Report Title:

Hospitals; Staffing

Description:

Requires health care facilities to staff departments sufficiently with qualified nurses. Establishes required staffing ratios. Limits mandatory overtime for nurses. Allows nurses to refuse certain assignments. Allows enforcement through private right of action.

HOUSE OF REPRESENTATIVES

H.B. NO.

867

TWENTY-SECOND LEGISLATURE, 2003

 

STATE OF HAWAII

 


 

A BILL FOR AN ACT

 

RELATING TO HOSPITAL CARE.

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

SECTION 1. The legislature finds that the State has a substantial interest in ensuring that delivery of health care services to patients in health care facilities located within this State is adequate and safe and that health care facilities retain sufficient nursing staff so as to promote optimal health care outcomes.

Recent changes in our health care delivery system are resulting in a higher acuity level among patients in health care facilities. Inadequate hospital staffing results in dangerous medical errors and patient infections. Inadequate and poorly monitored nurse staffing practices can adversely impact the health of patients who enter hospitals and outpatient emergency and surgical centers. A substantial number of nurses indicate that hospital-patient acuity measurements are inadequate and that many hospitals rarely, if ever, staff according to an acuity measurement tool. Establishing staffing standards will ensure that health care facilities throughout the State operate in a manner that guarantees the public safety and the delivery of quality health care services. Hospital nurses work substantial overtime hours, and nurses working twelve-hour shifts work the most additional overtime hours per week. Mandatory overtime and lengthy work hours for direct-care nurses constitute a threat to the health and safety of patients, adversely impact the general wellbeing of nurses, and result in greater turnover, which increases long-term shortages of nursing personnel.

The purpose of this Act is to protect the health and safety of the residents of this State by ensuring adequate protection and care for patients in health care facilities.

SECTION 2. The Hawaii Revised Statutes is amended by adding a new chapter to be appropriately designated and to read as follows:

"Chapter

Safe staffing for hospital care

§ -1 Facility staffing standard. (a) Each health care facility, as defined in section 323D-2, shall ensure that it is staffed in a manner that provides sufficient and appropriately qualified nursing staff of each classification in each department or unit within the facility in order to meet the individualized care needs of patients.

(b) Each health care facility shall annually submit to the department of health a documented staffing plan, together with a written certification that the staffing plan is sufficient to provide adequate and appropriate delivery of health care services to patients for the ensuing year. The staffing plan shall:

(1) Meet the minimum requirements set forth in subsection (c);

(2) Be adequate to meet any additional requirements provided by other laws or rules;

(3) Employ and identify an approved acuity system for addressing fluctuations in actual patient acuity levels and nursing care requirements necessitating increased staffing levels above the minimums set forth in the plan;

(4) Take into account other unit or department work, such as discharges, transfers and admissions, and administrative and support tasks, that are expected to be done in addition to direct nursing care, by direct-care nurses;

(5) Identify the assessment tool used to validate the acuity system relied upon in the plan;

(6) Identify the system that will be used to document actual staffing on a daily basis within each department or unit;

(7) Include a written assessment of the accuracy of the prior year's staffing plan in light of actual staffing needs;

(8) Identify each nurse staff classification referenced, together with a statement setting forth minimum qualifications for each classification; and

(9) Be developed in consultation with the direct-care nursing staff within each department or unit or, where the staff is represented, with the applicable recognized or certified collective bargaining representative of the direct-care nursing staff.

(c) The health care facility's staffing plan shall incorporate, at a minimum, the following direct-care nurse-to-patient ratios:

(1) Pediatric recovery room, 1 to 1;

(2) Operating room circulating nurse, 1 to 1;

(3) Special procedures, 1 to 1;

(4) Trauma, 1 to 1;

(5) Burn unit, 1 to 2;

(6) Critical care, 1 to 2;

(7) Labor and delivery, 1 to 2;

(8) Adult recovery room, 1 to 2;

(9) Emergency room, 1 to 3;

(10) Oncology/chemotherapy, 1 to 3;

(11) Intermediate care unit, 1 to 3;

(12) Telemetry, 1 to 3;

(13) Mother/baby couplets and normal post-partum, 1 to 4;

(14) Pediatrics, 1 to 4;

(15) Psychiatric unit, 1 to 4; and

(16) Adult medical-surgical unit, 1 to 6.

