HB2878

SECTION 1. The legislature recognizes the fundamental need to promote quality medical care and improve the delivery of services to patients in health care facilities in Hawaii. Health care facility nurse staffing is a matter of major concern because of the effects it can have on patient safety and quality of care.

Recent changes in health-care-delivery systems have resulted in higher acuity levels among patients. Acuity determines how much care a patient needs; the higher the acuity level, the more care required, and often more specialized care is necessary. "The Joint Commission on Accreditation of Healthcare Organizations" report of 2002 concluded that the lack of direct care provided by registered nurses contributed to nearly a quarter of the unanticipated problems that resulted in injury or death to health care facility patients.

Establishing standards for direct care registered nurse-to-patient ratios that take into account acuity measures based on the American Nurses Association's staffing principles will protect nurses and patients from possible harmful ramifications of unsafe staffing practices. Additionally, these standards will:

(1) Address the nursing shortage in Hawaii;

(2) Aid in recruitment of new registered nurses and licensed practical nurses; and

(3) Improve retention of nurses who are considering leaving direct patient care because of demands created by constant inadequate and inappropriate staffing.

The purpose of this Act is to ensure patient safety and quality health care by establishing direct care registered nurse-to-patient staffing requirements in health care facilities.

SECTION 2. Chapter 321, Hawaii Revised Statutes, is amended by adding a new section to be appropriately designated and to read as follows:

"§321- Nurse staffing standards. (a) Each health care facility shall implement a staffing plan that provides appropriate delivery of health care services and protects patient safety.

(b) A health care facility's staffing plan shall provide that during each shift within a unit of the health care facility, a direct-care registered nurse shall be assigned to no more than the following number of patients in the unit, subject to acuity that is based upon the American Nurses Association staffing principles:

(1) One patient in operating room units or trauma emergency units;

(2) Two patients in critical care and intensive care units, labor and delivery units, or post-anesthesia units;

(3) Three patients in ante-partum units, emergency room units, pediatric units, step-down units, or telemetry units;

(4) Four patients in intermediate care nursery units, medical/surgical units, or acute care psychiatric units;

(5) Five patients in rehabilitation units; and

(6) Six patients in postpartum (3 couplets) units or well-baby nursery units.

(c) In developing the staffing plan, a health care facility shall provide for direct care registered nurse-to-patient ratio under subsection (b) in conjunction with the American Nurses Association's staffing principles addressing the following factors:

(1) The anticipated admissions, discharges, and transfers of patients during each shift that impact direct patient care;

(2) Specialized experience required of direct care registered nurses in a particular unit;

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

(4) The level of technology available that affects the delivery of direct patient care;

(5) The level of familiarity with health care facility practices, policies, and procedures by temporary-agency direct care registered nurses used during a shift; and

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

(d) A health care facility shall specify the system used to document actual staffing in each unit for each shift.

(e) A health care facility shall annually evaluate its staffing plan in each unit in relation to actual patient care requirements and the accuracy of its acuity system, and shall update its staffing plan and acuity system to the extent appropriate based on outcomes research and evaluation of nursing indicators reflected in the American Nurses Association's staffing principles.

Evaluations shall be conducted under this subsection on the basis of input from direct care registered nurses at the health care facility, or where these nurses are represented through collective bargaining, from the exclusive representative of the nurses.

(f) Each health care facility shall submit to the department’s office of health care assurance its staffing plan and any annual updates.

(g) The office of health care assurance shall adjust payments made to health care facilities, other than federally operated health care facilities, under the Social Security Act, 42 United States Code Section 1395 (2005), in an amount equal to the net amount of additional costs incurred in providing services to medicare beneficiaries that are attributable to compliance with requirements of this section.

(h) A nurse may refuse to accept an assignment as a nurse in a health care facility if:

(1) The assignment would violate this section; or

(2) The nurse is not prepared by education, training, or experience to fulfill the assignment without compromising the safety of any patient or jeopardizing the license of the nurse.

No health care facility shall discharge, discriminate, or retaliate in any manner with respect to any aspect of employment, including discharge, promotion, compensation, or terms, conditions, or privileges of employment against a nurse based on the nurse’s refusal of a work assignment pursuant to this subsection.

No health care facility shall file a complaint or a report against a nurse with the state board of nursing because of the nurse’s refusal of a work assignment under this subsection.

(i) Any nurse who has been discharged, discriminated against, retaliated against, or against whom a complaint has been filed in violation of subsection (h) may bring a cause of action in a state district court. A nurse who prevails on the cause of action shall be entitled to one or more of the following:

(1) Reinstatement;

(2) Reimbursement of lost wages, compensation, and benefits;

(3) Attorney’s fees;

(4) Court costs; and

(5) Other damages.

(j) A nurse or other individual may file a complaint with the department against a health care facility that violates this section. For any complaint filed, the department’s office of health care assurance shall:

(1) Receive and investigate the complaint;

(2) Determine whether a violation as alleged in the complaint has occurred; and

(3) If such a violation has occurred, issue an order that the complaining nurse or individual shall not suffer any retaliation pursuant to subsection (k).

(k) No health care facility shall discriminate or retaliate in any manner with respect to any aspect of employment, including hiring, discharge, promotion, compensation, or terms, conditions, or privileges of employment against any individual who in good faith, individually or in conjunction with another person or persons:

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

(2) Initiates, cooperates, or otherwise participates in an investigation or proceeding brought by the department’s office of health care assurance, a public regulatory agency, or a private accreditation body concerning matters covered by this section; or

(3) Informs or discusses with other individuals or with representatives of health care facility employees a violation or suspected violation of this section.

(l) Every health care facility shall post in an appropriate location in each unit a conspicuous notice in a form specified by the department that:

(1) Explains the rights of nurses and other individuals under this section;

(2) Includes a statement that a nurse or other individual may file a complaint with the department of health against a health care facility that violates the provisions of this section; and

(3) Provides instructions on how to file a complaint.

(m) The director of health shall adopt rules pursuant to chapter 91 to effectuate the purposes of this section.

(n) If necessary to protect patient safety, and after consultation with affected health care facilities' registered nurses, the department may adopt rules pursuant to chapter 91 that:

(1) Change the minimum direct care registered nurse-to-patient ratios under this section to further limit the number of patients that may be assigned to each direct care nurse; or

(2) Add minimum direct care registered nurse-to-patient ratios for units not referred to in subsection (b).

(o) This section shall not apply during a declared state of emergency if a health care facility is requested or expected to provide an exceptional level of emergency or other medical services.

(p) As used in this section:

"Declared state of emergency" means a state of emergency that has been declared by the state or federal government, but does not include a state of emergency that results from a labor dispute in the health care industry or consistent understaffing.

"Department" means the department of health.

"Health care facility" means a health care facility as defined in section 323D-2."

SECTION 3. New statutory material is underscored.

SECTION 4. This Act shall take effect upon its approval.

INTRODUCED BY:	_____________________________

HOUSE OF REPRESENTATIVES	H.B. NO.	2878
TWENTY-FOURTH LEGISLATURE, 2008
STATE OF HAWAII