113 S2353 IS: Registered Nurse Safe Staffing Act of 2014
U.S. Senate
2014-05-15
text/xml
EN
Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.
1.
This Act may be cited as the
Registered Nurse Safe Staffing Act of 2014
.
2.
Congress makes the following
findings:
(1)
Research shows
that patient safety in hospitals is directly proportionate to the number
of
registered nurses working in the hospital. Higher staffing levels by
experienced registered nurses are related to lower rates of negative
patient
outcomes.
(2)
A
2011 study on nurse staffing and inpatient hospital mortality shows that
sub-optimal nurse staffing is linked with a greater likelihood of patient
death
in the hospital. A 2012 study of serious patient events reported to the
Joint
Commission demonstrates that one of the leading causes of all hospital
sentinel
events is human factors, including staffing and staffing skill mix.
(3)
Health care worker
fatigue has been identified as a major patient safety hazard, and
appropriate
staffing policies and practices are indicated as an effective strategy to
reduce health care worker fatigue and to protect patients. A national
survey of
registered nurses found that 74 percent experience acute or chronic
effects of
stress and overwork.
(4)
A
strategy that ensures optimal nurse staffing and skill mix greatly
influences
patient satisfaction and results in greater overall savings to hospitals
through reductions in adverse patient events.
(5)
A
2009 study demonstrated that improved patient satisfaction due to
increased and
appropriate nurse staffing is reflected on hospital scores on HCAHPS,
which is
a key measure for value-based payment programs under the Medicare program
and
used by other payors.
(6)
Registered nurses
play a vital role in preventing patient care errors. A 2009 study found
that
sufficient staffing of critical care nurses can prevent adverse patient
events,
which can cost anywhere from $2,200,000 to $13,200,000. By contrast, the
nurse
staffing costs in the study time period were only $1,360,000.
(7)
Higher nurse
staffing also generates cost savings to payors, as demonstrated in a 2011
cost-benefit analysis that weighed registered nursing personnel costs
against
emergency department utilization after patient discharge from a
hospital.
(8)
A
2012 study of Pennsylvania hospitals shows that by reducing nurse burnout,
which is attributed in part to poor nurse staffing, those hospitals could
prevent an estimated 4,160 infections with an associated savings of
$41,000,000. That study also found that for each additional patient
assigned to
a registered nurse for care, there is an incidence of roughly one
additional
catheter-acquired urinary tract infection per 1,000 patients or 1,351
infections per year, costing those hospitals as much as $1,100,000
annually.
(9)
When hospitals
employ insufficient numbers of nursing staff, registered nurses are being
required to perform professional services under conditions that do not
support
quality health care or a healthful work environment for registered
nurses.
(10)
As a payor for
inpatient and outpatient hospital services furnished to Medicare
beneficiaries,
the Federal Government has a compelling interest in promoting the safety
of
these patients by requiring any hospital participating in the Medicare
program
to establish minimum safe staffing levels for registered nurses.
3.
Establishment of
safe nurse staffing levels by Medicare participating hospitals
(a)
Requirement of
medicare provider agreement
Section 1866(a)(1) of the Social
Security Act (42 U.S.C. 1395cc(a)(1)) is amended—
(1)
in subparagraph
(V), by striking and
at the end;
(2)
in subparagraph
(W), as added by section 3005 of the Patient Protection and Affordable
Care Act
(Public Law 111–148)—
(A)
by moving such
subparagraph 2 ems to the left; and
(B)
by striking the
period at the end;
(3)
in subparagraph
(W), as added by section 6406(b) of the Patient Protection and Affordable
Care
Act (Public Law 111–148)—
(A)
by moving such
subparagraph 2 ems to the left;
(B)
by redesignating
such subparagraph as subparagraph (X); and
(C)
by striking the
period at the end and inserting , and
; and
(4)
by inserting after
subparagraph (X), as redesignated by paragraph (3)(B), the following new
subparagraph:
(Y)
in the case of a
hospital (as defined in section 1861(e)), to meet the requirements
of section
1899B.
.
(b)
Title
XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is amended by
adding
at the end the following new section:
1899B.
