Safe Staffing for Hospital Care Act
SECTION 1. SHORT TITLE
This Act shall be called the “Safe Staffing for Hospital Care Act.”
SECTION 2. FINDINGS AND PURPOSE
(A) FINDINGS – The legislature finds that:
1. [STATE] has a substantial interest in assuring that delivery of healthcare services to patients in
healthcare facilities located within this state is adequate and safe and that healthcare facilities retain
sufficient nursing staff so as to promote optimal healthcare outcomes.
2. Recent changes in our healthcare delivery system are resulting in a higher acuity level among patients in
healthcare facilities. Inadequate hospital staffing results in dangerous medical errors and patient infections.
3. Inadequate and poorly monitored nurse staffing practices can adversely impact the health of patients
who enter hospitals and outpatient emergency and surgical centers.
4. A substantial number of nurses indicate that hospital-patient acuity measurements are inadequate and
that many hospitals rarely, if ever, staff according to an acuity measurement tool.
5. Establishing staffing standards will ensure that healthcare facilities throughout the state operate in a
manner that guarantees the public safety and the delivery of quality healthcare services.
6. Hospital nurses work substantial overtime hours and nurses working 12-hour shifts work the most
additional overtime hours per week.
7. Mandatory overtime and lengthy work hours for direct-care nurses constitute a threat to the health and
safety of patients, adversely impact the general wellbeing of nurses and result in greater turnover, which
increases long-term shortages of nursing personnel.
(B) PURPOSE – This law is enacted to protect the health and safety of the residents of [STATE] by ensuring
adequate protection and care for patients in healthcare facilities.
SECTION 3. SAFE STAFFING FOR HOSPITAL CARE
After section XXX, the following new section XXX shall be inserted:
(A) FACILITY STAFFING STANDARD
1. Each facility licensed pursuant to this statute shall ensure that it is staffed in a manner that provides
sufficient, appropriately qualified nursing staff of each classification in each department or unit within the
facility in order to meet the individualized care needs of patients.
2. As a condition of licensing, each healthcare facility licensed pursuant to [citation] shall annually submit
to the [appropriate agency] a documented staffing plan together with a written certification that the staffing
plan is sufficient to provide adequate and appropriate delivery of healthcare services to patients for the
ensuing year. The staffing plan must:
a. Meet the minimum requirements set forth in subsection 3.
b. Be adequate to meet any additional requirements provided by other laws or regulations.
c. Employ and identify an approved acuity system for addressing fluctuations in actual patient acuity levels
and nursing care requirements requiring increased staffing levels above the minimums set forth in the plan.
d. Factor in other unit or department work, such as discharges, transfers and admissions, and administrative
and support tasks, that is expected to be done by direct-care nurses in addition to direct nursing care.
e. Identify the assessment tool used to validate the acuity system relied on in the plan.
f. Identify the system that will be used to document actual staffing on a daily basis within each department
or unit.
g. Include a written assessment of the accuracy of the prior year’s staffing plan in light of actual staffing
needs.
h. Identify each nurse staff classification referenced therein together with a statement setting forth
minimum qualifications for each such classification.
i. Be developed in consultation with the direct-care nursing staff within each department or unit or,
where such staff is represented, with the applicable recognized or certified collective bargaining
representative(s) of the direct-care nursing staff.
3. The healthcare facility’s staffing plan must incorporate, at a minimum, the following direct-care nurse-topatient
ratios: pediatric recovery room—1 to 1, operating room circulating nurse—1 to 1, special procedures
(e.g. cath lab, radiology, endoscopy)—1 to 1, trauma—1 to 1, burn unit— 1 to 2, critical care—1 to 2, labor
and delivery—1 to 2, adult recovery room—1 to 2, emergency room—1 to 3, oncology/chemotherapy—1 to
3, intermediate care unit—1 to 3, telemetry—1 to 3, mother/baby couplets and normal post-partum—1 to 4,
pediatrics—1 to 4, psychiatric unit—1 to 4, adult medical-surgical unit—1 to 6.
4. The [appropriate agency] shall adopt regulations that establish minimum, specific, numerical direct-care
nurse-to-patient ratios for other healthcare facility nursing departments and units that must be incorporated
into the staffing plan.
5. The minimum numbers of direct-care nurse-to-patient staff set forth in the preceding paragraphs shall
constitute the minimum numbers of direct-care nursing staff that shall be assigned to and be present within
a nursing department or unit. Where the approved acuity system adopted by the facility indicates that
additional staff is required, the healthcare facility must staff at the higher staffing level.
6. The skill mix reflected in a staffing plan must assure that all of the following elements of the nursing
process are performed in the planning and delivery of care for each patient:
a. Assessment, nursing diagnosis, planning, intervention, evaluation and patient advocacy.
b. Registered nurses must constitute at least 50 percent of the direct-care nurses included in the staffing plan.
c. The skill mix may not incorporate or assume that nursing care functions required by licensing law or
regulations or accepted standards of practice to be performed by a licensed nurse are to be performed by
unlicensed personnel.
7. The [Department of Health] shall adopt regulations prescribing the method by which it will approve a
healthcare facility’s acuity system. Such regulations may include a system for class approval of acuity
systems.
(B) COMPLIANCE WITH PLAN AND RECORDKEEPING
1. As a condition of licensing, a healthcare facility must at all times staff in accordance with its staffing
plan and the staffing standards set forth herein, provided, however, that nothing herein shall be deemed to
preclude a healthcare facility from implementing higher direct-care nurse-to-patient staffing levels.
