THE SAFE STAFFING AND QUALITY PATIENT CARE ACT
H.335 Introduced
by Representatives Tracy of Burlington, Audette of South
Burlington, Brooks of Montpelier, Deen of Westminster, Donahue
of Northfield, Donovan
of Burlington, Hingtgen of Burlington, Hunt of Essex, Larson of Burlington
and Marek of Newfane
AN ACT RELATING TO SAFE STAFFING AND
QUALITY PATIENT CARE
It is hereby enacted by the General Assembly of the State
of Vermont:
Sec. 1. 18 V.S.A. chapter 43 is amended to read:
CHAPTER 43. LICENSING OF HOSPITALS
Subchapter 1. General Provisions
* * *
Subchapter 2. Nurse Staffing Standards
§ 1920.
FINDINGS AND PURPOSE
(a) The purpose of this subchapter is to assure that the
delivery of health care services to patients in health care
facilities located within Vermont is adequate and safe, and
that health care facilities retain sufficient registered nursing
staff so as to promote optimal health care outcomes.
(b) Inadequate hospital staffing results in dangerous medical errors and patient
infections. Registered nurses constitute the highest percentage of direct health
care staff in acute care facilities and have a central role in health care
delivery. To ensure the adequate protection and care for patients in health
care facilities, it is essential that qualified registered nurses be accessible
and available to meet the nursing needs of patients.
(c) The basic principles of staffing in health care facilities should be focused
on patient health care needs and based on consideration of patient acuity levels
and services that need to be provided to ensure optimal outcomes.
(d) The general assembly recognizes the findings and recommendations contained
in the 2001 report, Blue Ribbon Nursing, A Call to Action: Addressing Vermont’s
Nursing Shortage, especially the high stress workplace environment caused by
an increase in the number of patients assigned to nurses coupled with a decrease
in the amount of time nurses have to participate in direct patient care.
(e) Establishing staffing standards for registered nurses in health care facilities
ensures that these facilities throughout the state provide a safe workplace
environment, and guarantees the public safety and the delivery of quality health
care services.
§ 1921. DEFINITIONS
As used in this subchapter, the following words and phrases
shall be defined as follows:
(1) “Acuity-based patient classification system” means a standard
set of criteria based on scientific data that acts as a measurement instrument
which: predicts registered nursing care requirements for individual patients
based on severity of patient illness, need for specialized equipment and technology,
intensity of nursing interventions required, and the complexity of clinical
judgment needed to design, implement, and evaluate the patient’s nursing
care plan consistent with professional standards of care; details the amount
of registered nursing care needed, both in number of direct-care registered
nurses and skill mix of nursing personnel required on a daily basis for each
patient in a nursing department or unit; and is stated in terms that can be
used readily and understood by direct-care registered nurses. The acuity system
criteria shall take into consideration the patient care services provided not
only by registered nurses but also by licensed practical nurses and other health
care personnel.
(2) “Assessment tool” means a measurement system which compares
the registered nurse staffing level in each nursing department or unit against
actual patient nursing care requirements in order to review the accuracy of
an acuity system.
(3) “Department” means the Vermont department of health.
(4) “Direct-care registered nurse” means a registered nurse who
has accepted direct responsibility and accountability to carry out medical
regimens, nursing, or other bedside care for patients.
(5) “Facility” means a hospital licensed in Vermont, any licensed
private or state-owned and operated general acute care program hospital, psychiatric
facility, specialty hospital, or an acute care within a state-operated facility.
(6) “Nursing care” means care that falls within the scope of practice
as prescribed by state law or otherwise encompassed within recognized professional
standards of nursing practice, including assessment, nursing diagnosis, planning,
intervention, evaluation, and patient advocacy.
(7) “Ratio” means the actual number of patients to be assigned
to each direct care registered nurse.
§ 1922.