Nurse staffing requirements for Medicare participating
hospitals(a)
Implementation of
nurse staffing plan
(1)
Each participating hospital shall implement a
hospital-wide staffing plan for nursing services furnished in the
hospital.
(2)
Requirement for
development of staffing plan by hospital nurse staffing
committee
The hospital-wide staffing plan for nursing services
implemented by a hospital pursuant to paragraph (1)—
(A)
shall be developed
by the hospital nurse staffing committee established under
subsection (b);
and
(B)
shall require that
an appropriate number of registered nurses provide direct patient
care in each
unit and on each shift of the hospital to ensure staffing levels
that—
(i)
address the unique
characteristics of the patients and hospital units; and
(ii)
result in the
delivery of safe, quality patient care, consistent with the
requirements under
subsection (c).
(b)
Hospital nurse
staffing committee
(1)
Each
participating hospital shall establish a hospital nurse staffing
committee
(hereinafter in this section referred to as the
Committee
).
(2)
A
Committee established pursuant to this subsection shall be composed
of members
as follows:
(A)
Minimum 55
percent nurse participation
Not less than 55 percent of the
members of the Committee shall be registered nurses who provide
direct patient
care but who are neither hospital nurse managers nor part of the
hospital
administration staff.
(B)
Inclusion of
hospital nurse managers
The Committee shall include members who
are hospital nurse managers.
(C)
Inclusion of
nurses from specialty units
The members of the Committee shall
include at least 1 registered nurse who provides direct care from
each nurse
specialty or unit of the hospital (each such specialty or unit as
determined by
the hospital).
(D)
The Committee shall include such other personnel of the
hospital as the hospital determines to be appropriate.
(3)
(A)
Development of
staffing plan
The Committee shall develop a hospital-wide
staffing plan for nursing services furnished in the hospital
consistent with
the requirements under subsection (c).
(B)
Review and
modification of staffing plan
The Committee shall—
(i)
conduct regular,
ongoing monitoring of the implementation of the hospital-wide
staffing plan for
nursing services furnished in the hospital;
(ii)
carry out
evaluations of the hospital-wide staffing plan for nursing services
at least
annually; and
(iii)
make such
modifications to the hospital-wide staffing plan for nursing
services as may be
appropriate.
(C)
The Committee shall—
(i)
develop policies
and procedures for overtime requirements of registered nurses
providing direct
patient care and for appropriate time and manner of relief of such
registered
nurses during routine absences; and
(ii)
carry out such
additional duties as the Committee determines to be appropriate.
(c)
Staffing plan
requirements
(1)
Subject to paragraph (2), a hospital-wide staffing
plan for nursing services developed and implemented under this
section
shall—
(A)
be based upon
input from the registered nurse staff of the hospital who provide
direct
patient care or their exclusive representatives, as well as the
chief nurse
executive;
(B)
be based upon the
number of patients and the level and variability of intensity of
care to be
provided to those patients, with appropriate consideration given to
admissions,
discharges, and transfers during each shift;
(C)
take into account
contextual issues affecting nurse staffing and the delivery of
care, including
architecture and geography of the environment and available
technology;
(D)
take into account
the level of education, training, and experience of those
registered nurses
providing direct patient care;
(E)
take into account
the staffing levels and services provided by other health care
personnel
associated with nursing care, such as certified nurse assistants,
licensed
vocational nurses, licensed psychiatric technicians, nursing
assistants, aides,
and orderlies;
(F)
take into account
staffing levels recommended by specialty nursing organizations;
(G)
establish upwardly
adjustable minimum ratios of direct care registered nurses to
patients for each
unit and for each shift of the hospital, based upon an assessment
by registered
nurses of the level and variability of intensity of care required
by patients
under existing conditions;
(H)
take into account
unit and facility level staffing, quality and patient outcome data,
and
national comparisons, as available;
(I)
ensure that a
registered nurse shall not be assigned to work in a particular unit
of the
hospital without first having established the ability to provide
professional
care in such unit; and
(J)
provide for
exemptions from some or all requirements of the hospital-wide
staffing plan for
nursing services during a declared state of emergency (as defined
in subsection
(l)(1)) if the hospital is requested or expected to provide an
exceptional
level of emergency or other medical services.