2. No nurse shall be assigned, or included in the count of assigned nursing staff for purposes of compliance
with minimum staffing requirements, in a nursing department or unit or a clinical area within the
healthcare facility without appropriate licensing, prior orientation, and verification that the nurse is
capable of providing competent nursing care to the patients therein.
3. As a condition of licensure, each healthcare facility licensed under this section shall maintain accurate
daily records showing:
a. The number of patients admitted, released and present in each nursing department or unit within the
facility.
b. The individual acuity level of each patient present in each nursing department or unit within the
facility.
c. The identity and duty hours of each direct-care nurse in each nursing department or unit within the
facility.
4. As a condition of licensure, each healthcare facility shall maintain daily statistics, by nursing department
and unit, of mortality, morbidity, infection, accident, injury and medical errors.
5. All records required to be kept under this subsection shall be maintained for a period of seven years.
6. All records required to be kept under this subsection shall be made available upon request to the [oversight
agency] and to the public, provided, however, that information released to the public shall not contain
the name or other personal identifying information, apart from acuity level, about any individual patient.
(C) MANDATORY OVERTIME AND EXCESSIVE DUTY HOURS
1. Except during a state of emergency declared by the Governor, a healthcare facility may not mandate or
otherwise require, directly or indirectly, a healthcare employee to work or be in on-duty status in excess of
any one of the following:
a. The scheduled work shift or duty period.
b. 12 hours in a 24-hour period.
c. 80 hours in a 14 consecutive-day period.
“Mandate” means any request which, if refused or declined by the healthcare employee, may result in
discharge, discipline, loss of promotion, or other adverse employment consequence. Nothing in this
subsection is intended to prohibit a healthcare employee from voluntarily working overtime.
2. Except during a state of emergency declared by the Governor:
a. No healthcare employee may work or be in on duty status more than 16 hours in any 24-hour period.
b. Any healthcare employee working 16 hours in any 24-hour period must have at least 8 consecutive
hours off duty before being required to return to duty.
c. No healthcare employee may be required to work or be on-duty more than 7 consecutive days without
at least one consecutive 24-hour period off duty within that time.
3. A work shift schedule or overtime program established pursuant to a collective bargaining agreement
negotiated on behalf of the healthcare employees by a bona fide labor organization may provide for mandatory
on-duty hours in excess of that permitted under this subsection, provided adequate measures are
included in the agreement to ensure against excessive fatigue on the part of the affected employees.
(D) EMPLOYEE RIGHTS
1. As a condition of licensure, each healthcare facility licensed under [insert statutory citation] shall adopt
and disseminate to direct-care nursing staff a written policy that complies with the requirements set forth in
paragraphs (2) and (3) below, detailing the circumstances under which a direct-care nurse may refuse a
work assignment.
2. At a minimum, the work assignment policy shall permit a direct-care nurse to refuse an 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.
b. The nurse has volunteered to work overtime but determines that his or her level of fatigue and/or
decreased alertness would compromise or jeopardize patient safety, the nurse’s ability to meet foreseeable
patient needs, or the nurse’s license.
c. The assignment otherwise would violate requirements set forth in this section.
3. At a minimum, the work assignment policy shall contain procedures for the following:
a. Reasonable requirements for prior notice to a nurse’s supervisor regarding the nurse’s request and
supporting reasons for being relieved of an 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 which permits the nurse to exercise the right to refuse the assignment or continued on-duty
status when the supervisor denies the request to be relieved if:
(1) The supervisor rejects the request without proposing a remedy, or the proposed remedy would
be inadequate or untimely.
(2) The complaint and investigation process with the [regulatory agency] would be untimely to
address the concern.
(3) The employee in good faith believes that the assignment meets conditions justifying refusal.
4. An employee is deemed to act in good faith if the employee reasonably believes that the information
reported or disclosed is true, and that a violation has occurred or may occur. A healthcare facility covered
by this section shall not penalize, discriminate or retaliate in any manner against an employee with respect
to compensation, terms, conditions or privileges of employment, who in good faith, individually or in
conjunction with another person or persons:
a. Reports a violation or suspected violation of this section to a public regulatory agency, a private
accreditation body, or management personnel of the healthcare facility,
b. Initiates, cooperates or otherwise participates in an investigation or proceeding brought by a regulatory
agency or private accreditation body concerning matters covered by this section,
c. Informs or discusses with other employees, with representative(s) of the employees, with patients or
patient representatives, or with the public, violations or suspected violations of this section, or
d. Otherwise avails himself or herself of the rights set forth in this section.
(E) ENFORCEMENT
1. This section may be enforced by a private cause of action under [appropriate section
of state law].
2. This section shall be enforced by [appropriate state agency], which shall promulgate such regulations as
are necessary to implement and administer compliance. Regulations shall include procedures to receive,
investigate, and attempt to resolve complaints, and bring actions in any court of competent jurisdiction to
recover appropriate relief for aggrieved employees.
3. No healthcare facility shall discharge, demote, harass or otherwise take adverse actions against any
individual because such individual seeks to enforce this section, or testifies, assists or participates in any
manner in an investigation, hearing or other proceeding to enforce this section.
4. In any action under this section in which an employee prevails:
a. The employee shall be awarded monetary relief, including back pay in an amount equal to the
difference between the employee’s actual earnings and what the employee would have earned but for the
healthcare facility’s unlawful practices, and an additional amount in punitive damages, as appropriate.
b. The healthcare facility shall be enjoined from continuing to violate the provisions of this section and
may be ordered to take such additional affirmative steps as are necessary to ensure an end to the unlawful
practices.
c. The healthcare facility shall pay a reasonable attorney’s fee, reasonable expert witness fees, and other
costs of the action.
SECTION 4. EFFECTIVE DATE
This Act shall take effect on July 1, 2004.