DUTIES OF THE DEPARTMENT
The department of health shall have the power and duty to:
(1) adopt rules necessary to carry out the purposes and provisions
of this subchapter, including defining terms and prescribing
the process for establishing a standardized acuity-based patient
classification system;
(2) assure that the provisions of this subchapter and all rules adopted under
it are enforced, and adopt, within one year of the effective date of this subchapter,
rules providing for an accessible and confidential system to report any failure
to comply with requirements of this subchapter and public access to information
regarding reports of inspections, results, deficiencies, and corrections under
this subchapter; and
(3) develop within one year of the effective date of this subchapter a standardized
acuity-based patient classification system as defined in section 1921 of this
subchapter to be used by all facilities for the purpose of increasing the number
of direct-care registered nurses to meet patient needs.
§ 1923.
MINIMUM NURSE STAFFING RATIOS
(a) Each facility shall incorporate and maintain the following
minimum direct-care registered nurse-to-patient ratios:
Critical Care Unit 1:2
Neonatal Intensive Care 1:2
Burn Unit 1:2
Step-down/Intermediate Care 1:3
Operating Room
Under Anesthesia 1:1
Post Anesthesia 1:2
Post Anesthesia Care Unit
Under Anesthesia 1:1
Post Anesthesia 1:2
Emergency Department 1:3*
Emergency Critical Care 1:2*
Emergency Trauma 1:1*
*The triage, radio, or other specialty registered nurse
shall not be counted as part of this number.
Perinatal Care
Antepartum 1:3
Active Labor 1:1
Immediate Postpartum 1:2
Postpartum 1:6
Intermediate Care Nursery 1:4
Well-baby Nursery 1:6
Pediatrics 1:3
Psychiatric 1:4
Medical and Surgical 1:4
Telemetry 1:3
Observational/Outpatient treatment 1:4
Transitional Care 1:5
Rehabilitation Unit 1:5
Specialty Care Unit* 1:4
*Any unit not otherwise listed above shall be considered
a specialty care unit
(b) The ratios in subsection (a) of this section shall constitute
the minimum number of direct-care registered nurses. Additional
direct-care registered nurses shall be added and the ratio
adjusted to ensure direct-care registered nurse staffing in
accordance with an approved acuity-based patient classification
system. Nothing herein shall be deemed to preclude any facility
from increasing the number of direct-care registered nurses,
nor shall the requirements set forth be deemed to supersede
or replace any requirements otherwise mandated by law, rule,
or collective bargaining contract, so long as the facility
meets the minimum requirements outlined.
§ 1924.
NURSE STAFFING PLAN
(a) As a condition of licensing, each facility annually shall
submit to the department a prospective staffing plan together
with a written certification that the staffing plan is sufficient
to provide adequate and appropriate delivery of health care
services to patients for the ensuing year, and does all of
the following:
(1) Meets the minimum direct-care registered nurse-to-patient
ratio requirements of section 1923 of this subchapter;
(2) Meets any additional requirements of other laws or regulations;
(3) Employs the acuity-based patient classification system for addressing
fluctuations in patient acuity levels requiring increased registered nurse
staffing levels above the minimums set forth in section 1923 of this subchapter;
(4) Provides for orientation of registered nursing staff to assigned clinical
practice areas, including temporary assignments, sufficient to provide competent
nursing care;
(5) Includes other unit or department activity such as discharges, transfers,
admissions, and administrative and support tasks that are expected to be
done by direct-care registered nurses in addition to direct nursing care;
(6) Submits the assessment tool used to validate the acuity system relied
upon in the plan; and
(7) Is produced in consultation with a majority of the direct-care nurses
in each department or unit or, where applicable, with the recognized or certified
collective bargaining representative of direct-care registered nurses.
As a condition
of licensing, each facility annually shall submit to the
department an audit of the preceding year’s
staffing plan as dictated in this subsection. The audit shall
compare the staffing plan with measurements of actual staffing
as well as measurements of actual acuity for all units within
the facility.
(b) As a condition of licensing, a facility required to have
a staffing plan under this subchapter shall:
(1) Prominently post within each unit the daily written
nurse staffing plan to reflect the registered nurse to patient
ratio as a means of consumer information and protection.
(2) Upon request, make copies of the staffing plan filed with the department
available to the public.
