[Congressional Bills 108th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4316 Introduced in House (IH)]






108th CONGRESS
  2d Session
                                H. R. 4316

    To amend the Public Health Service Act to establish direct care 
 registered nurse-to-patient staffing ratio requirements in hospitals, 
                        and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              May 6, 2004

Ms. Schakowsky (for herself, Mr. Andrews, Mr. Conyers, Ms. DeLauro, Mr. 
  Deutsch, Mr. Filner, Mr. Frost, Mr. Hoeffel, Mr. Holden, Ms. Eddie 
   Bernice Johnson of Texas, Mrs. McCarthy of New York, Mr. Meek of 
   Florida, Mr. Nadler, Ms. Norton, Ms. Roybal-Allard, Ms. Linda T. 
  Sanchez of California, and Mr. Visclosky) introduced the following 
 bill; which was referred to the Committee on Energy and Commerce, and 
  in addition to the Committee on Ways and Means, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
  of such provisions as fall within the jurisdiction of the committee 
                               concerned

_______________________________________________________________________

                                 A BILL


 
    To amend the Public Health Service Act to establish direct care 
 registered nurse-to-patient staffing ratio requirements in hospitals, 
                        and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; FINDINGS.

    (a) Short Title.--This Act may be cited as the ``Nurse Staffing 
Standards for Patient Safety and Quality Care Act of 2004''.
    (b) Findings.--Congress finds the following:
            (1) The Federal Government has a substantial interest in 
        promoting quality care and improving the delivery of health 
        care services to patients in health care facilities in the 
        United States.
            (2) Recent changes in health care delivery systems that 
        have resulted in higher acuity levels among patients in health 
        care facilities increase the need for improved quality measures 
        in order to protect patient care and reduce the incidence of 
        medical errors.
            (3) Inadequate and poorly monitored registered nurse 
        staffing practices that result in too few registered nurses 
        providing direct care jeopardize the delivery of quality health 
        care services.
            (4) Numerous studies have shown that patient outcomes are 
        directly correlated to direct care registered nurse staffing 
        levels, including a 2002 Joint Commission on Accreditation of 
        Healthcare Organizations report that concluded that the lack of 
        direct care registered nurses contributed to nearly a quarter 
        of the unanticipated problems that result in injury or death to 
        hospital patients.
            (5) Requirements for direct care registered nurse staffing 
        ratios will help address the registered nurse shortage in the 
        United States by aiding in recruitment of new registered nurses 
        and improving retention of registered nurses who are 
        considering leaving direct patient care because of demands 
        created by inadequate staffing.
            (6) Establishing adequate minimum direct care registered 
        nurse-to-patient ratios that take into account patient acuity 
        measures will improve the delivery of quality health care 
        services and guarantee patient safety.
            (7) Establishing safe staffing standards for direct care 
        registered nurses is a critical component of assuring that 
        there is adequate hospital staffing at all levels to improve 
        the delivery of quality care and protect patient safety.

SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE STAFFING REQUIREMENT.

    (a) Minimum Direct Care Registered Nurse Staffing Requirement.--The 
Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding 
at the end the following new title:

``TITLE XXIX--MINIMUM DIRECT CARE REGISTERED NURSE STAFFING REQUIREMENT

``SEC. 2901. MINIMUM NURSE STAFFING REQUIREMENT.

