitals
• Public, state-owned hospitals
• Chronic disease and acute inpatient
  rehabilitation hospitals
• The teaching hospital of the UMass Medical School

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Comparison of Nursing Bills (I)
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Comparison of Nursing Bills (II)
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Comparison of Nursing Bills (III)
Trust fund provisions to be funded from the
interest gained from 30 million (At 5/year
1.5 million/year)
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Presentation Overview
Review of the Literature on Nurse Staffing
Quality of Care

• Review of Other Technical Reports Data Sources
• The California Experience
• The MA Nursing Labor Market
• Nursing Education

Comparison of Nursing Bills HB 2663 SB 1260

• Potential Costs to
• Hospitals
• Public Agencies

Conclusions
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Potential Costs to HospitalsMethodology (I)

• No publicly-available source of unit-level nurse
  staffing data for hospitals statewide
• Only completed cost analysis for HB 2663
• No ratios in Senate bill
• We obtained data from a voluntary sample group of
  9 hospitals
• Three general acute care community hospitals (two
  suburban, one rural)
• Three general acute care teaching hospitals (two
  in greater Boston, one outside of Boston)
• One state-owned (Department of Public Health)
  hospital
• One free-standing psychiatric hospital
• One rehabilitation hospital
• Hospitals supplied 2004 data on registered nurse
  (RN) staffing and inpatient utilization (patient
  days) by unit

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Potential Costs to HospitalsMethodology (II)
Convert proposed nurse-to-patient ratio to HPPD
Compare proposed and actual nursing hours
Calculate cost to unit with shortfall
Calculate actual hours per patient day (HPPD) for
each unit
RN hours HPPD Ptnt days
Nurse HPPD Patient 24
Shortfall (Surplus) Proposed Hours Actual
Hours
Shortfall hrs x Avg. hourly pay Cost Pay
WagesBenefits

• Assumptions
• Nurses cannot be transferred from units with
  surplus to units with shortfall this
  assumption is critical, because many units did
  exceed required ratios.
• Staffing ratios must be met 24 hours per day.

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Potential Costs to HospitalsMethodology (III)

• Data and Analysis Limitations
• We could not analyze data for all hospital units
  data not available at level of detail required
  to do cost estimate.
• Some potential costs not considered recruitment
  and training costs, higher nurse wages because of
  increased demand.
• Potential savings not considered either as
  increased nurse staffing could create cost
  offsets through shorter patient length of stay.
• HB 2663 proposed ratios are only minimums if
  acuity-based Patient Classification System (PCS)
  calls for higher staffing, hospitals must staff
  above minimum ratios.

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Nurse Staffing Ratios as Proposed in HB 2663 (I)
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Nurse Staffing Ratios as Proposed in HB 2663 (II)

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HB 2663 - Summary of HospitalUnits Estimated to
be Deficient
As a percentage of total RN payroll in hospital
units analyzed.
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Potential Impact of Mandated Staffing Ratios

• Impact will vary greatly by hospital/unit type
• Psychiatric and rehab specialty hospitals (and
  psychiatric units in general hospitals) and
  state-owned (DPH) hospitals would have faced the
  greatest staffing challenges
• HB 2663 ratios may not fully account for
  different or evolving models of care
• Psychiatric care uses fewer nurses, more mental
  health workers, social workers, etc.
• Rehabilitation uses more physical therapists,
  personal care attendants
• Both require lower staffing intensity during
  overnight shift
• Some variation by region
• Boston-area community and teaching hospitals
  would have felt the least impact

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Potential Costs to Public Agencies of Provisions
in HB 2663 SB 1260

• Neither bill provides funds for roles assigned to
  DPH or other state entities.
• However, both bills permit non-compliant
  facilities to be fined said fines would be
  distributed to the Betsy Lehman Center.
• These figures provided by Department of Public
  Health.

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Presentation Overview
Review of the Literature on Nurse Staffing
Quality of Care

• Review of Other Technical Reports Data Sources
• The California Experience
• The MA Nursing Labor Market
• Nursing Education

Comparison of Nursing Bills HB 2663 SB 1260

• Potential Costs to
• Hospitals
• Public Agencies

Conclusions
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Policy ImplicationsPatient Safety and Quality
of Care

• Both bills include features that are likely to
  contribute to patient safety and improved quality
  of care
• Both require public oversight (via DPH) that may
  promote hospital accountability of nurse staffing
  and transparency to legislature and public.
• SB 1260 establishes a mechanism for data
  collection necessary for ongoing monitoring and
  evaluation.
• SB 1260s provisions for reporting nurse
  sensitive quality measures, combined with its
  staffing plan requirements, could be a powerful
  tool for evaluating impact of nurse staffing on
  the quality of patient care.
• Although the literature supports the premise that
  higher nurse staffing in general is associated
  with improved patient outcomes, there is no
  evidence that establishes unit-specific ratios or
  benchmarks at this time.

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Policy ImplicationsCosts/Impact to
Hospitals/Access

• HB 2663 would effect MA hospitals differently
  depending on facility type.
• Out of the 9 hospitals analyzed using 2004 data
• Specialty hospitals and the state-owned hospital
  had the greatest impact nurse staffing costs
  would have doubled or tripled on some units
• Hospitals outside greater Boston area were also
  affected, but not as strongly
• Boston-area community and teaching hospitals had
  the least impact
• The ratios proposed in HB 2663 do not appear to
  adequately account for hospital-specific
  characteristics, e.g., model of care delivery,
  staff mix, patient acuity.

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Policy ImplicationsLabor Market Nursing
Education

• HB 2663 will stimulate demand for RNs, while SB
  1260 potentially could do so.
• Therefore both bills could exacerbate the current
  nursing shortage.
• HB 2663 has no provisions regarding nursing
  education and workforce development.
• SB 1260s nurse workforce development provisions
  are a first step towards addressing the RN
  shortage, but more resources need to be devoted
  to expanding nursing school capacity (faculty and
  clinical training facilities).

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Comparison of Nursing BillsThe Similarities

• Both bills have a common goal to improve patient
  safety through more appropriate nurse staffing.
• Both focus on hospital accountability and
  transparency.
• Both create a role for DPH in monitoring hospital
  nurse staffing patterns and enforcing compliance.
  
• Both have a requirement that hospitals develop
  detailed nurse staffing plans, based on careful
  assessment of patient needs.

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Comparison of Nursing BillsThe Differences

• HB 2663 mandates specific nurse-to-patient ratios
  for various hospital units.
• SB 1260 requires hospitals to determine their own
  appropriate staffing levels based on patient
  acuity and hospital characteristics.
• SB 1260 has some limited support for nurse
  education.
• SB 1260 has provisions for collecting data on
  nurse sensitive indicators and hospital quality
  measures.

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For More Information

• To access the full text of our report, Analysis
  of House Bill 2663 and Senate Bill 1260 As
  Related to Nurse Staffing, go to
• www.umassmed.edu/healthpolicy/NurseStaffing.cfm