(3) Provide each patient and family member with a toll-free hotline number
at the department, which may be used to report inadequate registered nurse
staffing. Such complaint shall cause investigation by the department within
24 hours to determine whether any violation of law or regulation by the facility
has occurred.
(c) No facility may directly assign any other personnel to
perform undelegatable licensed nurse functions in lieu of care
delivered by a licensed registered nurse. Additionally, other
personnel are prohibited from performing tasks which require
the clinical assessment, judgment, and skill of a licensed
registered nurse. Such functions shall include:
(1) Nursing activities which require nursing assessment
and judgment;
(2) Physical, psychological, and social assessments which require nursing
judgment, intervention, referral, or follow-up;
(3) Formulation of the plan of nursing care and evaluation of the patient’s
response to the care provided;
(4) Administration of medications; and
(5) Health teaching and health counseling.
(d) A full-time registered nurse executive leader shall be
employed by each facility to be responsible for the following:
(1) overall execution of the resources to ensure sufficient
registered nurse staffing is provided by said facility;
(2) overall quality assurance of nursing care is provided by the facility;
and
(3) overall occupational health and safety of nursing staff employed by said
facility.
(e) For the purpose of compliance with the minimum registered
nurse staffing requirements set forth in this act, no registered
nurse shall be assigned or be included in the count of assigned
registered nurse staff in a nursing department or unit or a
clinical area within the facility unless that registered nurse
has an appropriate orientation in that clinical area sufficient
to provide competent nursing care to the patients in that area,
and has demonstrated current competence in providing care in
that area.
(f) As a condition of licensure, each facility shall adopt,
disseminate to direct-care nurses, and comply with a written
policy that meets the requirements under this section, detailing
the circumstances under which a direct-care registered nurse
may refuse a work assignment.
(1) At a minimum, the work assignment policy shall permit
a direct-care nurse to refuse any assignment for which:
(A) the nurse is not prepared by education, training, or
experience to safely fulfill the assignment without compromising
or jeopardizing patient safety,
the nurse’s ability to meet foreseeable patient needs, or the nurse’s
license; or
(B) the assignment otherwise would violate requirements under this subchapter.
(2) At a minimum, the work assignment policy shall contain procedures for
the following:
(A) Reasonable requirements for prior notice to the nurse’s supervisor
regarding the nurse’s request and supporting reasons for being relieved
of the assignment or continued duty.
(B) Where feasible, an opportunity for the supervisor to review the specific
conditions supporting the nurse’s request, and to decide whether to
remedy the conditions, to relieve the nurse of the assignment, or to deny
the nurse’s request to be relieved of the assignment or continued duty.
(C) A process will be in place that permits the nurse to exercise the right
to refuse the assignment or continued duty status when the supervisor denies
the request to be relieved if:
(i) The supervisor rejects the request without proposing a remedy or the
proposed remedy would be inadequate or untimely;
(ii) The complaint and investigation process with a regulatory agency would
be untimely to address the concern; and
(iii) The employee believes in good faith that the assignment meets conditions
justifying refusal.
(D) A nurse who refuses an assignment pursuant to a work assignment policy
established in this section shall not be deemed, by reason thereof, to have
engaged in negligent or incompetent action, patient abandonment, or otherwise
to have violated applicable nursing law.
§ 1925.
SANCTIONS
(a) Any facility that fails to anticipate, design, maintain,
or adhere to a daily written nurse staffing plan in accordance
with the provisions of this section, or any rule or regulation
promulgated hereunder, shall be subject to:
(1)
revocation of said facility’s license or registration,
or a fine of not more than $25,000.00, or both,
(2) a civil penalty of not more than $25,000.00, for each such violation.
(b) Each day each such violation occurs or continues shall
be deemed a separate offense. These penalties shall be in addition
to any other penalties that may be prescribed by law. The department
shall have jurisdiction to coordinate enforcement-related activities.
The civil penalty may be assessed in any action brought on
behalf of the state or on behalf of any patient or resident
aggrieved hereunder in any court of competent jurisdiction.
A facility shall be subject to fine when found to falsify or
cause to falsify documentation required by this act.