(d) The department of health shall adopt rules that establish minimum, specific, numerical direct-care nurse-to-patient ratios for other health care facility nursing departments and units that must be incorporated into the staffing plan.

(e) The minimum numbers of direct-care nurse-to-patient staff set forth in this section shall constitute the minimum numbers of direct-care nursing staff that shall be assigned to and present within a nursing department or unit. Where the approved acuity system adopted by the facility indicates that additional staff is required, the health care facility shall staff at the higher staffing level.

(f) The skill mix reflected in a staffing plan shall assure that all of the following elements of the nursing process are performed in the planning and delivery of care for each patient:

(1) Assessment, nursing diagnosis, planning, intervention, evaluation and patient advocacy;

(2) Registered nurses shall constitute at least fifty per cent of the direct-care nurses included in the staffing plan; and

(3) The skill mix shall not result in nursing care functions that are required by law, rule, or accepted standards of practice to be performed by a licensed nurse being performed by unlicensed personnel.

(g) The department of health shall adopt rules under chapter 91 prescribing the method by which it will approve a health care facility's acuity system. The rules may include a system for class approval of acuity systems.

§ -2 Compliance with plan and recordkeeping. (a) A health care facility at all times shall staff in accordance with its staffing plan and the staffing standards set forth in it; provided however, that nothing in this chapter shall be deemed to preclude a health care facility from implementing higher direct-care nurse-to-patient staffing levels.

(b) No nurse shall be assigned, or included in the count of assigned nursing staff for purposes of compliance with minimum staffing requirements, in a nursing department or unit or a clinical area within the health care facility without appropriate licensing, prior orientation, and verification that the nurse is capable of providing competent nursing care to the facility's patients.

(c) Each health care facility shall maintain accurate daily records showing:

(1) The number of patients admitted, released, and present in each nursing department or unit within the facility;

(2) The individual acuity level of each patient present in each nursing department or unit within the facility; and

(3) The identity and duty hours of each direct-care nurse in each nursing department or unit within the facility.

(d) Each health care facility shall maintain daily statistics, by nursing department and unit, of mortality, morbidity, infection, accident, injury, and medical errors.

(e) All records required to be kept under this section shall be maintained for a period of seven years; and shall be made available upon request to the department of health and to the public; provided that information released to the public shall not contain the name or other personal identifying information, apart from acuity level, about any individual patient.

§ -3 Mandatory overtime and excessive duty hours. (a) Except during a state of emergency declared by the governor, a health care facility may not mandate or otherwise require, directly or indirectly, a health care employee to work or be in on-duty status in excess of any one of the following:

(1) The scheduled work shift or duty period;

(2) Twelve hours in a twenty-four period; or

(3) Eighty hours in a fourteen consecutive-day period.

"Mandate", for the purposes of this section, means any request that, if refused or declined by the health care employee, may result in discharge, discipline, loss of promotion, or other adverse employment consequence. Nothing in this section is intended to prohibit a health care employee from voluntarily working overtime.

(b) Except during a state of emergency declared by the governor:

(1) No health care employee may work or be in on duty status more than sixteen hours in any twenty-four hour period;

(2) Any health care employee working sixteen hours in any twenty-four hour period shall have at least eight consecutive hours off duty before being required to return to duty; and

(3) No health care employee may be required to work or be on-duty more than seven consecutive days, without at least one consecutive twenty-four period off duty within that time.

