Get Involved in HPAE’s Campaign for Safe Staffing

July 19, 2010

We recently testified before the Health Care Administration Board on staffing and the re-adoption of the hospital licensing regulations. See what we support and what we recommend in the upcoming regulations.

Get involved here.

Read the proposed regulations here.

To: HCAB
From: Jeanne Otersen, Public Policy Director
Re: Proposed Re-Adoption and Amendments to Hospital Licensing Standards: Inspections; Staffing; Nurse Involvement
Date: July 15, 2010

Good morning and thank you for the opportunity to address the HCAB as it considers re-adoption of and amendments to New Jersey’s hospital licensing standards. My name is Jeanne Otersen and I am the Public Policy Director for the Health Professionals and Allied Employees, AFT, AFL-CIO (HPAE), representing 12,000 Registered Nurses and health professionals working in hospitals and other healthcare facilities across New Jersey.

HPAE supports the Department’s timely proposal to re-adopt state hospital licensing regulations. We would suggest some initial amendments or changes to the current re-adoption proposals, and ask that nurse staffing guidelines be addressed through a future process that involves all stakeholders and is based on current research on the relationship between nurse staffing levels and patient outcomes, nursing turnover, and patient satisfaction.

Proposed Rules on Complaint Inspections.

While HPAE would advocate that DHSS continue conducting biennial inspections, we recognize the economic and resource constraints facing the Department. Therefore, we support the Department’s intent to conduct monitoring surveys as set forth in the Summary to the proposed rules:

“Instead of focusing on biennial inspections, the program would concentrate its efforts on complaint investigations at licensed healthcare facilities, focused hospital surveys following a complaint investigation, and monitoring surveys in licensed healthcare facilities that declare financial difficulties or have strike activity” [italics added].

However, the body of the proposed rules do not include any specific reference to or requirement for the monitoring surveys described in the Summary to take place.

Proposed N.J.A.C. 8:43G-2.4(e) states: [Survey visits may be made to a hospital at any time by] Regardless of whether a facility holds deemed status, authorized staff of the Department[. Such] may make survey visits to a hospital at any time, which visits may include, but are not limited to, complaint investigations, the review of all hospital documents and patient records, and conferences with patients”.

We would ask that the following additions be made with respect to 8:43G-2.4(e):

• The words ‘and staff’ be added to the final phrase so that inspectors conference with staff who have filed the complaint with DHSS;
• Specific language be added to the proposed rules, requiring inspections in at least the following situations: for hospitals in violation of a bond covenant; hospitals facing a labor dispute; hospitals undergoing a pending sale or conversion under current CN laws and regulations; and in response to a request by local municipal or county elected governing bodies.”
• Definition of the circumstances under which a hospital should “declare financial difficulties”. The “Monitor Law” passed in 2008 sets forth some indicators to be used in determining when a hospital is in financial distress, but because the DHSS has not issued implementing rules or regulations, there are no specific levels attached to these indicators. We would ask that rules be promulgated to implement the “Monitor Law” which could then be used to clarify when a monitoring survey would be triggered.

Staff Involvement in Inspections

It has been our experience during extreme situations, such as labor disputes, that we are able to communicate regularly with the DHSS to report patient care concerns. However, during other staff-initiated complaint investigations, it is often difficult for the staff who reported the concern to receive information about the results of the complaint investigation until the plan of correction is submitted and approved, sometimes months later. In addition, staff have reported that their facility does not always follow the corrective plan of action approved by the Department. With the ending of regular inspections, complaint inspections will become even more important, and communication with front-line caregivers essential to maintaining quality of patient care.

Therefore, we propose an interview between the Department inspector and the staff filing the complaint, either prior to or during the inspection. The staff member who filed the complaint, and the collective bargaining representative for that staff member, where one exists, should be notified when the inspector arrives at the hospital. An interview should take place prior to or during the inspection, and the staff member and the representative, when appropriate, should be given a report of the inspectors findings, along with hospital administration, and given copies of the corrective plan of action, with an opportunity to comment and respond.

