Presentation to Special Committee on Nursing Workforce Issues

1
Presentation to Special Committee on Nursing
Workforce Issues

• An Analysis of House Bill 2663 and Senate Bill
  1260as Related to Nurse Staffing
• Presented by Jay Himmelstein, MD, MPHDebra
  Hurwitz, RN, BSN, MBA
• University of Massachusetts Worcester Campus
  Center for Health Policy and Research
  December 1, 2005

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Presentation Background

• At the suggestion of Senator Harriette Chandler
  (D-Worcester), Senator Richard Moore (D-Uxbridge)
  and Representative Stephen Tobin (D-Quincy), the
  Co-chairs of the Special Committee on Nursing
  Ratio Legislation, requested a report from the
  University of Massachusetts, Worcester Campus
  addressing specific issues before the committee.
• Is there a scientific basis for establishing
  mandatory nurse ratios?
• Is it possible to estimate the economic impact of
  mandatory nurse staffing ratios in Massachusetts?
• A multi-disciplinary project team was assembled
  that included faculty from UMass Graduate School
  of Nursing and UMass Medical School. Project
  management and research support was provided
  through the UMass Center for Health Policy and
  Research.

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Background on UMass Worcester

• UMass Worcester is one of 5 University of
  Massachusetts campuses. The Worcester Campus
  includes the Medical School, the Graduate School
  of Biomedical Sciences, and the Graduate School
  of Nursing.
• CHPR reports to the Chancellors Office of the
  Medical School and has no reporting relationship
  with UMass Memorial Health Care.
• CHPRs mission is to work with public agencies to
  conduct applied research, evaluation, and
  education aimed at informing policy decisions
  that improve the health and well-being of people
  served by public agencies.
• Funding for staff working on this project was
  provided by the Dean of the Medical School and no
  present operation of the University of
  Massachusetts Worcester will benefit from passage
  of either of the bills examined in this project.
• The views expressed in this report are based on
  research conducted by the project team working at
  the Center for Health Policy and Research, and
  may not reflect the institutional views of the
  University or its affiliates.

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Background to todays presentation

• 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 HB 2663 SB 1260 Key Provisions

• 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.
• Used PubMed search engine to ensure comprehensive
  coverage of journals.
• 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
9
Research StudiesNurse Staffing Quality of
Care (II)
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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. But these studies have some
  limitations
• Limited number of unit types analyzed
• Lack of analysis of staffing needs by shift
• Definition of nurse staffing varies
• 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, the studies do not recommend specific
  nurse-to-patient ratios 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 HB 2663 SB 1260 Key Provisions

• Potential Costs to
• Hospitals
• Public Agencies

Conclusions
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The California Experience (I)

• Assembly Bill 394 passed in 1999 which directed
  the Department of Health Services (DHS) to
  develop ratios.
• Took 5 years to develop and implement ratios
  January 2004.
• Staffing ratios refer to licensed nurses
• includes RNs (Registered Nurses) and LVNs
  (Licensed Vocational Nurses) similar to LPNs
  (Licensed Practical Nurses) in Massachusetts.
• Regulations allow hospitals to use up to 50 LVNs
  to comply with staffing ratios.

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The California Experience (II)

• Ratios enacted under AB 394 are different than
  those proposed in Massachusetts.
• AB 394 ratios permit up to 50 LVN, while HB 2663
  proposal requires 100 RN staffing.
• AB 394 ratios for some units require fewer nurses
  per patient than HB 2663.

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The California Experience (III)
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The California Experience (IV)

• California DHS is to report on ratios impact by
  2009
• The only published study to date (8/05) compared
  first 6 months of 04 to first 6 months of 02 as
  baseline for sample of 68 hospitals. Study found
  that nurse staffing on medical/surgical units
  increased after ratio implementation (04), but
  no improvement in patient safety (falls, pressure
  ulcers) was observed.
• It is too soon to determine the impact of
  Californias mandated nurse ratios on quality of
  care or on hospital finances.
• Stay tuned

Sources Donaldson N. et al., Impact of
Californias Licenses Nurse-Patient Ratios on
Unit-Level Nurse Staffing and Patient Outcomes.
Policy, Politics, Nursing Practice, August 2005.
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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 HB 2663 SB 1260 Key Provisions

• Potential Costs to
• Hospitals
• Public Agencies

Conclusions
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Comparison of Nursing Bills Facilities Affected

• 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 Key Provisions (I)
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Comparison of Nursing Bills Key Provisions (II)
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Comparison of Nursing Bills Key Provisions (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 HB 2663 SB 1260 Key Provisions

• 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) direct patient care hours and inpatient days
  by unit

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Potential Costs to HospitalsMethodology (II)
Calculate actual nursing hours required under
proposed ratio
Compare required and actual nursing hours
Calculate cost of compliance for unit with
shortfall
Convert proposed nurse-to-patient ratio to HPPD
Nurse HPPD Patient 24
RN Hours Req (Patient Days) x (Req HPPD)
Shortfall (Surplus) Required Hours Actual
Hours
Cost Shortfall hrs x Avg hourly pay 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)
- Example
Calculate actual nursing hours required under
proposed ratio
Compare required and actual nursing hours
Calculate cost of compliance for unit with
shortfall
Convert proposed nurse-to-patient ratio to HPPD

• Nurse HPPD
• Patient 24
• 1 HPPD
• 24
• HPPD24/46

RN Hours Req (Pt Days)(HPPD) (4,000)(6)
24,000 RN hours required
Shortfall (Surplus) Required Hours Actual
Hours 24,000-15,000 9,000 RN hours
shortfall
Cost Shortfall hrs x Avg hourly pay
(9,000)(40.00) 360,000 compliance cost

• Calculated using hypothetical example of a
  hospital medical/surgical unit
• Proposed HB 2663 nurse-to-patient ratio for
  medical/surgical units 14.
• FY 2004 data 4,000 patient days, 15,000
  direct-care RN hours.
• Average hourly pay (wages benefits
  non-productive time) 40.00

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Potential Costs to HospitalsMethodology (IV)

• 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
  already staff at or above proposed ratios on some
  units, and 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 HB 2663 SB 1260 Key Provisions

• 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, with many units already
  staffing at or above proposed ratios.

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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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Remaining Questions/Unresolved Issues For
Discussion

• Need for statewide data collection on nurse
  staffing, patient safety, and quality of care, to
  determine appropriate staffing levels.
• Need to collect statewide data on actual staffing
  levels by shift, skill mix, and patient acuity.
• Hospitals should use patient classification
  systems (PCSs) to determine staffing plans, but
  DPH could certify systems rather than impose one
  some hospitals have made major investments in
  PCSs, while others have none.
• 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.
• An effective nurse-staffing bill should
• address overtime issue - both mandatory and
  voluntary
• facilitate data collection
• address nursing workforce shortage, especially
  nursing faculty.

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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