(2)
A
hospital-wide staffing plan for nursing services developed and
implemented
under this section—
(A)
shall not preempt
any registered-nurse staffing levels established under State law or
regulation;
and
(B)
may not utilize
any minimum number of registered nurses established under paragraph
(1)(G) as
an upper limit on the nurse staffing of the hospital to which such
minimum
number applies.
(d)
Reporting and
release to public of certain staffing information
(1)
Requirements for
hospitals
Each participating hospital shall—
(A)
post daily for
each shift, in a clearly visible place, a document that specifies
in a uniform
manner (as prescribed by the Secretary) the current number of
licensed and
unlicensed nursing staff directly responsible for patient care in
each unit of
the hospital, identifying specifically the number of registered
nurses;
(B)
upon request, make
available to the public—
(i)
the nursing staff
information described in subparagraph (A);
(ii)
a
detailed written description of the hospital-wide staffing plan
implemented by
the hospital pursuant to subsection (a); and
(iii)
not later than
90 days after the date on which an evaluation is carried out by the
Committee
under subsection (b)(3)(B)(ii), a copy of such evaluation; and
(C)
not less
frequently than quarterly, submit to the Secretary in a uniform
manner (as
prescribed by the Secretary) the nursing staff information
described in
subparagraph (A) through electronic data submission.
(2)
Secretarial
responsibilities
The Secretary shall—
(A)
make the
information submitted pursuant to paragraph (1)(C) publicly
available in a
comprehensible format (as described in subsection (e)(2)(D)(ii)),
including by
publication on the Hospital Compare Internet Web site of the
Department of
Health and Human Services; and
(B)
provide for the
auditing of such information for accuracy as a part of the process
of
determining whether the participating hospital is in compliance
with the
conditions of its agreement with the Secretary under section 1866,
including
under subsection (a)(1)(Y) of such section.
(e)
Recordkeeping;
collection and reporting of quality data; evaluation
(1)
Each
participating hospital shall maintain for a period of at least 3
years (or, if
longer, until the conclusion of any pending enforcement activities)
such
records as the Secretary deems necessary to determine whether the
hospital has
implemented a hospital-wide staffing plan for nursing services
pursuant to
subsection (a).
(2)
Collection and
reporting of quality data on nursing services
(A)
The Secretary shall require the collection, aggregation,
maintenance, and reporting of quality data relating to nursing
services
furnished by each participating hospital.
(B)
In carrying out this paragraph, the Secretary shall use
only quality measures for nursing-sensitive care that are endorsed
by the
consensus-based entity with a contract under section 1890(a).
(C)
Use of qualified
third-party entities for collection and submission of data
(i)
A participating hospital may enter into agreements with
third-party entities that have demonstrated expertise in the
collection and
submission of quality data on nursing services to collect,
aggregate, maintain,
and report the quality data of the hospital pursuant to
subparagraph
(A).
(ii)
Nothing
in clause (i) shall be construed to excuse or exempt a
participating hospital
that has entered into an agreement described in such clause from
compliance
with requirements for quality data collection, aggregation,
maintenance, and
reporting imposed under this paragraph.
(D)
Reporting of
quality data
(i)
Publication on
hospital compare web site
Subject to the succeeding provisions of
this subparagraph, the Secretary shall make the data submitted
pursuant to
subparagraph (A) publicly available, including by publication on
the Hospital
Compare Internet Web site of the Department of Health and Human
Services.
(ii)
Data made available to the public under clause (i) shall
be presented in a clearly understandable format that permits
consumers of
hospital services to make meaningful comparisons among hospitals,
including
concise explanations in plain English of how to interpret the data,
of the
difference in types of nursing staff, of the relationship between
nurse
staffing levels and quality of care, and of how nurse staffing may
vary based
on patient case mix.
(iii)
Opportunity to
correct errors
The Secretary shall establish a process under
which participating hospitals may review data submitted to the
Secretary
pursuant to subparagraph (A) to correct errors, if any, contained
in that data
submission before making the data available to the public under
clause
(i).
