Nurse Staffing Standards for Patient Safety and Quality Care Act of 2004 - Amends the Public Health Service Act to require hospitals to implement staffing plans that meet specified ratios for direct care registered nurse-to-patient staffing levels for each unit and other requirements, including for receiving input from nurses. Allows the Secretary of Health and Human Services to further limit such ratios as needed to ensure public safety and to establish ratios for units not specified. Provides an exception to such staffing requirements for a declared state of emergency. Requires hospitals to provide the Secretary with their staffing plan and annual updates. Requires the Secretary to conduct audits to ensure the implementation of adequate staffing plans.
Requires the Secretary: (1) acting through the Director of the Agency for Healthcare Research and Quality, to complete a study of licensed practical nurse staffing and its effects on patient care in hospitals; and (2) to establish requirements for hospitals based on the outcome of the study.
Requires the Secretary to adjust payments to cover additional Medicare costs that are attributable to this Act. Requires the Medicare Payment Advisory Commission to submit to Congress and the Secretary a report estimating total costs and savings attributable to compliance with nurse staffing requirements.
Provides nurses with the right to refuse to accept assignments that would violate staffing requirements or for which they are not prepared. Prohibits retaliation by hospitals for such refusals or for reporting violations of staffing requirements.
[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>
Introduced in House
Introduced in House
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.
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.
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.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Health.
Llama 3.2 · runs locally in your browser
Ask anything about this bill. The AI reads the full text to answer.
Enter to send · Shift+Enter for new line