Both chambers of the General Assembly have approved legislation to require all Rhode Island hospitals to submit “core staffing” plans to the state Department of Health every year with the number of nurses they have assigned to each unit and the average number of patients they’ll serve.
The bills, which the Hospital Association of Rhode Island opposed, are meant to highlight the importance of adequate staffing and document hospitals’ staffing practices without actually mandating minimum nurse-patient ratios, as California has done.
“I feel it’s important as an intermediate step,” said state Sen. Elizabeth H. Roberts (D-Cranston), who has been pushing for passage of such legislation for three years. “There’s been quite a bit in the professional press about the connections between staffing levels, particularly nursing levels and the quality of care,” Roberts said. Rhode Island has also considered mandatory minimums, she said, but “I felt more comfortable with this compromise.”
The research is, indeed, extensive. Last year, the federal Agency for Healthcare Research and Quality analyzed 26 studies on the subject and found not only less burnout among nurses and a better perception among them of the care they gave, but actual reductions in adverse outcomes such as pneumonia, shock and gastrointestinal bleeding between 2 percent and 25 percent.
Working nurses in Rhode Island know this, said Rick Brooks, director of the United Nurses and Health Professionals (UNAP), and they are disturbed to see that hospitals have pared their staffing “down to the bone” to save money.
“I wouldn’t point the finger at any one hospital,” Brooks said. “I would say most hospitals at one point or another, for a variety of reasons, find themselves in a position where they’re providing less than optimal staffing and cutting corners.”
On most shifts, the nurses can make due, Brooks said, but when patient numbers spike – and it can happen quickly and unexpectedly – hospitals can’t respond as well as they should. “They simply don’t budget for enough staff, so when they have the inevitable peak, there’s no bodies available.”
The new legislation, approved in the House on April 26 and in the Senate on May 12, requires that every January, each hospital submit a staffing plan for each patient care unit and each shift, including “the number of registered nurses, licensed practical nurses and/or certified nursing assistants who shall ordinarily be assigned to provide direct patient care and the average number of patients upon which such staffing levels are based.”
The first thing this measure will do, Roberts said, is give Rhode Islanders “a sense of where the hospitals stand” – what they consider appropriate staffing. The next step will be to see “how much they’re able to maintain those staffing plans, given what happens with patient census, manpower availability and finances.”
If the new data makes it clear that hospitals aren’t staffing adequately, Roberts said, then state policy-makers can revisit the issue of mandatory minimums.
Brooks said measuring hospitals against their own staffing standards will be a big help, but it will also be informative for the public to compare how different hospitals staff, say, cardiac care units, or medical-surgical units.
Edward J. Quinlan, president of the Hospital Association of Rhode Island, disagrees. The hospitals are “very disappointed” by the bills’ passage, he said, because they will force them to report information that “will not serve the public in any meaningful way.”
“I think the complexities associated with that issue are such that it makes it very difficult to set up a system that allows you to make valid comparisons,” Quinlan added. Rhode Island’s hospitals and the populations they serve are so diverse, he said, that knowing that one keeps, say, one more nurse per unit isn’t helpful unless you know whether that hospital’s patients are also older or sicker or more severely injured.
“Without the context, it doesn’t give you any sense of what happens in a nursing unit in a hospital,” Quinlan said. “We’re unclear how such information will be of any value.”
Other hospital quality measures now used in Rhode Island are more appropriate, Quinlan said, because they were developed through years of work with the Department of Health, “founded in science” and using stronger data.
The staffing measures, by contrast, “would appear to be less sophisticated,” Quinlan said.
But the Department of Health, which in previous years had expressed some concerns about requiring core staffing reports, changed its stance this time around. Legislative liaison Helen Drew said it was because of “the increasing interest in the relationship between staffing and quality.” Asked whether the change in leadership at the department had also made a difference, Drew said “it’s fair to say” that new Director David R. Gifford’s “experience and goals” in health care quality issues had played a part.
As for the hospitals’ objections, Roberts said previous quality-reporting measures have also generated “some of the same comments” before gaining acceptance.
“It is true that if people look at these figures out of context they can be misleading,” she said. “But I hate to keep information from being made public because of the possibility that it could be misused.”