(3)
The Secretary shall provide for the analysis of quality data
collected from participating hospitals under paragraph (2) in order
to evaluate
the effect of hospital-wide staffing plans for nursing services
implemented
pursuant to subsection (a) on—
(A)
patient outcomes
that are nursing sensitive (such as pressure ulcers, fall
occurrence, falls
resulting in injury, length of stay, and central line catheter
infections);
and
(B)
nursing workforce
safety and retention (including work-related injury, staff skill
mix, nursing
care hours per patient day, vacancy and voluntary turnover rates,
overtime
rates, use of temporary agency personnel, and nurse satisfaction).
(f)
A nurse may refuse to accept an assignment as a nurse
in a participating hospital, or in a unit of a participating
hospital,
if—
(1)
the assignment is
in violation of the hospital-wide staffing plan for nursing
services
implemented pursuant to subsection (a); or
(2)
the nurse is not
prepared by education, training, or experience to fulfill the
assignment
without compromising the safety of any patient or jeopardizing the
license of
the nurse.
(g)
(1)
The
Secretary shall enforce the requirements and prohibitions of this
section in
accordance with the succeeding provisions of this subsection.
(2)
Procedures for
receiving and investigating complaints
The Secretary shall
establish procedures under which—
(A)
any person may
file a complaint that a participating hospital has violated a
requirement of or
a prohibition under this section; and
(B)
such complaints
are investigated by the Secretary.
(3)
Except
as provided in paragraph (5), if the Secretary determines that a
participating
hospital has violated a requirement of this section, the Secretary—
(A)
shall require the
hospital to establish a corrective action plan to prevent the
recurrence of
such violation; and
(B)
may impose civil
money penalties under paragraph (4).
(4)
(A)
In addition to any other penalties prescribed by law, the
Secretary may impose a civil money penalty of not more than $10,000
for each
knowing violation of a requirement of this section, except that the
Secretary
shall impose a civil money penalty of more than $10,000 for each
such violation
in the case of a participating hospital that the Secretary
determines has a
pattern or practice of such violations (with the amount of such
additional
penalties being determined in accordance with a schedule or
methodology
specified in regulations).
(B)
The
provisions of section 1128A (other than subsections (a) and (b))
shall apply to
a civil money penalty under this paragraph in the same manner as
such
provisions apply to a penalty or proceeding under section 1128A.
(C)
Public notice of
violations
(i)
The Secretary shall publish on an appropriate Internet Web
site of the Department of Health and Human Services the names of
participating
hospitals on which civil money penalties have been imposed under
this section,
the violation for which the penalty was imposed, and such
additional
information as the Secretary determines appropriate.
(ii)
With respect to a participating hospital that had a
change in ownership, as determined by the Secretary, penalties
imposed on the
hospital while under previous ownership shall no longer be
published by the
Secretary of such Internet Web site after the 1-year period
beginning on the
date of the change in ownership.
(5)
Penalty for
failure to collect and report quality data on nursing services
(A)
In the case of a participating hospital that fails to
comply with requirements under subsection (e)(2) to collect,
aggregate,
maintain, and report quality data relating to nursing services
furnished by the
hospital, instead of the remedies described in paragraph (3), the
provisions of
subparagraph (B) shall apply with respect to each such failure of
the
participating hospital.
(B)
In
the case of a failure by a participating hospital to comply with
the
requirements under subsection (e)(2) for a year, each such failure
shall be
deemed to be a failure to submit data required under section
1833(t)(17)(A),
section 1886(b)(3)(B)(viii), section 1886(j)(7)(A), or section
1886(m)(5)(A),
as the case may be, with respect to the participating hospital
involved for
that year.
(h)
Whistleblower
protections
(1)
Prohibition of
discrimination and retaliation
A participating hospital shall not
discriminate or retaliate in any manner against any patient or
employee of the
hospital because that patient or employee, or any other person, has
presented a
grievance or complaint, or has initiated or cooperated in any
investigation or
proceeding of any kind, relating to—
(A)
the hospital-wide
staffing plan for nursing services developed and implemented under
this
section; or
(B)
any right, other
requirement or prohibition under this section, including a refusal
to accept an
assignment described in subsection (f).
