More States Mandate Nurse-To-Patient Staffing Ratios

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Earlier this month, New York announced a new rule requiring at least one nurse to be assigned to every two patients in critical care units (CCU) at all of the state’s hospitals. This is part of a greater movement gaining steam in state legislatures to mandate nurse-to-patient staffing ratios in hospitals. Backed by their unions, nurses are committed to addressing problems of understaffing and associated burnout while advocating for safer working conditions and increased pay/benefits. Their advocacy is noteworthy, but legislative fiat and increased regulation will not address the long-standing problems plaguing an industry that has refused to change.

In 1999, California became the first state to require “specific numerical nurse-to-patient ratios for acute care, acute psychiatric, and specialty hospitals.” Now, Oregon, Maine, Pennsylvania and other states are pushing for similar measures. While there is no national law mandating minimum nurse-to-patient staffing requirements, federal legislation was reintroduced earlier this year in an attempt to try and make this a national requirement. While hospitals should have staffing guidelines to ensure patient and clinician safety, tailored to meet each facility’s unique needs, attempts to legislate outcomes have not yielded good results.

As far back as the early 1980’s, the Centers for Medicare and Medicaid Services (CMS) introduced Diagnosis-Related Groups (DRGs) in an effort to bend the cost curve. This moved the industry from ‘usual and customary reimbursement’ for services rendered after the fact to a prospective payment system. One of the major problems with the change was that it never connected payment with outcomes. But it also created an enormously complex coding and reimbursement structure which has become more complex over the years as delivery organizations work to ensure they maximize reimbursement. While financial well-being is important for all companies, delivery organizations have too often focused on the administrative complexity and associated bureaucracy at the expense of their real mission—the delivery of patient care with optimal outcomes. Forty years later, costs continue to rise while access and quality outcomes decline. Even with laws designed to enact needed change, there is the issue of compliance and enforcement. Unfortunately, health systems fiercely resistant to change seem to be winning the battle.

Elsewhere I have explained how hospital systems have found workarounds to CMS’ 40-year attempts at reform aimed to rein in rising healthcare costs, while also improving quality. Even when CMS recently ushered in a measure as simple as price transparency, powerful lobby groups fiercely fought it. And after it became law, resistance continued; compliance has been a major issue. Not surprisingly, we are seeing significant resistance to the idea of mandated staffing ratios.

In a recent example, the Mayo Clinic successfully lobbied to kill a nurse-to-patient staffing ratio requirement in Minnesota, even using threats to rescind billions in infrastructure investments it had planned in the state. And, the American Hospital Association (AHA) and American Health Care Association (AHCA) voiced their concerns in a letter to CMS earlier this year over the agency’s plans to implement minimum staffing requirements in nursing homes. One might think such associations would welcome standards aimed at protecting patients’ safety. Proper staffing ratios would seem to be an important measure to guard against error and increase the likelihood of achieving good outcomes. That legislative action is being contemplated to address something as basic as adequate staffing ratios raises concerns about hospital safety more generally.

A new report from the Leapfrog Group shows a significant uptick in healthcare-associated infections (HAIs), even after Covid-19. The data also shows a decline in the patient experience along with other metrics used to assess hospital safety, with close to 50% of hospitals receiving a “C” grade or lower. When you stop and think about the flurry of legislative activity around staffing ratios happening now, 15 years after CMS decided not to reimburse hospitals for creating their own costly and preventable mistakes–“Never Events”–it only reinforces the grim reality that many hospitals still aren’t safe and that nurses and other clinicians might be stretched in ways that create even more harm.

Every healthcare executive, whether their facility is making the grade or not, should be very concerned about this latest national report card. But, institutional challenges like safety and key staff shortages are not new crises; they’re largely the result of years of institutional neglect. In 2003, I co-authored Employee Retention: Solving the Healthcare Crisis, which highlighted major challenges facing healthcare delivery at the time–including the ever-present reality of scarce resources and the inability of executives to effectively deal with financial pressures, ensure hospital cleanliness, fill open clinical staff positions with qualified candidates in a timely manner, support managers properly and improve efficiency within bloated and bureaucratic organizations. Unfortunately, many hospitals dealt with these cost pressures by cutting staff and internal services under the guise of redesign. Too often such decisions reflected short-term, siloed thinking. With no one listening or able to turn things around, people with options opted to leave.

It’s no surprise that 20 years later, little has changed.

Hospital layoffs continue due to financial hemorrhaging—made worse by Covid—and administrative staff, as well as nurses, are being handed pink slips. As in years past hospitals have turned to traveling nurses to plug staffing holes. Paid a premium, this has further strained hospital budgets and in many cases exacerbated morale issues among full time staff. As today’s nursing shortage crisis worsens, the government has shown incompetence in alleviating the problem, placing a freeze on the processing of EB-3 work visas for foreign-born nurses, who comprise 16% of the U.S. nursing workforce. These nurses could provide needed care but they are prevented from coming here.

It’s clear that the U. S. healthcare delivery system, already in critical condition, is fast careening toward a cliff. The warning lights have been going off for quite some time but the people who created this morass do not seem to understand the sheer magnitude or severity of it. Nor do they know how to find a way out. And, it’s unlikely that people outside the system are able to grasp it given their willingness to throw more money to mandate staffing ratios.

As consumers continue to pay a high price for maltreatment and nurses are placed in unsafe clinical situations, legislative and regulatory “fixes,” no matter how well intentioned, will not do what healthcare delivery should have been doing on its own long ago: deliver better health outcomes at lower cost, while increasing accountability, efficiency and transparency across the continuum. Until that happens, industry lobbyists and their lawyers will dance all the way to the bank in this latest round of politicians know best for “what ails us.”

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