S AMDT 1031

S 1031 IS

To amend the Public Health Service Act to establish direct care registered nurse-to-patient staffing ratio requirements in hospitals, and for other purposes.

May 13, 2009

Mrs. BOXER introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions

To amend the Public Health Service Act to establish direct care registered nurse-to-patient staffing ratio requirements in hospitals, and for other purposes.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ‘National Nursing Shortage Reform and Patient Advocacy Act’.

SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE STAFFING REQUIREMENTS.

(a) Minimum Direct Care Registered Nurse Staffing Requirements- The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following new title:

‘TITLE XXXI--MINIMUM DIRECT CARE REGISTERED NURSE STAFFING REQUIREMENTS

‘SEC. 3101. MINIMUM NURSE STAFFING REQUIREMENTS.

‘(a) Staffing Plan-

‘(1) IN GENERAL- A hospital shall implement a staffing plan that--

‘(A) provides adequate, appropriate, and quality delivery of health care services and protects patient safety; and

‘(B) is consistent with the requirements of this title.

‘(2) EFFECTIVE DATES-

‘(A) IMPLEMENTATION OF STAFFING PLAN- Subject to subparagraph (B), the requirements under paragraph (1) shall take effect not later than 1 year after the date of enactment of this title.

‘(B) APPLICATION OF MINIMUM DIRECT CARE REGISTERED NURSE-TO-PATIENT RATIOS- The requirements under subsection (b) shall take effect as soon as practicable, as determined by the Secretary, but not later than 2 years after the date of enactment of this title, or in the case of a hospital in a rural area (as defined in section 1886(d)(2)(D) of the Social Security Act), not later than 4 years after the date of enactment of this title.

‘(b) Minimum Direct Care Registered Nurse-to-Patient Ratios-

‘(1) IN GENERAL- Except as otherwise provided in this section, a hospital’s staffing plan shall provide that, at all times during each shift within a unit of the hospital, a direct care registered nurse shall be assigned to not more than the following number of patients in that unit, subject to paragraph (4):

‘(A) 1 patient in trauma emergency units.

‘(B) 1 patient in operating room units, provided that a minimum of 1 additional person serves as a scrub assistant in such unit.

‘(C) 2 patients in critical care units, including neonatal intensive care units, emergency critical care and intensive care units, labor and delivery units, coronary care units, acute respiratory care units, postanesthesia units, and burn units.

‘(D) 3 patients in emergency room units, stepdown units, pediatrics units, telemetry units, and combined labor, delivery, and postpartum units.

‘(E) 4 patients in antepartum units, intermediate care nursery units, psychiatric units, and other specialty care units.

‘(F) 5 patients in medical-surgical units, rehabilitation units, and skilled nursing units.

‘(G) 8 patients in well-baby nursery units and postpartum (4 couplets) units.

‘(2) SIMILAR UNITS WITH DIFFERENT NAMES- The Secretary may apply minimum direct care registered nurse-to-patient ratios established in paragraph (1) to a type of hospital unit not referred to in such paragraph if such other unit performs a function similar to the function performed by the unit referred to in such paragraph.

‘(3) RESTRICTIONS-

‘(A) PROHIBITION AGAINST AVERAGING- A hospital shall not average the number of patients and the total number of direct care registered nurses assigned to patients in a hospital unit during any 1 shift or over any period of time for purposes of meeting the requirements under this subsection.

‘(B) PROHIBITION AGAINST IMPOSITION OF MANDATORY OVERTIME REQUIREMENTS- A hospital shall not impose mandatory overtime requirements to meet the hospital unit direct care registered nurse-to-patient ratios required under this subsection.

‘(C) RELIEF DURING ROUTINE ABSENCES- A hospital shall ensure that only a direct care registered nurse may relieve another direct care registered nurse during breaks, meals, and other routine, expected absences from a hospital unit.

‘(D) PROHIBITION AGAINST IMPOSITION OF LAY-OFFS- A hospital shall not impose lay-offs of licensed vocational or practical nurses, licensed psychiatric technicians, certified nursing assistants, or other ancillary staff to meet the hospital unit direct care registered nurse-to-patient ratios required under this subsection.