    ``(a) Staffing Plan.--
            ``(1) In general.--A hospital shall implement a staffing 
        plan that--
                    ``(A) provides adequate, appropriate, and quality 
                delivery of health care services and protects patient 
                safety; and
                    ``(B) is consistent with the requirements of this 
                title.
            ``(2) Effective dates.--
                    ``(A) Implementation of staffing plan.--Subject to 
                subparagraph (B), the requirements under paragraph (1) 
                shall take effect not later than 1 year after the date 
                of the enactment of this title.
                    ``(B) Application of minimum direct care registered 
                nurse-to-patient ratios.--The requirements under 
                subsection (b) shall take effect as soon as 
                practicable, as determined by the Secretary, but not 
                later than 2 years after the date of the enactment of 
                this title, or in the case of a hospital in a rural 
                area (as defined in section 1886(d)(2)(B) of the Social 
                Security Act (42 U.S.C. 1395ww(d)(2)(B)), not later 
                than 4 years after the date of the enactment of this 
                title.
    ``(b) Minimum Direct Care Registered Nurse-To-Patient Ratios.--
            ``(1) In general.--A hospital's staffing plan shall provide 
        that, during each shift within a unit of the hospital, a direct 
        care registered nurse may be assigned to not more than the 
        following number of patients in that unit, subject to paragraph 
        (3):
                    ``(A) 1 patient in operating room units and trauma 
                emergency units.
                    ``(B) 2 patients in critical care units, including 
                emergency critical care and intensive care units, labor 
                and delivery units, and postanesthesia units.
                    ``(C) 3 patients in antepartum units, emergency 
                room units, pediatrics units, stepdown units, and 
                telemetry units.
                    ``(D) 4 patients in intermediate care nursery 
                units, medical/surgical units, and acute care 
                psychiatric units.
                    ``(E) 5 patients in rehabilitation units.
                    ``(F) 6 patients in postpartum (3 couplets) units 
                and well-baby nursery units.
            ``(2) Similar units with different names.--The Secretary 
        may apply minimum direct care registered nurse-to-patient 
        ratios established in paragraph (1) to a type of hospital unit 
        not referred to in such paragraph if such other unit performs a 
        function similar to the function performed by the unit referred 
        to in such paragraph.
            ``(3) Adjustment of ratios.--
                    ``(A) In general.--If necessary to protect patient 
                safety, the Secretary may prescribe regulations that--
                            ``(i) increase minimum direct care 
                        registered nurse-to-patient ratios under this 
                        subsection to further limit the number of 
                        patients that may be assigned to each direct 
                        care nurse; or
                            ``(ii) add minimum direct care registered 
                        nurse-to-patient ratios for units not referred 
                        to in paragraphs (1) and (2).
                    ``(B) Consultation.--Such regulations shall be 
                prescribed after consultation with affected hospitals 
                and registered nurses.
            ``(4) Relationship to state-imposed ratios.--
                    ``(A) No preemption of certain state-imposed 
                ratios.--Nothing in this title shall preempt State 
                standards that the Secretary determines to be at least 
                equivalent to Federal requirements for a staffing plan 
                established under this title. Minimum direct care 
                registered nurse-to-patient ratios established under 
                this subsection shall not preempt State requirements 
                that the Secretary determines are at least equivalent 
                to Federal requirements for a staffing plan established 
                under this title.
                    ``(B) Satisfaction of certain federal requirements 
                with certain state-imposed nurse-to-patient ratios.--
                States that, at least 2 years prior to the date of the 
                enactment of this title, have enacted minimum direct 
                care nurse-to-patient ratios that allow the use of 
                licensed practical nurses to meet State-imposed minimum 
                direct care nurse-to-patient ratios may continue to 
                make such allowance, and such allowance shall be 
                considered to satisfy requirements imposed under this 
                subsection, so long as the particular licensed 
                practical nurse is employed in the same or a comparable 
                position.
            ``(5) Exemption in emergencies.--
                    ``(A) In general.--The requirements established 
                under this subsection shall not apply during a declared 
                state of emergency if a hospital is requested or 
                expected to provide an exceptional level of emergency 
                or other medical services.
                    ``(B) Emergency defined.--For purposes of 
                subparagraph (A), the term `declared state of 
                emergency' means a 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 such term does not include a state of emergency 
                that results from a labor dispute in the health care 
                industry or consistent understaffing.
    ``(c) Development and Reevaluation of Staffing Plan.--
            ``(1) Considerations in development of plan.--In developing 
        the staffing plan, a hospital shall provide for direct care 
        registered nurse-to-patient ratios above the minimum direct 
        care registered nurse-to-patient ratios required under 
        subsection (b) if appropriate based upon consideration of the 
        following factors:
                    ``(A) The number of patients and acuity level of 
                patients as determined by the application of an acuity 
                system (as defined in section 2906(1)), on a shift-by-
                shift basis.
                    ``(B) The anticipated admissions, discharges, and 
                transfers of patients during each shift that impacts 
                direct patient care.
                    ``(C) Specialized experience required of direct 
                care registered nurses on a particular unit.
                    ``(D) Staffing levels and services provided by 
                other health care personnel in meeting direct patient 
                care needs not required by a direct care registered 
                nurse.
                    ``(E) The level of technology available that 
                affects the delivery of direct patient care.
                    ``(F) The level of familiarity with hospital 
                practices, policies, and procedures by temporary agency 
                direct care registered nurses used during a shift.
                    ``(G) Obstacles to efficiency in the delivery of 
                patient care presented by physical layout.
            ``(2) Documentation of staffing.--A hospital shall specify 
        the system used to document actual staffing in each unit for 
        each shift.
            ``(3) Annual reevaluation of plan and acuity system.--
                    ``(A) In general.--A hospital shall annually 
                evaluate--
                            ``(i) its staffing plan in each unit in 
                        relation to actual patient care requirements; 
                        and
                            ``(ii) the accuracy of its acuity system.
                    ``(B) Update.--A hospital shall update its staffing 
                plan and acuity system to the extent appropriate based 
                on such evaluation.
            ``(4) Registered nurse participation.--A staffing plan of a 
        hospital shall be developed and subsequent reevaluations shall 
        be conducted under this subsection on the basis of input from 
        direct care registered nurses at the hospital or, where such 
        nurses are represented through collective bargaining, from the 
        applicable recognized or certified collective bargaining 
        representative of such nurses. Nothing in this title shall be 
        construed to permit conduct prohibited under the National Labor 
        Relations Act or under the Federal Labor Relations Act.
    ``(d) Submission of Plan to Secretary.--A hospital shall submit to 
the Secretary its staffing plan and any annual updates under subsection 
(c)(3)(B). A federally operated hospital may submit its staffing plan 
through the department or agency operating the hospital.