(c) Fines relative to the violations under this section shall
be collected and distributed to a foundation developed for
the purpose of advancing the nursing profession and enhancing
patient safety.
S.158
Introduced by Senator Lyons of Chittenden County and Senator Munt of Chittenden
County
AN ACT RELATING TO SAFE STAFFING AND
QUALITY PATIENT CARE
It is hereby enacted by the General Assembly of the State
of Vermont:
Sec. 1. 18 V.S.A. chapter 43 is amended to read:
CHAPTER 43. LICENSING OF HOSPITALS
Subchapter 1. General Provisions
* * *
Subchapter 2. Nurse Staffing Standards
§ 1920.
FINDINGS AND PURPOSE
(a) The purpose of this subchapter is to assure that the
delivery of health care services to patients in health care
facilities located within Vermont is adequate and safe, and
that health care facilities retain sufficient registered nursing
staff so as to promote optimal health care outcomes.
(b) Inadequate hospital staffing results in dangerous medical errors and patient
infections. Registered nurses constitute the highest percentage of direct health
care staff in acute care facilities and have a central role in health care
delivery. To ensure the adequate protection and care for patients in health
care facilities, it is essential that qualified registered nurses be accessible
and available to meet the nursing needs of patients.
(c) The basic principles of staffing in health care facilities should be focused
on patient health care needs and based on consideration of patient acuity levels
and services that need to be provided to ensure optimal outcomes.
(d) The general assembly recognizes the findings and recommendations contained
in the 2001 report, Blue Ribbon Nursing, A Call to Action: Addressing Vermont’s
Nursing Shortage, especially the high stress workplace environment caused by
an increase in the number of patients assigned to nurses coupled with a decrease
in the amount of time nurses have to participate in direct patient care.
(e) Establishing staffing standards for registered nurses in health care facilities
ensures that these facilities throughout the state provide a safe workplace
environment, and guarantees the public safety and the delivery of quality health
care services.
§ 1921. DEFINITIONS
As used in this subchapter, the following words and phrases
shall be defined as follows:
(1) “Acuity-based patient classification system” means a standard
set of criteria based on scientific data that acts as a measurement instrument
which: predicts registered nursing care requirements for individual patients
based on severity of patient illness, need for specialized equipment and technology,
intensity of nursing interventions required, and the complexity of clinical
judgment needed to design, implement, and evaluate the patient’s nursing
care plan consistent with professional standards of care; details the amount
of registered nursing care needed, both in number of direct-care registered
nurses and skill mix of nursing personnel required on a daily basis for each
patient in a nursing department or unit; and is stated in terms that can be
used readily and understood by direct-care registered nurses. The acuity system
criteria shall take into consideration the patient care services provided not
only by registered nurses but also by licensed practical nurses and other health
care personnel.
(2) “Assessment tool” means a measurement system which compares
the registered nurse staffing level in each nursing department or unit against
actual patient nursing care requirements in order to review the accuracy of
an acuity system.
(3) “Department” means the Vermont department of health.
(4) “Direct-care registered nurse” means a registered nurse who
has accepted direct responsibility and accountability to carry out medical
regimens, nursing, or other bedside care for patients.
(5) “Facility” means a hospital licensed in Vermont, any licensed
private or state-owned and operated general acute care program hospital, psychiatric
facility, specialty hospital, or an acute care within a state-operated facility.
(6) “Nursing care” means care that falls within the scope of practice
as prescribed by state law or otherwise encompassed within recognized professional
standards of nursing practice, including assessment, nursing diagnosis, planning,
intervention, evaluation, and patient advocacy.
(7) “Ratio” means the actual number of patients to be assigned
to each direct care registered nurse.
§ 1922.
DUTIES OF THE DEPARTMENT
The department of health shall have the power and duty to:
(1) adopt rules necessary to carry out the purposes and provisions
of this subchapter, including defining terms and prescribing
the process for establishing a standardized acuity-based patient
classification system;
(2) assure that the provisions of this subchapter and all rules adopted under
it are enforced, and adopt, within one year of the effective date of this subchapter,
rules providing for an accessible and confidential system to report any failure
to comply with requirements of this subchapter and public access to information
regarding reports of inspections, results, deficiencies, and corrections under
this subchapter; and
(3) develop within one year of the effective date of this subchapter a standardized
acuity-based patient classification system as defined in section 1921 of this
subchapter to be used by all facilities for the purpose of increasing the number
of direct-care registered nurses to meet patient needs.
