Nurse-patient Ratio Law in MA Raises Cost, Quality Concerns

Alexandra Wilson Pecci, June 23, 2015

Data shows that mandated nurse-patient staffing ratios are good for nurses, but patient safety benefits have not been clearly demonstrated. In California, where a similar law has been in effect for 11 years, hospital operating expenses have risen.

Eleven years after passage in California, the country's first mandated nurse-patient ratio law has largely resolved the nurse burnout problem.

Still, the Massachusetts Health Policy Commission voted unanimously this month to approve the state's first nurse staffing mandate. It calls for no more than two patients to be assigned to a single nurse in all ICUs, including burn units and NICUs, and in some cases, just one patient per nurse.

To determine proper staffing levels, hospitals must use an acuity tool to, according to the final rule. A nurse manager will intervene if there's a disagreement between an RN and the tool. Also, hospitals must report on four ICU quality measures:


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Patricia M. Noga, PhD, RN
  • Central line-associated blood stream infection
  • Catheter-associated urinary tract infection
  • Hospital-acquired pressure ulcers, and
  • Patient falls with injury

Although there are no monetary or other specific penalties in the law, Patricia M. Noga, PhD, RN, vice president of clinical affairs for the Massachusetts Hospital Association, says the law will have a financial impact.

"There will be costs associated with implementing the law, such as developing acuity tools," she said, responding to questions by email. "We'll be monitoring the implementation of the regulations to assess the cost over time."

Massachusetts joins California as the only other state in the nation to have adopted a mandated nurse-patient ratio. However, California's law goes far beyond ICUs, mandating minimum nurse-to-patient ratios at all times on a unit. And 11 years after its passage, it remains to be seen whether it's a model or a cautionary tale.

"I think it's a bit of both," says Patrick S. Romano, MD,professor of medicine and pediatrics and senior faculty in the Graduate Groups in Epidemiology, Public Health, Clinical Research, and Nursing Science and Healthcare Leadership at the University of California Davis.

"I think it's a cautionary tale in that it was certainly expensive, and the benefit in terms of patient safety has not been clearly demonstrated, and the process has certainly been contentious," he says. "But on the other hand it is a model, perhaps, because it has largely resolved the [nurse] burnout problem."

Romano was one of the co-investigators who did work for the state of California in the early 2000s to estimate the impact of different ratio proposals.

Because of the California law, hiring increases happened almost across the board. Although a few hospital leaders said staffing was already at or above mandate levels, most "reported that they needed to hire more RNs to meet the requirements, particularly to cover meals and breaks," according to a California HealthCare Foundation study.

Alexandra Wilson Pecci

Alexandra Wilson Pecci is an editor for HealthLeaders Media.

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