``SEC. 2902. POSTING, RECORDS, AND AUDITS.

    ``(a) Posting Requirements.--In each unit, a hospital shall post a 
uniform notice in a form specified by the Secretary in regulation 
that--
            ``(1) explains requirements imposed under section 2901;
            ``(2) includes actual direct care registered nurse-to-
        patient ratios during each shift; and
            ``(3) is visible, conspicuous, and accessible to staff, 
        patients, and the public.
    ``(b) Records.--
            ``(1) Maintenance of records.--Each hospital shall maintain 
        accurate records of actual direct care registered nurse-to-
        patient ratios in each unit for each shift for no less than 3 
        years. Such records shall include--
                    ``(A) the number of patients in each unit;
                    ``(B) the identity and duty hours of each direct 
                care registered nurse assigned to each patient in each 
                unit in each shift; and
                    ``(C) a copy of each notice posted under subsection 
                (a).
            ``(2) Availability of records.--Each hospital shall make 
        its records maintained under paragraph (1) available to--
                    ``(A) the Secretary;
                    ``(B) registered nurses and their collective 
                bargaining representatives (if any); and
                    ``(C) the public under regulations established by 
                the Secretary, or in the case of a federally operated 
                hospital, under section 552 of title 5, United States 
                Code (commonly known as the `Freedom of Information 
                Act').
    ``(c) Audits.--The Secretary shall conduct periodic audits to 
ensure--
            ``(1) implementation of the staffing plan in accordance 
        with this title; and
            ``(2) accuracy in records maintained under this section.

``SEC. 2903. MINIMUM DIRECT CARE LICENSED PRACTICAL NURSE STAFFING 
              REQUIREMENTS.