‘(4) ADJUSTMENT OF RATIOS-

‘(A) IN GENERAL- If necessary to protect patient safety, the Secretary may prescribe regulations that--

‘(i) increase minimum direct care registered nurse-to-patient ratios under this subsection to further limit the number of patients that may be assigned to each direct care nurse; or

‘(ii) add minimum direct care registered nurse-to-patient ratios for units not referred to in paragraphs (1) and (2).

‘(B) CONSULTATION- Such regulations shall be prescribed after consultation with affected hospitals and registered nurses.

‘(5) NO PREEMPTION OF CERTAIN STATE-IMPOSED RATIOS- Nothing in this title shall preempt State standards that the Secretary determines to be at least equivalent to Federal requirements for a staffing plan established under this title. Minimum direct care registered nurse-to-patient ratios established under this subsection shall not preempt State requirements that the Secretary determines are at least equivalent to Federal requirements for a staffing plan established under this title.

‘(6) EXEMPTION IN EMERGENCIES- The requirements established under this subsection shall not apply during a declared state of emergency if a hospital is requested or expected to provide an exceptional level of emergency or other medical services.

‘(c) Development and Reevaluation of Staffing Plan-

‘(1) CONSIDERATIONS IN DEVELOPMENT OF PLAN- In developing the staffing plan, a hospital shall provide for direct care registered nurse-to-patient ratios above the minimum direct care registered nurse-to-patient ratios required under subsection (b) if appropriate based upon consideration of the following factors:

‘(A) The number of patients and acuity level of patients as determined by the application of an acuity system (as defined in section 3107(1)), on a shift-by-shift basis.

‘(B) The anticipated admissions, discharges, and transfers of patients during each shift that impacts direct patient care.

‘(C) Specialized experience required of direct care registered nurses on a particular unit.

‘(D) Staffing levels and services provided by other health care personnel in meeting direct patient care needs not required by a direct care registered nurse.

‘(E) The level of technology available that affects the delivery of direct patient care.

‘(F) The level of familiarity with hospital practices, policies, and procedures by temporary agency direct care registered nurses used during a shift.

‘(G) Obstacles to efficiency in the delivery of patient care presented by physical layout.

‘(2) DOCUMENTATION OF STAFFING- A hospital shall specify the system used to document actual staffing in each unit for each shift.

‘(3) ANNUAL REEVALUATION OF PLAN AND ACUITY SYSTEM-

‘(A) IN GENERAL- A hospital shall annually evaluate--

‘(i) its staffing plan in each unit in relation to actual patient care requirements; and

‘(ii) the accuracy of its acuity system.

‘(B) UPDATE- A hospital shall update its staffing plan and acuity system to the extent appropriate based on such evaluation.

‘(4) TRANSPARENCY-

‘(A) IN GENERAL- Any acuity-based patient classification system adopted by a hospital under this section shall be transparent in all respects, including disclosure of detailed documentation of the methodology used to predict nursing staffing, identifying each factor, assumption, and value used in applying such methodology.

‘(B) PUBLIC AVAILABILITY- The Secretary shall establish procedures to provide that the documentation submitted under subsection (e) is available for public inspection in its entirety.

‘(5) REGISTERED NURSE PARTICIPATION- A staffing plan of a hospital shall be developed and subsequent reevaluations shall be conducted under this subsection on the basis of input from direct care registered nurses at the hospital or, where such nurses are represented through collective bargaining, from the applicable recognized or certified collective bargaining representative of such nurses. Nothing in this title shall be construed to permit conduct prohibited under the National Labor Relations Act or under the Federal Labor Relations Act.

‘(d) Acuity Tool-

‘(1) IN GENERAL- Not later than 2 years after the date of enactment of the National Nursing Shortage Reform and Patient Advocacy Act, the Secretary shall develop a national acuity tool that provides a method for establishing nurse staffing requirements above the hospital unit direct care registered nurse-to-patient ratios required under subsection (b).

‘(2) IMPLEMENTATION- Each hospital shall adopt and implement the national acuity tool described in paragraph (1), and provide staffing based on such tool. Any additional direct care registered nursing staffing above the hospital unit direct care registered nurse-to-patient ratios described in subsection (b) shall be assigned in a manner determined by such national acuity tool.

‘(e) Submission of Plan to Secretary- A hospital shall submit to the Secretary its staffing plan required under subsection (a)(1) and any annual updates under subsection (c)(3)(B).

‘SEC. 3102. POSTING, RECORDS, AND AUDITS.

Full Text of Legislation