Nurse Staffing

The re-adoption maintains existing nurse staffing regulations (subchapter 17). While we understand that timing does not allow a full review, existing staffing regulations:

• Have not kept pace with changing patient needs, higher acuity levels and demands of technology;
• Do not specify staffing numbers in the medical/surgical or emergency departments, and rely on poorly articulated ‘acuity’ systems to expand staffing in most units;
• Do not require plans to correct inadequate staffing in ‘real time’;
• Fail to involve front-line caregivers in assessment of staffing needs, or in contingency planning; and
• Do not have the enforcement capacity needed to ensure patient safety at all times.

Therefore, we propose two measures:

• Add to pending regulations a requirement that “hospitals establish joint staffing committees to assess and develop safe staffing guidelines for all units; develop methods to revise and maintain safe nurse staffing levels; formulate timely contingency plans for unanticipated changes in census; require proper orientation before floating RNs from unit to unit; and provide adequate ancillary and support services for patient care.”
• Establish a working group of stakeholders to review with the Department future changes necessary to improve nurse staffing in medical surgical units and emergency departments, and update nurse staffing levels in critical care areas to meet standards set by national specialty associations.

Thank you for your consideration.

The Health Care Administration Board will be releasing the regulations in August, and we'll have the opportunity to provide testimony regarding how this will affect safe staffing. Please sign up by clicking here in order to share you're comments!

Senate Health Committee Hearings

April 30, 2010
There will be Senate Health Committee hearings on May 10 in Trenton at 1pm to talk about the hospital licensing regulations, which include nurse staffing ratios/acuity systems.

We would like to have some of our members testify, in particular on Med/Surg and Emergency Department issues related to staffing and the need to improve on these regs and legislation.

Please contact Jeanne Oterson at 201-262-5005 or joterson@hpae.org if you can attend to testify, or simply to show your support.

Implications of the California Nurse Staffing Mandate for Other States

Statement of Ann Twomey, President of HPAE, NJ's largest nursing union in response to University of Penn Study showing higher mortality in NJ and Pa patients due to lower staffing ratios. Read More

HPAE SAFE STAFFING BROCHURE

Check out our new Safe Staffing Brochure

HPAE is fighting to make sure that all of our patients have the right number of qualified staff by their bedside… Find out more…

High Hospital Occupancy Confers Increased Inpatient Mortality Risk

By: Megan Brooks
Taken From: MedScape Medical News
March 10, 2010 — To varying degrees, higher hospital occupancy, lower nurse staffing levels, weekend admission, and admission during high seasonal influenza activity all independently increase the risk of dying in the hospital, according to a study published in Medical Care this month.

"The increased risk of mortality conferred by each of these factors is not small, ranging from nearly one-quarter of a percentage point for high hospital occupancy to one-half of a percentage point for influenza," report first author Peter L. Schilling, MD, MSc, from the Department of Orthopaedic Surgery at the University of Michigan, Ann Arbor, and colleagues.

"We've known about these factors in single studies, but to have somebody put it all together on a scale as large as this and get the relative weighting of these factors is very interesting information," noted William A. Conway, MD, who was not involved in the study, in a telephone interview with Medscape Critical Care.

"The real study that needs to be done now is an intervention [trial] around these factors: What happens if you do something about these factors? Does that have any impact?" questioned Dr. Conway, a pulmonary–critical care physician who is chief medical officer, Henry Ford Hospital, and senior vice president and chief quality officer, Henry Ford Health System, Detroit, Michigan.

In a retrospective cohort study, Dr. Schilling and colleagues used administrative data to analyze 166,920 patients (57.7% women; mean age, 79.6 years) discharged from 39 Michigan hospitals during a 4-year period (2003 - 2006). All of the patients were admitted via the emergency department (ED) for 1 of 6 common diagnoses generally viewed as indicators of hospital quality: acute myocardial infarction, congestive heart failure, stroke, pneumonia, hip fracture, and gastrointestinal bleeding.

Inpatient mortality was 5.9% overall, with some variation across hospitals. In multivariate analysis, each of the 4 factors analyzed — hospital occupancy, nurse staffing levels, weekend admission, and seasonal influenza activity — had statistically significant associations with in-hospital mortality.

Hospital admission during widespread or regional seasonal influenza activity conferred the greatest increase in absolute risk for inpatient mortality (0.5 percentage points; 95% confidence interval [CI], 0.23 - 0.76), followed by weekend admission (0.32 percentage points; 95% CI, 0.11 - 0.54) and high hospital occupancy on admission (0.24 percentage points; 95% CI, 0.06 - 0.43).

