Defining ‘Safe’ Proposed ‘Patient Safety Act’ Would Let Health Professionals Set Nursing Levels

When asked to define the word ‘safe,’ as used in the phrases safe staffing levels and safe patient care, Karen Moore said that, from a patient’s perspective, it means having “the right nurse with the right set of skills at the right time.”


And she believes that health care professionals, and not the state Legislature, should be able to determine just what constitutes ‘safe.’ That’s why she fully supports a bill filed recently by state Sen. Richard Moore (no relation) called the Patient Safety Act.

The full name of the measure is “an act to promote safe patient care and support the nursing profession,” said Karen Moore, vice president of Hospital Operations at Franklin Medical Center in Greenfield and current president of the Mass. Organization of Nurse Executives (MONE). She told The Healthcare News that, if the bill is passed, it should accomplish both of those stated goals.

Paul Wingle, director of communications for the Mass. Hospital Assoc., agreed. He said the bill will provide strong measures of oversight and accountability when it comes to nurse staffing, and it will also put in place programs that will encourage more young people to get into the nursing profession and give more individuals an opportunity to pursue a career in that field.

It will also provide something that supporters of the bill say is missing from legislation that would create minimum nurse-staffing levels — flexibility. “Mandated ratios put doctors, nurses, and hospitals in a straitjacket,” said Wingle. “We need a better answer.”

Dr. James Fanale, chief operating officer at Mercy Medical Center and chief medical officer for the Sisters of Providence Health System, concurred. He said that, while safe is, indeed, a relative term, he believes it is up to medical professionals, and not the government, to define it.

“We need to help drive the train and not be driven,” he said of the process of defining ‘safe.’ “If the hospitals and the health care community don’t want to lead this effort, someone else will do it for them — and I think we should lead it.”

But the Mass. Nurses Association (MNA), a strong supporter of mandated nurse-staffing ratios and a bill (which never came to a full vote last spring) that would have created them, has a different take on the Moore bill. MNA President Karen Higgins said the Patient Safety Act does not address the problem of understaffing in the Commonwealth’s hospitals, a situation that she believes ultimately contributes to the ongoing nurse shortage.

“The evidence makes clear that poor staffing and dangerous working conditions created by the hospital industry have caused and continue to exacerbate a shortage of nurses — nurses who are no longer willing to work in hospitals,” she said in a prepared statement, adding that this is one of many reasons why the MNA, acting in conjunction with the Coalition to Protect Massachusetts Patients, has re-filed its minimum staffing levels bill.

Higgins said that the Patient Safety Act, as written, would create too much ambiguity when it comes to setting safe staffing levels, a situation that would be averted through the establishment of strict minimums.

The Healthcare News looks this month at the Patient Safety Act and how it differs from the MNA-supported legislation — and also from the current system, if there is one, for determining just what is ‘safe staffing.’

Numbers Game

Fanale told The Healthcare News that, had the minimum staffing levels proposed in the MNA-backed bill become law this year, Mercy Medical Center would have faced additional costs in the neighborhood of $1 million to $3 million annually.

But it wasn’t the cost alone that prompted the strong opposition to the measure, he said. Instead, it was what most hospital administrators consider the arbitrary nature of those minimum staffing levels and the loss of control that would have resulted.

He said a hospital might have been faced with the prospect of shutting down an emergency department or an entire wing if a few nurses should call in sick at the wrong time.

Moore concurred, and said the mandated ratios rob health care professionals of the ability to make their own judgments on how many patients they can tend to a given time.

“In an emergency room, patients are highly variable,” she said, using a hypothetical example in which there is a mandated ratio of one nurse for three patients. “You can have three patients with sore throats, or you can have one or more that was in a serious motor vehicle accident; in a professional model and a fluid system, you would have a team of professionals evaluating those patients, taking care of them, and directing patient flow.

“To arbitrarily set a ratio when the nurses could be saying, ‘we can absolutely be handling more patients right now,’ is the wrong approach,” she continued. “Because if another person comes to the emergency room door, the nurses couldn’t care for them — they’d have to go somewhere else.”

This is exactly what has happened in California, the only state that has minimum staffing levels, she said. Rigid staffing manadates have led to a number of problems involving access to care and overall quality of care — so many that the state recently froze implementation of new, more stringent stages of its law.

“The California experience has caused delays in care, it’s decreased access to care, it’s increased emergency room diversions, and it’s delayed elective surgeries,” said Moore. “It’s done all the things we feared it would, because it’s a rigid, inflexible approach to assessing and providing for staffing.”

The Patient Safety Act was crafted to address that issue of control, said Richard Moore, by putting decision-making on staffing levels in the hands of medical professionals.

