Nurse Staffing In Ohio

1. Nurse Staffing In Ohio A Toolkit for Implementing HB 346 (ORC § 3727.50 to 3727.57)

2. Learning Objectives After attending this session the participant will be able to: • Describe the role of the Chief Nursing Officer (CNO) in implementing the requirements of HB 346. • Describe the duties of the staffing committee as required in HB 346. • Describe the role of direct care nurses in implementing HB 346 and contributing to the development and once a year review of the hospital-wide nursing services staffing plan.

3. Learning Objectives • Identify methods to aid in successful committee process. • Articulate key metrics and definitions for developing a nursing services staffing plan.

4. The California Experience • Mandatory RN to patient ratios implemented in 2004 after legislation passed and became law in 1999 • Key provisions • Hospital must be in continuous compliance • Hospital must utilize patient classification system & staff to required ratios when system requires • Hospital must develop a written staffing plan for each patient care unit that specifies staffing levels for RNs and other licensed and unlicensed staff 22 CCR Sec 70217

5. The California Experience • Hospital must maintain detailed documentation of assigned nurses by licensure category on shift-by-shift basis • No more than 50% of licensed nurses can be comprised by LVNs • RN only in Neonatal ICU, ED and OR 22 CCR Sec 70217

6. California Ratios 22 CCR Sec 70217

7. Reported California Outcomes • 1st study - pre mandated ratios • A Response to California’s Mandated Nursing Ratios, Bolton, Jones, Aydia, Donaldson, Brown, Lowe, McFarland and Haims, in June 2001 J. Nursing Scholarship • 2nd Study – 1st year after implementation • Impact of California Licensed Nurse-patient Ratios on Unit Level Nurse Staffing and Patient Outcomes; Donaldson, Bolton, Aydin, Brown, Elashoff, Sandhu in Aug 2005 Policy, Politics and Nursing Practice • 3rd Study – 2 years post implementation • Mandated Nurse Staffing Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Post regulation; Bolton, Aydin, Donaldson, Brown, Sandhu, McFarland, & Aronow in November 2007 Policy, Politics and Nursing Practice

8. Ohio Safe Nurse Staffing Legislative History • Substitute HB 346 was introduced by Rep. Jim Hughes • HB 346 is a result of collaborative efforts between the founders of the Nursing 2015 initiative: • The Ohio Hospital Association • The Ohio Nurses Association • The Ohio Organization of Nurse Executives • Signed by Gov. Strickland on June 12, 2008 • Statute effective date is September 10, 2008

9. Statute Implementation Timeline

10. Statute §3727.50 Definitions • “Direct patient care” – care provided by a nurse with direct responsibility to carry out medical regimens or nursing care for one or more patients. • “Inpatient care unit” - hospital unit, including operating room or other inpatient care are, in which nursing care is provided to patients who have been admitted to the hospital. • “Nurse” – a person who is licensed to practice as a registered nurse under Chapter 4723. of the ORC or, if hospital employs LPNs, a person licensed to practice as a licensed practical nurse under that chapter.

11. §3727.51 Establishment of hospital-wide nursing care committee • Convene committee within 90 days of statute effective date (9-10-08) • Hospital will select committee members • CNO shall be a member • Minimum 50% of members shall consist of direct care nurses • All types of nursing care services must be represented by direct care nurses • CNO must have mechanism for obtaining input from all direct care inpatient nurses

12. Sample Nursing Care Committee Composition

13. Surveys Pencil and paper Online Utilize committee members to design Unit specific staff meetings Open staff forums Open office hours Solicit emails from nurses Unit rounds Post drafts online for nurses to review and respond to Ask members of committee to hold unit meetings to discuss plan development Seek suggestions from Public Relations, Communications or Human Resources Obtaining Input from Direct Care Nurses

14. §3727.52 Committee Charge • Evaluate hospital’s current nursing services staffing plan if one exists or • Recommend a nursing services staffing plan consistent with current standards established by private accreditation organizations or governmental entities and addresses all of the following: • Selection, implementation and evaluation of minimum staffing levels for all inpatient units that ensure that the hospital has a staff of competent nurses with specialized skills needed to meet patient needs in accordance with evidence-based safe nurse staffing standards;

15. §3727.52 Committee Charge • The complexity of complete care, • assessment on patient admission, • volume of patient admissions, • discharges and transfers, • evaluation of the progress of a patient’s problems, • the amount of time needed for patient education, • ongoing physical assessments, • planning for a patient’s discharge, • assessment after a change in patient condition, and • assessment of the need for patient referrals;

16. §3727.52 Committee Charge • Patient acuity and the number of patients for whom care is being provided; • The need for ongoing assessments of a unit’s patients and its nursing staff levels; • The hospital’s policy for identifying additional nurses who can provide direct patient care when patients’ unexpected needs exceed the planned workload for direct care staff.

17. §3727.53 Evidence-based staffing plan • Each hospital shall create an evidence-based written staffing plan guiding the assignment of nurses hospital-wide. • Staffing plan must be implemented within 90 days after the hospital-wide nursing care committee is convened, except • If hospital’s next fiscal year starts within 180 days after date committee was convened the plan can be delayed in implementation until the next fiscal year starts.

18. §3727.53 Evidence-based staffing plan • Staffing plan created under this provision shall, at a minimum, reflect current standards established by private accreditation organizations or governmental entities; • The plan shall be based on multiple nurse and patient considerations that yield minimum staffing levels for inpatient care units that ensure that the hospital has a staff of competent nurses with specialized skills needed to meet patient needs including: • Recommendations of the committee shall be given significant considerations;

19. §3727.54 Annual Review • At least once per year the hospital-wide nursing care committee shall do the following: • Review how the most current nursing services staffing plan does all of the following: • Affects inpatient care outcomes; • Affects clinical management; • Facilitates a delivery system that provides, on a cost-effective basis, quality nursing care consistent with acceptable and prevailing standards of safe nursing care and evidenced-based guidelines established by national nursing organizations. • Make recommendations, based on the most recent review conducted, regarding how the most current nursing services staffing plan should be revised, if at all.

20. §3727.55 Adjusting Staffing Plan • To provide flexibility to meet patient needs, every hospital shall identify a model for adjusting the nursing services staffing plan for each inpatient care unit. • Short term Flexibility • Shift-to-shift or day-to-day • Voluntary overtime • Float Pools • In-house per diem staff • Short term agency • Staff floating • Longer term flexibility • New services or changes in patient types, expansion of beds • What process would be used to evaluate staffing levels to determine if staffing resources require adjustment

21. §3727.56 Plan distribution • Hospital shall provide copies of its nursing services staffing plan in accordance with both of the following: • A copy of the staffing plan and subsequent changes to the plan shall be provided to each member of the hospital’s nursing staff free of charge. • The staffing plan shall be provided to any person who requests it for a fee not to exceed actual copying costs. • A notice shall be posted In a conspicuous location in the hospital informing the public of the availability of the staffing plan that specifies the appropriate person, office or department to be contacted to review or obtain a copy of the staffing plan.

22. §3727.57 Collective Bargaining • Nothing in these sections shall be construed to limit, alter, or modify any of the terms, conditions, or provisions of a collective bargaining agreement entered into by a hospital.

23. Questions