    ``(a) Establishment.--A hospital's staffing plan shall comply with 
minimum direct care licensed practical nurse staffing requirements that 
the Secretary establishes for units in hospitals. Such staffing 
requirements shall be established not later than 18 months after the 
date of the enactment of this title, and shall be based on the study 
conducted under subsection (b).
    ``(b) Study.--Not later than 1 year after the date of the enactment 
of this title, the Secretary, acting through the Director of the Agency 
for Healthcare Research and Quality, shall complete a study of licensed 
practical nurse staffing and its effects on patient care in hospitals. 
The Director may contract with a qualified entity or organization to 
carry out such study under this paragraph. The Director shall consult 
with licensed practical nurses and organizations representing licensed 
practical nurses regarding the design and conduct of the study.
    ``(c) Application of Registered Nurse Provisions to Licensed 
Practical Nurse Staffing Requirements.--Paragraphs (2), (3), (4)(A), 
and (5) of section 2901(b), section 2901(c), and section 2902 shall 
apply to the establishment and application of direct care licensed 
practical nurse staffing requirements under this section in the same 
manner that they apply to the establishment and application of direct 
care registered nurse-to-patient ratios under section 2901.
    ``(d) Effective Date.--The requirements of this section shall take 
effect as soon as practicable, as determined by the Secretary, but not 
later than 2 years after the date of the enactment of this title, or in 
the case of a hospital in a rural area (as defined in section 
1886(d)(2)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(2)(B)), 
not later than 4 years after the date of the enactment of this title.

``SEC. 2904. ADJUSTMENT IN REIMBURSEMENT.

    ``(a) Medicare Reimbursement.--The Secretary shall adjust payments 
made to hospitals (other than federally operated hospitals) under title 
XVIII of the Social Security Act in an amount equal to the net amount 
of additional costs incurred in providing services to medicare 
beneficiaries that are attributable to compliance with requirements 
imposed under sections 2901 through 2903. The amount of such payment 
adjustments shall take into account recommendations contained in the 
report submitted by the Medicare Payment Advisory Commission under 
subsection (c).
    ``(b) Authorization of Appropriation for Federally Operated 
Hospitals.--There are authorized to be appropriated such additional 
sums as are required for federally operated hospitals to comply with 
the additional requirements established under sections 2901 through 
2903.
    ``(c) MedPAC Report.--Not later than 2 years after the date of the 
enactment of this title, the Medicare Payment Advisory Commission 
(established under section 1805 of the Social Security Act (42 U.S.C. 
1395b-6)) shall submit to Congress and the Secretary a report 
estimating total costs and savings attributable to compliance with 
requirements imposed under sections 2901 through 2903. Such report 
shall include recommendations on the need, if any, to adjust 
reimbursement for Medicare payments under subsection (a).

``SEC. 2905. PROTECTION OF NURSES AND OTHER INDIVIDUALS.