“The act allows nurses and doctors — not state government — to make patient-care decisions and ensures the high level of safety and quality of care that we expect from our world-class hospitals,” said Moore, chairman of the Legislature’s Joint Committee on Health Care. “This is a much more effective and less-costly approach than an expensive, inflexible government mandate.”

In a statement endorsing the act, the Mass. Hospital Assoc. (MHA) said the measure would:
• Increase the number of hospital nurses by providing financial aid for people who attend nursing school and who agree to work in a Massachusetts hospital. The program would help address the current shortfall of trained nurses;
• Allow nurse leaders to continue to set safe staffing levels, with required input from staff nurses, rather than imposing a costly government mandate that deprives doctors and nurses of the flexibility they need to decide best how to care for their patients;
• Provide oversight of hospital staffing plans through the Department of Public Health (DPH). Hospitals will be required to report variances from their staffing plans to DPH. They will also have to tell DPH what appropriate action they took when those variances occurred, and DPH will have the right to audit hospitals to ensure that providers are following the bill’s provisions relating to the staffing plans;
• Offer new reports through the Betsy Lehman Center (BLC) on the quality of nursing care. The BLC will make public evidence-based data on measures of patient care that are closely associated with the quality of nursing care.

Code Blue

When asked how the system to be put in place by the Moore bill would be an improvement over what exists now, in terms of ensuring adequate, or safe, staffing levels, Fanale and Karen Moore said the measure includes large doses of oversight and accountability.

One section of the bill requires hospitals, through their quality-improvement programs, to institute a process to collect, monitor, and evaluate patient care through the statewide use of three evidence-based nurse-sensitive performance measures. These measures will be selected by the Betsy Lehman Center from the National Quality Forum’s performance measures, and will include patient care hours per patient day.

The center will also develop the annual reporting process and will publicly report both hospital-specific performance measure data and aggregated industry trends and best practices developed from the annual reports.

Meanwhile, another section of the bill requires that all hospitals licensed by the Department of Public Health file and post a nurse-staffing plan that addresses patient nursing needs by identifying the appropriate number and mix of staff for each hospital, specific to each shift in the hospital inpatient units, special care units, and emergency departments by day of the week.

Each plan will identify relevant factors, such as: the number of patients in a unit; the intensity of care required; skill and experience of various care givers including registered nurses, licensed practical nurses, ancillary personnel, and other members of the patient care team.

Beyond the oversight, the bill contains that measure of flexibility desired by hospital administrators, said Fanale.

“Staffing models vary from hospital to hospital,” he explained. “One hospital may have a 20-bed unit and have four nurses and four nursing assistants, and those assistants may make that workload very manageable. Another hospital may have three nurses and six assistants in a system that works just as well.”

But MNA leaders say the Patient Safety Act, as proposed, does not address either the issue of patient safety or the supply of nurses for the future.

Higgins said the MNA-backed bill would protect patients by ensuring that they “receive nursing care appropriate to the severity of their medical conditions.
“To ensure maximum flexibility,” she continued in a prepared statement, “the bill also requires that the Department of Mental Health develop an objective system for monitoring patient medical conditions so that staffing levels can be adjusted and improved to meet patient needs. The bill would set minimum staffing standards specific to every unit and department in a hospital to ensure that major disparities in care levels do not exist in the Commonwealth’s hospitals …”

As for the nursing shortage, Julie Pinkham, RN, MNA executive director, said the MNA-supported legislation would address that problem by improving working conditions in the state’s hospitals.

‘There is no shortage of nurses in Massachusetts,” said Pinkham. “What we have is a shortage of nurses willing to work under the conditions created by the hospital industry. The fact is that our state has more nurses per capita than any state in the nation.”

But Wingle said the nursing shortage is better addressed through the Patient Safety Act, which works to put more nurses in the pipeline rather than set ratios at a time when the supply of nurses does not meet the demand.

“This is a better answer,” he said of Moore’s bill. “The solution to a shortage isn’t a union-backed government mandate; the right response to a shortage is to increase the supply and to create incentives for more young people to enter nursing. Ratios, in the environment of a shortage, can’t work.”

Bill of Fair?

Assessing the Patient Safety Act, Fanale said it is an attempt to achieve some middle ground in a debate that, until recently, hasn’t seen any.

He called the proposal a more flexible, and, therefore, more palatable measure than the MNA-backed bill — at least from the prospective of hospital administrators. But he also said it provides more accountability than exists at present.

Time will tell if the bill gains support of the Legislature, but for now, the measure shifts debate from how ‘safe’ is defined to who is ultimately responsible for defining it.