Increased nurse staffing levels decreased the absolute risk for in-hospital mortality by 0.25 percentage points (95% CI, 0.04 - 0.48) for each additional full-time equivalent nurse per patient-day.

"We believe our findings are particularly robust because they maintain their significance in the presence of one another, as well as in the presence of relevant patient controls such as illness severity," Dr. Schilling and colleagues write.

These structural, temporal, and organizational factors are, to varying degrees, modifiable. "There are things we could do about this — like work on getting flu shots distributed — and a facility can certainly manage occupancy and nurse staffing levels," Dr. Conway said.

In terms of nurse staffing levels, Dr. Conway cautioned that in his experience, "There is a plateau on how much staffing is effective as it relates to mortality and complications. Assigning a single nurse to every single patient in a hospital is not going to make your mortality rate that much better," he explained. "It levels off around 5-to-1 nursing. If you go down to 10-to-1 nursing, I assure you [the] mortality rate is going to go up."

In terms of hospital occupancy, Dr. Schilling said this study establishes that there is an association between occupancy and mortality in US hospitals. He acknowledged in a telephone interview with Medscape Critical Care that "filling a hospital is financially efficient, and filling it with elective surgical cases is profitable, but full hospitals prevent flow of patients from the ED up to the hospital floor when they are admitted, or 'access block,' which leads to ED overcrowding."

Addressing this problem, Dr. Schilling said, will take "very vigilant careful management of patient flow and the realization that when a hospital is exceedingly full a large influx of patients from the ED can be a problem."

The study was supported by the Robert Wood Johnson Foundation Clinical Scholars Program. Dr. Schilling was a Robert Wood Johnson Clinical Scholar during this research. Dr. Schilling and Dr. Conway have disclosed no relevant financial relationships.

Safe Staffing Saves Lives

While it is true that the economic recession has exacerbated financial instability in our hospitals, it is more important than ever that hospitals re-focus their efforts on bedside care, given the debate over medical errors, the introduction of health information technologies and the continuing issue of hospital financial problems that stem from mismanagement and waste.

Studies have demonstrated the clear link between understaffing and patient outcomes, and the additional costs to our healthcare system of preventable medical errors, and hospital re-admissions.

When CMS (Medicare) and state laws come into effect for non-payment for 'never' events, understaffing will have a clear and direct impact on the finances of our already fiscally vulnerable hospitals. In report after report, understaffing is linked to exactly the complications, infections and medical errors that will now be ineligible for reimbursement, as well as made public. (S2471/A3633, which the Governor is expected to sign on August 31.)

Both the public and nurses also know that our hospitals are understaffed. Both the Collaborating Center for Nursing in NJ and HPAE conducted surveys in which the majority of nurses say they are working short-staffed, affecting their ability to provide quality health care. Most recently, in January of 09, HPAE polled NJ registered voters, who also agreed - more than 55% said their own area hospital had too few staff - and 72% said nurses care for too many patients at a time.

HPAE has advocated for staffing ratios, both in our contracts and in legislation. S1233 (Vitale/Weinberg/Gordon/VanDrew) and A660 (Greenstein/Moriarity and 15 co-sponsors)requires that DHSS to adopt regulations that provide minimum registered professional nurse staffing standards for hospitals, ambulatory surgery facilities and certain DHSS facilities, and to establish acuity systems approved by the DHSS Commissioner to increase staffing to meet patient needs.
Hospitals have resisted staff ratio policies, citing costs, while ignoring the documented research showing the improved patient outcomes; reduction in medical errors and increased nurse retention - and the cost-savings related to these improvements.

In addition, HPAE proposes that hospital staff and collective bargaining representatives be allowed to accompany DHSS on complaint inspections that originate with staff, or relate to staffing or safety conditions, and to require hospitals to establish staffing committees, comprised of 50% front-line caregivers in health professional categories, to assure safe staffing in all areas of caregiving.

Join HPAE's effort to win safe staffing. Contact HPAE COPE representatives in your local or jotersen@hpae.org.

Numbers Matter
Click here to download the brochure.


Summary of Research Supporting Safe Staffing Ratios, 2007
Click here to download the brochure.