    ``(a) Refusal of Assignment.--A nurse may refuse to accept an 
assignment as a nurse in a hospital if--
            ``(1) the assignment would violate section 2901 or 2903; 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.
    ``(b) Retaliation for Refusal of Assignment Barred.--
            ``(1) No discharge, discrimination, or retaliation.--No 
        hospital shall discharge, discriminate, or retaliate in any 
        manner with respect to any aspect of employment (as defined in 
        section 2906(5)), including discharge, promotion, compensation, 
        or terms, conditions, or privileges of employment against a 
        nurse based on the nurse's refusal of a work assignment under 
        subsection (a).
            ``(2) No filing of complaint.--No hospital shall file a 
        complaint or a report against a nurse with the appropriate 
        State professional disciplinary agency because of the nurse's 
        refusal of a work assignment under subsection (a).
    ``(c) Cause of Action.--Any nurse who has been discharged, 
discriminated, or retaliated against in violation of subsection (b)(1) 
or against whom a complaint has been filed in violation of subsection 
(b)(2) may bring a cause of action in a United States district court. A 
nurse who prevails on the cause of action shall be entitled to one or 
more of the following:
            ``(1) Reinstatement.
            ``(2) Reimbursement of lost wages, compensation, and 
        benefits.
            ``(3) Attorneys' fees.
            ``(4) Court costs.
            ``(5) Other damages.
    ``(d) Complaint to Secretary.--A nurse or other individual may file 
a complaint with the Secretary against a hospital that violates the 
provisions of this title. For any complaint filed, the Secretary 
shall--
            ``(1) receive and investigate the complaint;
            ``(2) determine whether a violation of this title as 
        alleged in the complaint has occurred; and
            ``(3) if such a violation has occurred, issue an order that 
        the complaining nurse or individual shall not suffer any 
        retaliation under subsection (b) or under subsection (e).
    ``(e) Protection for Reporting.--
            ``(1) Retaliation barred.--A hospital shall not 
        discriminate or retaliate in any manner with respect to any 
        aspect of employment, including hiring, discharge, promotion, 
        compensation, or terms, conditions, or privileges of employment 
        against any individual who in good faith, individually or in 
        conjunction with another person or persons--
                    ``(A) reports a violation or a suspected violation 
                of this title to the Secretary, a public regulatory 
                agency, a private accreditation body, or the management 
                personnel of the hospital;
                    ``(B) initiates, cooperates, or otherwise 
                participates in an investigation or proceeding brought 
                by the Secretary, a public regulatory agency, or a 
                private accreditation body concerning matters covered 
                by this title; or
                    ``(C) informs or discusses with other individuals 
                or with representatives of hospital employees a 
                violation or suspected violation of this title.
            ``(2) Good faith defined.--For purposes of this subsection, 
        an individual shall be deemed to be acting in good faith if the 
        individual reasonably believes--
                    ``(A) the information reported or disclosed is 
                true; and
                    ``(B) a violation of this title has occurred or may 
                occur.
    ``(f) Notice.--A hospital shall post in an appropriate location in 
each unit a conspicuous notice in a form specified by the Secretary 
that--
            ``(1) explains the rights of nurses and other individuals 
        under this section;
            ``(2) includes a statement that a nurse or other individual 
        may file a complaint with the Secretary against a hospital that 
        violates the provisions of this title; and
            ``(3) provides instructions on how to file a complaint 
        under paragraph (2).
    ``(g) Effective Dates.--
            ``(1) Refusal; retaliation; cause of action.--
                    ``(A) In general.--Subsections (a) through (c) 
                shall apply to refusals occurring on or after the 
                effective date of the provision to which the refusal 
                relates.
                    ``(B) Exception.--Subsection (a)(2) shall not apply 
                to refusals in any hospital before the requirements of 
                section 2901(a) apply to that hospital.
            ``(2) Protections for reporting.--Subsection (e) shall 
        apply to actions described in subparagraphs (A) and (C) of 
        subsection (e)(1) occurring on or after the effective date of 
        the provision to which the violation relates. Subsection (e) 
        shall apply to initiation, cooperation, or participation in an 
        investigation or proceeding on or after the date of the 
        enactment of this title.
            ``(3) Notice.--Subsection (f) shall take effect 18 months 
        after the date of the enactment of this title.

``SEC. 2906. DEFINITIONS.

