All about the Ratios: Nurse Staffing Ratios that is

Welcome! This year in Michigan politics has been an interesting one for healthcare. As we see the rise of COVID cases going up recently, it is not without note that the Governor just gave an update of what she calls her Fall Priorities: Lower Health Care. We will provide an update on her Fall priorities next article but for this article, we will be analyzing the Nurse Staffing Ratio legislation. 
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​Overview

The Michigan Health & Hospital Association (MHA) brought forward an action plan to focus on the negative effects that Nurse Staffing Ratios would have on our hospital systems if the bills were to pass. The MHA is advocating for hospital systems to keep the current flexibility they have in the nurse staffing that hospitals offer. With the loss of so many nurses from burnout, COVID-19, retirement, and the opportunity to work-from-home in numerous industries, the solution to staffing shortages is not nurse ratios. At this time, there are already numerous hospital systems that are unable to fill the beds they have due to the lack of staff available. Nurse staffing ratios would only exacerbate that problem.

​It is believed that the House intends to have a hearing this Fall but there has been little word on the intent of the hearing. The next page will describe the proposal in further detail. 
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Nurse Staffing Ratios

The House and Senate Chambers each have a package of bills that deal with nurse staffing ratios. Both sets are the same language. House Bills 4550, 4551, and 4552 are sponsored by Representatives Young, Coffia, and Rheingans respectively. Senate Bills 334, 335, and 336 are sponsored by Senators Santana, Chang, and Moss, respectively. The bills are further described below.

If the bills were to pass as written, the following would occur:

HB 4550 & SB 334
Within one year, or two years for hospitals located in a rural area, excluding any collective bargaining agreements that would prevent implementation, hospitals must implement the following nurse staffing ratios:

• Intensive/critical care: 1 R.N. to 1 patient;
• Operating room: 1 R.N. to 1 patient;
• Labor & Delivery: Ranges depending on if the woman is in active labor but most of the ratios are 1 R.N. to each patient, excluding Antepartum which is 1 R.N. to 3 pregnant patients;
• Postanesthesia care unit: 1 R.N. to 1 patient;
• Emergency Department: For non-trauma 1 R.N. to 3 patients, plus 1 R.N. for triage duties; for trauma 1 R.N. to 1 patient;
• Stepdown or intermediate intensive care: 1 R.N. to 3 patients;
• Telemetry: 1 R.N. to 3 patients;
• Medical/Surgical: 1 R.N. to 4 patients;
• Pediatrics: 1 R.N. to 3 patients;
• Behavioral Health: 1 R.N. to 4 patients; and
• Acute Rehabilitation: 1 R.N. to 4 patients.

If a ratio is not there that the hospital needs for a service, the hospital must provide the ratio closets to the level of care that is being provided above. Additionally, these ratios must remain in effect the whole time, including but not limited to, breaks, meals, and other expected absences. A hospital cannot fill the positions with R.N.s that are not qualified to provide the proper patient care and cannot utilize an “average” ratio to meet the requirements. 

Additionally, a hospital is prohibited from mandating overtime unless there is a declared state of emergency. 

A public notice with the above requirements will be located in each unit and the notice will specify how a nurse, patient, or any other individual may file a complaint with the Department for any violation of the nurse staffing ratios. Each shift that does not meet the requirements of the ratios will be a separate violation. The hospital will be required to do a corrective action plan and each administrative fine will be worth $10,000 minimum, up to $25,000 for each violation. If there is a pattern of violations, the minimum fee rises to $25,000, up to $50,000.  The Department will publish on its website a list of hospitals that are found to violate this law. 

HB 4551 & SB 335
Updates the Public Health Code to ensure that a R.N.’s refusal to work mandatory overtime is not considered grounds for administrative action within LARA’s licensure systems. Additionally, each violation of mandating overtime will be at an administrative rate of $1,000. If a R.N. works 12 or more consecutive hours then the hospital must provide him or her with 8 consecutive hours of off-duty time immediately after the shift. 

A violation of mandatory overtime will not apply if it occurs during a declared state of emergency, if the R.N. was with a patient and had to stay late because the R.N.’s immediate supervisor said leaving could have an adverse effect on the patient, or if a R.N. voluntarily accepts over time. Additionally, a hospital cannot discharge, discipline, or threaten to discharge or discipline, or discriminate against any R.N. that refuses to accept overtime. If they do, they are subject to the sanctions under HB 4550 and SB 334. 

HB 4552 & SB 336
Requires each hospital to create an accurate record of actual direct care R.N. nurse to patient ratios for each unit and for each shift. The hospital will have to maintain the records for three years. The records will include the number of patients in each unit, and the identity and hours of each direct R.N. in each unit for each shift. This information will be made available to the public pending rules being promulgated by the Department.