Contact: Sherry Mirasola
(517) 323-3443
Michigan hospitals strive to create a positive working environment and offer fair compensation to employees. Legislation that mandates a “one-size-fits-all” approach to staffing would result in an undue financial burden to hospitals and to the conduct of professional practice, with no guarantee of improved patient outcomes. In addition, requiring hospitals to maintain a supply of nurses that simply does not exist ignores the realities of the current nursing shortage.
There is no conclusive evidence that legislatively mandated nurse-patient staffing ratios actually improve the quality of care. A 2000 study of California’s nurse staffing ratios found that (1) more research is needed to determine the actual effects of staffing ratios on quality of care, (2) nurse staffing ratios strap hospitals with significant additional costs at a time of declining government funding for health care, and (3) there is no clear indication of “what minimum nurse staffing ratios might be ideal.” In Michigan, the Michigan Organization of Nurse Executives has taken the position that additional legislation is an “inefficient response to the challenge of meeting the complexity of specialized patient populations and organizations.”
Study: Training more important than quantities. A study in the September 2003 issue of the Journal of the American Medical Association demonstrates that death rates for patients undergoing surgery are lower at hospitals with a higher percentage of nurses with at least a bachelor’s degree. Highly trained nurses make a difference, not arbitrarily chosen ratios that have no proven relationship to patient safety or more positive patient outcomes. Efforts would be better directed at identifying additional ways to fund nursing education and to obtain additional faculty for nursing education programs. Data collected in 2003 by the West Michigan Nursing Advisory Council revealed that, in the 12-county Alliance for Health region, 401 qualified applicants to RN nursing education programs were denied admission due to lack of capacity, including faculty availability. This is compared to 153 qualified applicants denied admission in 2002.
Michigan and the nation face a severe nursing shortage. Hospitals simply can’t maintain a supply of nurses that does not exist. Michigan’s current nursing shortage is expected to do nothing but worsen. The United American Nurses, AFL-CIO projects that by 2020, Michigan will have a 22-percent nursing shortage. That’s a shortage of more than 18,000 nurses in Michigan.
Michigan’s state government and its hospitals are simply not in a position to address the financial realities of nurse-patient ratios. California’s nurse staffing ratio law included a $68 million appropriation to build the state’s nursing workforce. Since 1998, Michigan has cut funding to hospitals by more than $505 million. The state’s Medicaid program is currently underfunded by nearly $1 billion. The average Michigan hospital lost money on patient care in 2002. Where will the funding come from to pay for staffing ratios?
The average salary of a nurse who works in a hospital is $22.50 an hour. On an annual basis, that is $46,800 a year, without including benefits costs. Where will the funding come from to pay for staffing ratios? If these mandated ratios are implemented with no funding to support them, hospitals may have no choice but to decrease numbers of LPNs and/or other assistive personnel who help RNs care for patients. This could result in decreased RN satisfaction with the work environment, one factor used to justify the need for staffing ratios.
Health care professionals — not lawmakers or regulators — are best qualified to determine staffing needs. Because Michigan hospitals continually adjust their staffing to reflect both increases in the number of patients and changes in the severity of their medical conditions, a one-size-fits-all formula such as statewide uniform ratios would not give hospitals the flexibility they need to ensure proper coverage and patient safety.
Mandated ratios will divert hospital resources away from patient care and toward compliance (increased reporting requirements and other record keeping) at a time when hospitals are working hard to relieve nurses and other direct caregivers of existing regulatory burdens that keep them away from the bedside.
The right to work independently, or as part of a bargaining unit, is important. When a hospital needs to reduce costs by adjusting payroll, it generally does so by cutting or freezing the salaries of managers and executives rather than caregivers. That said, 50 percent of hospital expenses are spent on labor.
Legislative ratios would duplicate existing standards and laws. Michigan hospitals comply with more than 25 government mandates concerning patient safety from state and federal agencies.
Nurse staffing ratios seem reasonable in the abstract, but in reality they are unattainable. California passed nurse staffing ratio legislation in 1999, which went into effect in January 2004. Despite this five-year lead-time, nine out of 10 hospitals are still noncompliant with the law (particularly, this lack of compliance stems from the "at all times" interpretation by the California Department of Health Services, which requires hospitals to maintain minimum ratios even during breaks and meal times.
· Additionally, in the first quarter of 2004, the California Department of Health Services approved 23 of 60 wavier requests by hospitals that were unable to meet the stringent requirements of the nurse staffing ratio law.
· Despite these facts, the bill assumes Michigan hospitals can not only meet the California ratios without the $68 million in appropriations for training, education and recruiting California hospitals received, but can somehow manage to meet ratios that are
100 percent higher than those in California. This legislation proposes higher ratios in 10 patient care areas like telemetry (1:3 vs. 1:5 in California) and med/surg (1:4 vs. 1:6 in California). Moreover, the legislation requires double the staffing in cases like ICU (1:1 vs. 1:2);
NICU (1:1 vs. 1:2); and emergency department critical care (1:1 vs. 1:2). Despite these facts, Michigan’s proposed legislation has no lead time for implementation. California hospitals were given five years and are still struggling to implement.
Nurse staffing ratios increase hospital liability. Nurse staffing ratios will be used to demonstrate a hospital's liability when they fail to meet, at any point during a patient's hospital stay, the rigors of the proposed statutory ratios. Even before the first case is filed, insurance companies will be monitoring hospital compliance rates. Any facility failing to comply with the staffing ratios will be met with premium hikes as insurance carriers attempt to limit losses.
Nurse staffing ratios impact reimbursement. If a health care institution is out of compliance with any applicable state law, Medicare can withhold payments retroactively. Therefore, if Medicare determines that a particular hospital has been noncompliant with the nurse staffing ratios, it can deny payments. Given that Medicare reimbursement makes up nearly half of a hospital’s revenue, such legislation could potentially bankrupt any facility that is unable to comply with the minimum staffing ratios.
Federal law, such as EMTALA, runs counter to the proposed staffing minimums. The Emergency Medical Treatment and Active Labor Act, or EMTALA, mandates that a hospital must accept any individual who presents to the emergency department and requests treatment (or treatment is requested on the individual's behalf) for an emergency medical condition. Under the proposed nurse staffing ratio legislation, a hospital could be out of compliance with the addition of a single patient. There will be a point when a hospital is forced to choose between violating either a state law (by failing to comply with the staffing ratios) or a federal law (by virtue of EMTALA).
Hospital viability will be affected by mandated ratios.
Nurse staffing ratios would serve only as minimums, not maximums. Even if a hospital had the ability to staff beyond the minimum ratios, there is no incentive to do so. This lack of incentive stems from the financial strain placed on an institution to maintain staffing minimums. Stated differently, because of nurse staffing ratios, a hospital will be forced to limit its expenditures in other areas whenever possible.