(2)
Relief for
prevailing employees
An employee of a participating hospital who
has been discriminated or retaliated against in employment in
violation of this
subsection may initiate judicial action in a United States district
court and
shall be entitled to reinstatement, reimbursement for lost wages,
and work
benefits caused by the unlawful acts of the employing hospital.
Prevailing
employees are entitled to reasonable attorney’s fees and costs
associated with
pursuing the case.
(3)
Relief for
prevailing patients
A patient who has been discriminated or
retaliated against in violation of this subsection may initiate
judicial action
in a United States district court. A prevailing patient shall be
entitled to
liquidated damages of $5,000 for a violation of this statute in
addition to any
other damages under other applicable statutes, regulations, or
common law.
Prevailing patients are entitled to reasonable attorney’s fees and
costs
associated with pursuing the case.
(4)
No action may be brought under paragraph (2) or (3) more
than 2 years after the discrimination or retaliation with respect
to which the
action is brought.
(5)
Treatment of
adverse employment actions
For purposes of this
subsection—
(A)
an adverse
employment action shall be treated as discrimination or
retaliation; and
(B)
the term
adverse employment action includes—
(i)
the failure to
promote an individual or provide any other employment-related
benefit for which
the individual would otherwise be eligible;
(ii)
an adverse
evaluation or decision made in relation to accreditation,
certification,
credentialing, or licensing of the individual; and
(iii)
a personnel
action that is adverse to the individual concerned.
(i)
Relationship to
state laws
Nothing in this section shall be construed as
exempting or relieving any person from any liability, duty,
penalty, or
punishment provided by the law of any State or political
subdivision of a
State, other than any such law which purports to require or permit
any action
prohibited under this title.
(j)
Relationship to
conduct prohibited under the national labor relations act or other
collective
bargaining laws
Nothing in this section shall be construed
as—
(1)
permitting conduct
prohibited under the National Labor Relations Act or under any
other Federal,
State, or local collective bargaining law; or
(2)
preempting,
limiting, or modifying a collective bargaining agreement entered
into by a
participating hospital.
(k)
(1)
The Secretary shall promulgate such regulations as are
appropriate and necessary to implement this section.
(2)
(A)
Except as provided in subparagraph (B), as soon as
practicable but not later than 2 years after the date of the
enactment of this
section, a participating hospital shall have implemented a
hospital-wide
staffing plan for nursing services under this section.
(B)
Special rule for
rural hospitals
In the case of a participating hospital located
in a rural area (as defined in section 1886(d)(2)(D)), such
participating
hospital shall have implemented a hospital-wide staffing plan for
nursing
services under this section as soon as practicable but not later
than 4 years
after the date of the enactment of this section.
(l)
In
this section:
(1)
Declared state
of emergency
The term declared state of emergency
means an officially designated state of emergency that has been
declared by the
Federal Government or the head of the appropriate State or local
governmental
agency having authority to declare that the State, county,
municipality, or
locality is in a state of emergency, but does not include a state
of emergency
that results from a labor dispute in the health care industry or
consistent
understaffing.
(2)
The term participating hospital means a
hospital (as defined in section 1861(e)) that has entered into a
provider
agreement under section 1866.
(3)
The
term person means one or more individuals, associations,
corporations, unincorporated organizations, or labor unions.
(4)
The term registered nurse means an individual
who has been granted a license to practice as a registered nurse in
at least 1
State.
(5)
The
term shift means a scheduled set of hours or duty period to be
worked at a participating hospital.
(6)
The
term unit means, with respect to a hospital, an organizational
department or separate geographic area of a hospital, including a
burn unit, a
labor and delivery room, a post-anesthesia service area, an
emergency
department, an operating room, a pediatric unit, a stepdown or
intermediate
care unit, a specialty care unit, a telemetry unit, a general
medical care
unit, a subacute care unit, and a transitional inpatient care
unit.
.