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

 |  By 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:


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.

Continuous Coverage

In fact, Romano notes that hospitals had to create a new position: A break nurse, because under the law, hospitals have to meet the ratio at all times. "That's been the biggest point of controversy," he says. "Even if a nurse has to go to the bathroom, someone has to be covering."

Whether having constant coverage is actually needed or is beneficial has "never been subjected to rigorous scrutiny. Do you really need to have coverage every minute, or could you get by with short periods of shared coverage?" Romano adds.

That won't be the case in Massachusetts, though.

"The law does not call for the ratios to be applied at all times and the HPC explicitly said that the staffing requirements apply on all shifts, but not at all moments during the shift," says Joan M. Vitello, PhD, RN, president of the Organization of Nurse Leaders, MA, RI & NH and associate chief nurse at Brigham and Women's Hospital in Boston.

"For practical reasons," she said via email, "there are situations during every shift that, if the ratio were literally applied at all times, it would create problems for maintaining good patient care."


Joan M. Vitello, PhD, RN

In California, the ramp-up in hiring certainly increased costs for hospitals. Romano points to 2012 research that concluded that "Relative to hospitals in comparison states," operating margins declined significantly for many hospitals in California. Operating expenses increased significantly in many of them, too.

"It probably did have some effect on the financial performance," Romano says. "Particularly concentrated in the hospitals that had to make the largest increase in their staffing levels."

But "it hasn't been a bloodbath," he adds. And even though some hospital closures were blamed on the law, those hospitals likely were at a financial tipping point anyhow, he says. "It's hard to find any disastrous long-range impact."

Effect on Patient Outcomes

Whether it has improved patient outcomes is also unclear. For instance, a 2013 study published in the journal Health Services Research, found that although the California law succeeded in boosting nurse staffing, the staffing increase had only "mixed effects on quality." Another showed that "Higher registered nurse staffing per patient day had a limited impact on adverse events in California hospitals," showing that mandates are not a silver bullet.

Noga contends that there wasn't any "evidence or documentation that there was a quality of care, safety, or staffing problem in Massachusetts hospital ICUs. The law was a political resolution of a political problem, not a clinical problem."

The "political problem" she's referring to was a ballot initiative, proposed by the Massachusetts Nurses Association, which would have mandated certain staffing levels across the board.

As Noga noted, it will take time to determine the cost impact in Massachusetts. But in California, there has been one area where hospital costs may have actually gone down as a result of the law.


Paul Leigh

"The occupational injuries dropped. They dropped around 30%," according to Paul Leigh, a professor of public health sciences and an investigator with the Center for Healthcare Policy and Research at UC Davis, who published the findings last year. The researchers said that the "evidence suggests that the law was effective in reducing occupational injury and illness rates for both RNs and LPNs."

As the number of occupational injuries drop, so do worker's compensation costs. Although his study didn't publish cost data, Leigh says he has calculated it himself, and found that because injuries dropped more than hiring rose, the law likely resulted in a decline in worker's compensation costs for hospitals.

"The hospital is not thinking per nurse," Leigh says. "The hospital is thinking of the total dollar amount."

Caution Urged

Romano says that before the law was passed, some hospitals in California had unacceptably low staffing levels. He would have liked to have seen a remedy in the form of voluntary action, such as reporting staffing levels, rather than mandates.

Vitello and Noga are urging caution, too, pointing to potential issues that could arise from the new MA law, such as separating twins when one may not need to be in the NICU, or with ICU patients who don't need critical care because they're awaiting discharge or being transferred.

"The new law requires that all patients in an ICU, whether they need critical care or not, receive nurse staffing levels used for critical care patients," Vitello says. "Patients and caregivers should always be concerned any time something as sensitive, complex, and ever-changing as registered nurse staffing in hospitals is set into statute."

Alexandra Wilson Pecci is an editor for HealthLeaders.

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