§ 1923.
MINIMUM NURSE STAFFING RATIOS
(a) Each facility shall incorporate and maintain the following
minimum direct-care registered nurse-to-patient ratios:
Critical Care Unit 1:2
Neonatal Intensive Care 1:2
Burn Unit 1:2
Step-down/Intermediate Care 1:3
Operating Room
Under Anesthesia 1:1
Post Anesthesia 1:2
Post Anesthesia Care Unit
Under Anesthesia 1:1
Post Anesthesia 1:2
Emergency Department 1:3*
Emergency Critical Care 1:2*
Emergency Trauma 1:1*
*The triage, radio, or other specialty registered nurse
shall not be counted as part of this number.
Perinatal Care
Antepartum 1:3
Active Labor 1:1
Immediate Postpartum 1:2
Postpartum 1:6
Intermediate Care Nursery 1:4
Well-baby Nursery 1:6
Pediatrics 1:3
Psychiatric 1:4
Medical and Surgical 1:4
Telemetry 1:3
Observational/Outpatient treatment 1:4
Transitional Care 1:5
Rehabilitation Unit 1:5
Specialty Care Unit* 1:4
*Any unit not otherwise listed above shall be considered
a specialty care unit
(b) The ratios in subsection (a) of this section shall constitute
the minimum number of direct-care registered nurses. Additional
direct-care registered nurses shall be added and the ratio
adjusted to ensure direct-care registered nurse staffing in
accordance with an approved acuity-based patient classification
system. Nothing herein shall be deemed to preclude any facility
from increasing the number of direct-care registered nurses,
nor shall the requirements set forth be deemed to supersede
or replace any requirements otherwise mandated by law, rule,
or collective bargaining contract, so long as the facility
meets the minimum requirements outlined.
§ 1924.
NURSE STAFFING PLAN
(a) As a condition of licensing, each facility annually shall
submit to the department a prospective staffing plan together
with a written certification that the staffing plan is sufficient
to provide adequate and appropriate delivery of health care
services to patients for the ensuing year, and does all of
the following:
(1) Meets the minimum direct-care registered nurse-to-patient
ratio requirements of section 1923 of this subchapter;
(2) Meets any additional requirements of other laws or regulations;
(3) Employs the acuity-based patient classification system for addressing
fluctuations in patient acuity levels requiring increased registered nurse
staffing levels above the minimums set forth in section 1923 of this subchapter;
(4) Provides for orientation of registered nursing staff to assigned clinical
practice areas, including temporary assignments, sufficient to provide competent
nursing care;
(5) Includes other unit or department activity such as discharges, transfers,
admissions, and administrative and support tasks that are expected to be
done by direct-care registered nurses in addition to direct nursing care;
(6) Submits the assessment tool used to validate the acuity system relied
upon in the plan; and
(7) Is produced in consultation with a majority of the direct-care nurses
in each department or unit or, where applicable, with the recognized or certified
collective bargaining representative of direct-care registered nurses.
As a condition
of licensing, each facility annually shall submit to the
department an audit of the preceding year’s
staffing plan as dictated in this subsection. The audit shall
compare the staffing plan with measurements of actual staffing
as well as measurements of actual acuity for all units within
the facility.
(b) As a condition of licensing, a facility required to have
a staffing plan under this subchapter shall:
(1) Prominently post within each unit the daily written
nurse staffing plan to reflect the registered nurse to patient
ratio as a means of consumer information and protection.
(2) Upon request, make copies of the staffing plan filed with the department
available to the public.
(3) Provide each patient and family member with a toll-free hotline number
at the department, which may be used to report inadequate registered nurse
staffing. Such complaint shall cause investigation by the department within
24 hours to determine whether any violation of law or regulation by the facility
has occurred.
