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California Health & Safety Code for Acute Care Staffing

In 1999 the California Legislature required that minimum staffing levels for nurses be set for hospitals. According to section 1276.4 (a) of the California Health and Safety Code, by Jan. 1, 2002, the State Department of Health Services would establish minimum nurse-to-patient rations for all acute care facilities. According to section (b), this applied to registered and licensed nurses (RNs and LVNs). Other staff would be assigned according to patient classification, including severity of illness and other factors.

  1. Preparation

    • According to gateway.nlm.nih.gov, for the California Department of Health Services (CDHS) to develop the best staffing rations, it needed to consider literature on the subject and data related to then-current staffing in California. This should be compared to what other hospitals were doing, including "best practices" hospitals. It is not entirely clear that simply increasing RN hours results in better patient outcomes.

    Implementation

    • Trial ratios were announced in January 2002. Proposed ratios varied from one nurse per patient in surgery to one nurse per eight newborns. Acute care facilities include most hospitals and skilled nursing facilities, known as nursing homes or rehabilitation facilities, which are able to provide post-surgical care. For these facilities, ratios were set at one RN or LVN per six patients, later changed to one per five.

    Stakeholders

    • According to an article in Health Affairs, "Proposed ratios called for fewer patients per nurse than hospitals recommend and more patients per nurse than unions recommend." The California Healthcare Association (affiliate of the American Hospital Association) prefers a ratio of one nurse per 10 patients. California's largest union of nurses, the California Nurses Association (CAN), recommends one RN per three patients. Another union recommends one nurse per four. The state did not distinguish between RNs and LVNs, whereas CAN proposed only ratios of registered nurses.

    Results

    • By 2004, the established minimum ratios began to be enforced. But as of 2009, according to the California HealthCare Foundation, there is little to indicate positive results. It has been difficult to clarify the role of RNs and to comply with meal break requirements. Costs increased. Emergency departments became bottlenecked. No one has noticed, much less documented, an increase in quality of patient care or of health-care outcomes, according to the foundation.

    National Impact

    • As of 2009, according to the University of Pennsylvania, California remains the only state to have adopted minimal staffing requirements for nurses. When California benchmarks are met, whether in California or in other states, there is better nurse retention and less burnout. There are fewer complaints from families and patients. Improved nurse staffing is associated with better patient outcomes, but staffing ratios may not be the best way to achieve that. Mandatory reporting and mandating the process by which staffing is determined have also proved successful.

    Other Staffing Requirements

    • Other sections of the California Health and Safety Code require that each hospital have a single medical staff, that treating physicians be members of that staff and that all staff have liability insurance. The code states that there is a need for interpreters for California's multicultural population and that flexibility in staffing is to be allowed in rural hospitals. It is also required that each institution designate a physician to serve as head epidemiologist and coordinate training to better control infectious diseases.

    Exception for University Hospitals

    • Section 1276.4 (L) of the California Code states that the CDHS may consider the unique nature of the University of California (UC) teaching hospitals when establishing licensed nurse-to-patient ratios because of trainee staff. This provision remains disputed as of June 2010 when nurses had to settle for rallies instead of a strike to protest staffing shortages in UC hospitals. UC responded that all five medical centers meet and often exceed required ratios and are frequently cited for excellence.

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