    ``For purposes of this title:
            ``(1) Acuity system.--The term `acuity system' means an 
        established measurement tool that--
                    ``(A) predicts 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 nursing judgment needed to 
                design, implement, and evaluate the patient's nursing 
                care plan;
                    ``(B) details the amount of nursing care needed, 
                both in number of nurses and in skill mix of nursing 
                personnel required, on a daily basis, for each patient 
                in a nursing department or unit;
                    ``(C) takes into consideration the patient care 
                services provided not only by registered nurses but 
                also by direct care licensed practical nurses and other 
                health care personnel; and
                    ``(D) is stated in terms that can be readily used 
                and understood by nurses.
            ``(2) Direct care licensed practical nurse.--The term 
        `direct care licensed practical nurse' means an individual who 
        has been granted a license by at least 1 State to practice as a 
        licensed practical nurse or a licensed vocational nurse and who 
        provides bedside care for 1 or more patients.
            ``(3) Nurse.--The term `nurse' means any direct care 
        registered nurse or direct care licensed practical nurse (as 
        the case may be), regardless of whether or not the nurse is an 
        employee.
            ``(4) Direct care registered nurse.--The term `direct care 
        registered nurse' means an individual who has been granted a 
        license by at least 1 State to practice as a registered nurse 
        and who provides bedside care for 1 or more patients.
            ``(5) Employment.--The term `employment' includes the 
        provision of services under a contract or other arrangement.
            ``(6) Hospital.--The term `hospital' has the meaning given 
        that term in section 1861(e) of the Social Security Act (42 
        U.S.C. 1395x(e)), and includes a hospital that is operated by 
        the Department of Veterans Affairs, the Department of Defense, 
        the Indian Health Services Program, or any other department or 
        agency of the United States.
            ``(7) Staffing plan.--The term `staffing plan' means a 
        staffing plan required under section 2901.''.
    (b) Recommendations to Congress.--No later than 1 year after the 
date of the enactment of this Act, the Secretary of Health and Human 
Services shall submit to Congress a report containing recommendations 
for ensuring that sufficient numbers of nurses are available to meet 
the requirements imposed by title XXIX of the Public Health Service 
Act, as added by subsection (a).

SEC. 3. ENFORCEMENT OF REQUIREMENTS THROUGH FEDERAL PROGRAMS.

    (a) Medicare Program.--Section 1866(a)(1) of the Social Security 
Act (42 U.S.C. 1395cc(a)(1)), as amended by the Medicare Prescription 
Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173), 
is amended--
            (1) by striking ``and'' at the end of subparagraph (U);
            (2) by striking the period at the end of subparagraph (V) 
        and inserting ``, and''; and
            (3) by inserting after subparagraph (V) the following:
                    ``(W) in the case of a hospital, to comply with the 
                provisions of title XXIX of the Public Health Service 
                Act.''.
    (b) Medicaid Program.--The first sentence of section 1902(a) of the 
Social Security Act (42 U.S.C. 1396(a)) is amended--
            (1) by striking ``and'' at the end of paragraph (66);
            (2) by striking the period at the end of paragraph (67) and 
        inserting ``; and''; and
            (3) by inserting after paragraph (67) the following new 
        paragraph:
            ``(68) provide that any hospital receiving payments under 
        such plan must comply with the provisions of title XXIX of the 
        Public Health Service Act.''.
    (c) Health Benefits Program of the Department of Veterans 
Affairs.--Section 8110(a) of title 38, United States Code, is amended 
by adding at the end the following new paragraph:
    ``(7) In the case of a Department medical facility that is a 
hospital, the hospital shall comply with the provisions of title XXIX 
of the Public Health Service Act.''.
    (d) Health Benefits Program of the Department of Defense.--
            (1) In general.--Chapter 55 of title 10, United States 
        Code, is amended by adding at the end the following new 
        section:
``Sec. 1110a. Staffing requirements
    ``In the case of a facility of the uniformed services that is a 
hospital, the hospital shall comply with the provisions of title XXIX 
of the Public Health Service Act.''.
            (2) Clerical amendment.--The table of sections at the 
        beginning of such chapter is amended by inserting after the 
        item relating to section 1110 the following new item:

``1110a. Staffing requirements.''.
    (e) Indian Health Services Program.--Title VIII of the Indian 
Health Care Improvement Act (25 U.S.C. 1671 et seq.) is amended by 
adding at the end the following new section:

``SEC. 826 STAFFING REQUIREMENTS.

    ``A hospital of the Service shall comply with the provisions of 
title XXIX of the Public Health Service Act.''.
                                 <all>