(c) A work shift schedule or overtime program established pursuant to a collective bargaining agreement negotiated on behalf of the health care employees by a bona fide labor organization may provide for mandatory on-duty hours in excess of that permitted under this section; provided that adequate measures are included in the agreement to ensure against excessive fatigue on the part of the affected employees.

§ -4 Employee rights. (a) Each health care facility shall adopt and disseminate to direct-care nursing staff a written policy that complies with the requirements set forth in this section, detailing the circumstances under which a direct-care nurse may refuse a work assignment.

(b) At a minimum, the work assignment policy shall permit a direct-care nurse to refuse an assignment for which:

(1) The nurse is not prepared by education, training, or experience to safely fulfill the assignment, without compromising or jeopardizing patient safety, the nurse's ability to meet foreseeable patient needs, or the nurse's license;

(2) The nurse has volunteered to work overtime, but determines that the nurse's level of fatigue or decreased alertness would compromise or jeopardize patient safety, the nurse's ability to meet foreseeable patient needs, or the nurse's license; or

(3) The assignment otherwise would violate requirements set forth in this chapter.

(c) At a minimum, the work assignment policy shall contain procedures for the following:

(1) Reasonable requirements for prior notice to a nurse's supervisor regarding the nurse's request to be relieved and supporting reasons for being relieved of an assignment or continued duty;

(2) When feasible, an opportunity for the supervisor to review the specific conditions, to relieve the nurse of the assignment, or to deny the nurse's request to be relieved of the assignment or continued duty; and

(3) A process that permits the nurse to exercise the right to refuse the assignment or continued on-duty status when the supervisor denies the request to be relieved if:

(A) The supervisor rejects the request without proposing a remedy, or the proposed remedy would be inadequate or untimely;

(B) The complaint and investigation process would be untimely to address the concern; or

(C) The nurse in good faith believes that the assignment meets conditions justifying the refusal.

(d) An employee of a health/care facility is deemed to act in good faith if the employee reasonably believes that the information reported or disclosed is true and that a violation has occurred or may occur. A health care facility covered by this chapter shall not penalize, discriminate, or retaliate in any manner, with respect to compensation, terms, conditions or privileges of employment, against an employee who in good faith, individually or in conjunction with another person or persons:

(1) Reports a violation or suspected violation of this chapter to a public regulatory agency, a private accreditation body, or management personnel of the health care facility;

(2) Initiates, cooperates, or otherwise participates in an investigation or proceeding brought by a regulatory agency or private accreditation body concerning matters covered by this chapter;

(3) Informs or discusses with other employees, representatives of employees, patients or patient representatives, or the public violations or suspected violations of this chapter; or

(4) Otherwise exercises the rights set forth in this chapter.

§ -5 Enforcement. (a) This chapter may be enforced by a private cause of action.

(b) This chapter shall be enforced by the department of health, which shall adopt rules under chapter 91 necessary to implement and administer compliance. The rules shall include procedures to receive, investigate, and attempt to resolve complaints, and bring actions in any court of competent jurisdiction to recover appropriate relief for aggrieved employees.

(c) No health care facility shall discharge, demote, harass, or otherwise take adverse actions against any individual because the individual seeks to enforce this chapter or testifies, assists, or participates in any manner in an investigation, hearing, or other proceeding to enforce this chapter.

(d) In any action under this chapter in which an employee prevails:

(1) The employee shall be awarded monetary damages, including back pay in an amount equal to the difference between the employee's actual earnings and what the employee would have earned but for the health care facility's unlawful practices, and an additional amount in punitive damages, as appropriate;

(2) The health care facility shall be enjoined from continuing to violate this chapter and may be ordered to take such additional affirmative steps as are necessary to ensure an end to the unlawful practices; and

(3) The health care facility shall pay a reasonable attorney's fee, reasonable expert witness fees, and other costs of the action."

SECTION 3. This Act shall take effect on July 1, 2003.

INTRODUCED BY:

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