Eleven months after the nation’s first comprehensive nurse-to-patient ratio rules went into effect, the reviews at California hospitals are mixed but generally favorable.
Nurses say mandated ratios are the right call for the health of patients and the profession. The California Nurses Association, the largest of three major labor groups representing registered nurses in the state, is taking the ratio campaign national, one state at a time.
Consumer groups and patient advocates say the new law is a step toward healing an ailing health care system. The Department of Health Services, charged with overseeing the new regulations, says the transition is proceeding relatively smoothly with fewer complaints than anticipated.
However, some hospitals and a statewide trade organization representing hospitals say the new state law is too stringent and is not flexible enough for normal day-to-day operations. They also say that a statewide nurse shortage makes it hard to maintain fully staffed hospitals.
On Jan. 1, the rules specifying nurse staffing levels for California’s 450 acute care hospitals took effect. The nurse-to-patient ratios vary depending on patient acuity. Generally, the more direct care patients require, the more nurses a hospital needs. In emergency departments, intensive care units and pediatric departments, the ratio is one nurse per four patients. In medical-surgical units — where the majority of patients in most hospitals usually are found — hospitals got a one-year break-in period, during which they are required to maintain a 1-6 ratio. Beginning Jan. 1, 2005, the med-surge ratio drops to 1-5.
“So far, it seems like a fairly smooth transition,” Gina Henning, DHS manager in charge of overseeing the new regulations, said. “We’ve been tracking complaints and hospital requests for waivers and flexibility. We’re seeing lower numbers than we expected,” Henning said.
Through mid-October, DHS received 77 complaints from nurses, patients and families that hospitals were out of compliance with the new ratios.
“And almost all of those were in January and February when everybody was scrambling and getting used to the new law,” Henning said.
Deborah Burger — president of CNA, which represents more than 45,000 registered nurses in the state — said the hospital industry is handling the new law “a lot better than we anticipated.”
“Some hospital chains have recognized that keeping enough nurses on the job actually saves money in addition to saving lives,” Burger said.
Burger and CNA are helping nursing representatives from several other states — Massachusetts, New York, Pennsylvania, Illinois and Arizona — lobby for similar nurse staffing legislation.
“I think this is helping to put health care back on the national agenda, and that’s a good thing for everybody,” Burger said.
Beth Capell — health advocate for Service Employees International Union, which represents more than 30,000 registered nurses in California — said changes won’t come overnight.
“Based on 30 years of experience with this issue — we started talking about nursing ratios in the early ’70s in California — we have a sense it will take a while for the industry to get comfortable with it,” Capell said.
Hospitals may petition DHS to request a waiver from the ratio law or to get exceptions to the new regulations in specific circumstances.
Rural hospitals, with smaller patient loads and generally lower acuity levels, were offered the option to apply for an exemption to the law. Of the 69 hospitals defined as rural by DHS, 16 applied for an exemption. Eleven were granted, one was denied, three received mixed rulings — partially granted and partially denied — and one already was in compliance.
Larger, urban hospitals were offered the opportunity to apply for flexibility within the new regulations.
“This allows the department to take a look at hospitals that meet the intent if not the letter of the law,” Henning said.
Of the 381 nonrural acute care hospitals in the state, 52 requested “program flexibility,” Henning said. Thirteen were approved, 28 were denied, three got mixed rulings and seven were in compliance.
“It’s hard to judge these numbers because we have nothing to compare them to since this is a brand new law, but they don’t seem high to us,” Henning said. “If hospitals are having difficulty and need to get a waiver or request for program flexibility, they’re not telling us about it,” Henning said.
Part of the legislation creating the ratios calls for a formal review and potential revamping after five years.
“We don’t plan to wait that long,” Henning from DHS said. “We’ll continue to monitor for another year or two and then probably start talking about some adjustments.”
Assembly member Keith Richman (R-Granada Hills) said the nurse staffing rules will create extra financial burdens for hospitals, which he says are already struggling in California.
“We’re in the middle of a crisis right now in parts of this state,” Richman, who was an internal medicine physician before jumping to politics, said. “Access to care is being limited by hospitals closing down completely or closing some of their departments, including emergency rooms. If it continues, we’re not going to have enough beds.”
In the first 10 months of this year, eight California hospitals closed their doors completely or shut down some departments. The annual average is two or three, according to the California Healthcare Association.
“In all these cases, these hospitals were having financial problems before the ratios went into effect,” Jan Emerson — executive director of CHA, a trade group representing hospitals — said. “The ratios, coupled with a nursing shortage that requires offering high salaries to attract nurses, were the final nails in some cases.”
The increase in med-surge nurse ratios taking effect Jan. 1 has some hospital officials worried.
“We’re very concerned with the drop from one-to-six to one-to-five,” Emerson said. “We can’t find enough nurses to meet the one-to-six ratio.”
For the first six months of the new law, CHA tracked compliance at about 300 hospitals per week. Each week about 85 percent of the hospitals were unable to comply, Emerson said.
“So far, there have been no repercussions, but we’re worried that trial attorneys will capitalize on the situation and make a case for negligence because these ratios weren’t met,” Emerson said. “Frankly, we’ve been expecting them and we’re a little surprised we haven’t seen them.”
Jamie Court with Consumers for Quality Care, a patients’ advocacy group, said it’s probably too early and the compliance too spotty to develop accurate data on how the ratios are affecting patient care and outcomes.
“But it isn’t too early to say that people agree — including the hospitals — that the more people you have giving care, the better the care is going to be,” Court said. “That’s pretty basic.”