(c) No facility may directly assign any other personnel to
perform undelegatable licensed nurse functions in lieu of care
delivered by a licensed registered nurse. Additionally, other
personnel are prohibited from performing tasks which require
the clinical assessment, judgment, and skill of a licensed
registered nurse. Such functions shall include:
(1) Nursing activities which require nursing assessment
and judgment;
(2) Physical, psychological, and social assessments which require nursing
judgment, intervention, referral, or follow-up;
(3) Formulation of the plan of nursing care and evaluation of the patient’s
response to the care provided;
(4) Administration of medications; and
(5) Health teaching and health counseling.
(d) A full-time registered nurse executive leader shall be
employed by each facility to be responsible for the following:
(1) overall execution of the resources to ensure sufficient
registered nurse staffing is provided by said facility;
(2) overall quality assurance of nursing care is provided by the facility;
and
(3) overall occupational health and safety of nursing staff employed by said
facility.
(e) For the purpose of compliance with the minimum registered
nurse staffing requirements set forth in this act, no registered
nurse shall be assigned or be included in the count of assigned
registered nurse staff in a nursing department or unit or a
clinical area within the facility unless that registered nurse
has an appropriate orientation in that clinical area sufficient
to provide competent nursing care to the patients in that area,
and has demonstrated current competence in providing care in
that area.
(f) As a condition of licensure, each facility shall adopt,
disseminate to direct-care nurses, and comply with a written
policy that meets the requirements under this section, detailing
the circumstances under which a direct-care registered nurse
may refuse a work assignment.
(1) At a minimum, the work assignment policy shall permit
a direct-care nurse to refuse any assignment for which:
(A) the nurse is not prepared by education, training, or
experience to safely fulfill the assignment without compromising
or jeopardizing patient safety,
the nurse’s ability to meet foreseeable patient needs, or the nurse’s
license; or
(B) the assignment otherwise would violate requirements under this subchapter.
(2) At a minimum, the work assignment policy shall contain procedures for
the following:
(A) Reasonable requirements for prior notice to the nurse’s supervisor
regarding the nurse’s request and supporting reasons for being relieved
of the assignment or continued duty.
(B) Where feasible, an opportunity for the supervisor to review the specific
conditions supporting the nurse’s request, and to decide whether to
remedy the conditions, to relieve the nurse of the assignment, or to deny
the nurse’s request to be relieved of the assignment or continued duty.
(C) A process will be in place that permits the nurse to exercise the right
to refuse the assignment or continued duty status when the supervisor denies
the request to be relieved if:
(i) The supervisor rejects the request without proposing a remedy or the
proposed remedy would be inadequate or untimely;
(ii) The complaint and investigation process with a regulatory agency would
be untimely to address the concern; and
(iii) The employee believes in good faith that the assignment meets conditions
justifying refusal.
(D) A nurse who refuses an assignment pursuant to a work assignment policy
established in this section shall not be deemed, by reason thereof, to have
engaged in negligent or incompetent action, patient abandonment, or otherwise
to have violated applicable nursing law.
§ 1925.
SANCTIONS
(a) Any facility that fails to anticipate, design, maintain,
or adhere to a daily written nurse staffing plan in accordance
with the provisions of this section, or any rule or regulation
promulgated hereunder, shall be subject to:
(1)
revocation of said facility’s license or registration,
or a fine of not more than $25,000.00, or both,
(2) a civil penalty of not more than $25,000.00, for each such violation.
(b) Each day each such violation occurs or continues shall
be deemed a separate offense. These penalties shall be in addition
to any other penalties that may be prescribed by law. The department
shall have jurisdiction to coordinate enforcement-related activities.
The civil penalty may be assessed in any action brought on
behalf of the state or on behalf of any patient or resident
aggrieved hereunder in any court of competent jurisdiction.
A facility shall be subject to fine when found to falsify or
cause to falsify documentation required by this act.
(c) Fines relative to the violations under this section shall
be collected and distributed to a foundation developed for
the purpose of advancing the nursing profession and enhancing
patient safety.
