Senate Bill sb2302
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Florida Senate - 2003 SB 2302
By Senator Dawson
29-1412A-03
1 A bill to be entitled
2 An act relating to the staffing of health care
3 facilities; providing a short title; providing
4 legislative findings; defining terms;
5 prescribing facility staffing standards
6 relating to nurse-to-patient ratios, staffing
7 plans, and the minimum skill mix; allowing the
8 implementation of higher staffing levels;
9 providing recordkeeping requirements;
10 prohibiting mandatory overtime and excessive
11 duty hours; allowing voluntary overtime work;
12 providing a statement of employee rights;
13 providing for the Agency for Health Care
14 Administration to ensure compliance with the
15 act and to adopt rules; providing an effective
16 date.
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18 Be It Enacted by the Legislature of the State of Florida:
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20 Section 1. Short title.--This act may be cited as "The
21 Safe Staffing for Quality Care Act."
22 Section 2. Legislative findings.--The Legislature
23 finds that:
24 (1) The state has a substantial interest in assuring
25 that delivery of health care services to patients in health
26 care facilities located within this state is adequate and safe
27 and that health care facilities retain sufficient nursing
28 staff so as to promote optimal health care outcomes.
29 (2) Recent changes in our health care delivery system
30 are resulting in a higher acuity level among patients in
31 health care facilities.
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1 (3) Extensive research indicates that inadequate
2 registered-nurse staffing in hospitals can result in increased
3 patient death rates, dangerous medical errors, and increased
4 length of stay.
5 (4) To ensure the adequate protection and care for
6 patients in health care facilities, it is essential that
7 qualified registered nurses be accessible and available to
8 meet the nursing needs of patients.
9 Section 3. Definitions.--As used in this act, the
10 term:
11 (1) "Acuity system" means an established measurement
12 instrument that:
13 (a) Predicts nursing care requirements for individual
14 patients based on severity of patient illness, need for
15 specialized equipment and technology, intensity of nursing
16 interventions required, and the complexity of clinical nursing
17 judgment needed to design, implement, and evaluate the
18 patient's nursing care plan;
19 (b) Details the amount of nursing care needed, both in
20 number of registered nurses and in skill mix of nursing
21 personnel required daily for each patient in a nursing
22 department or unit; and
23 (c) Is stated in terms that can be readily used and
24 understood by direct-care nursing staff.
25 (2) "Assessment tool" means a measurement system that
26 compares the staffing level in each nursing department or unit
27 to actual patient nursing care requirements in order to review
28 the accuracy of an acuity system.
29 (3) "Documented staffing plan" means a detailed
30 written plan setting forth the minimum number, skill mix, and
31 classification of licensed nurses required in each nursing
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1 department or unit in the health facility for a given year,
2 based on reasonable projections derived from the patient
3 census and average acuity level within each department or unit
4 during the previous year, the department or unit size and
5 geography, the nature of services provided, and any forseeable
6 changes in department or unit size or function during the
7 current year.
8 (4) "Critical care unit" means a unit of a hospital
9 which is established to safeguard and protect patients the
10 severity of whose medical conditions requires continuous
11 monitoring and complex nursing intervention.
12 (5) "Declared state of emergency" means an officially
13 designated state of emergency which has been declared by a
14 federal, state, or local government official who has the
15 authority to declare that the state, county, municipality, or
16 locality is in a state of emergency, but does not include a
17 state of emergency which results from a labor dispute in the
18 health care industry.
19 (6) "Direct-care nurse" or "direct-care nursing staff"
20 means any registered nurse who has direct responsibility to
21 oversee or carry out medical regimens or nursing care for one
22 or more patients. Only registered nurses who have specific
23 patient care assignments shall be included in the calculation
24 of the registered nurse-to-patient ratio.
25 (7) "Health care facility" means an acute care
26 hospital; an emergency care, ambulatory, or outpatient surgery
27 facility licensed under section 395.003, Florida Statutes; or
28 a psychiatric facility licensed under chapter 394, Florida
29 Statutes.
30 (8) "Nurse" means a registered nurse.
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1 (9) "Nursing care means care that falls within the
2 scope of practice set forth in chapter 464, Florida Statutes,
3 and other laws and regulations or that is otherwise
4 encompassed within recognized professional standards of
5 nursing practice, including assessment, nursing diagnosis,
6 planning, intervention, evaluation, and patient advocacy.
7 (10) "Off-duty" means that the individual has no
8 restrictions placed on his or her whereabouts and is free of
9 all restraint or duty on behalf of the health care facility.
10 (11) "On-duty" means that the individual is required
11 to be available and ready to perform services on request
12 within or on behalf of the health care facility and includes
13 any rest periods or breaks during which the individual's
14 ability to leave the health care facility is restricted either
15 expressly or by work-related circumstances beyond the
16 individual's control.
17 (12) "Overtime" means the hours worked in excess of
18 any of the following:
19 (a) An agreed-upon, predetermined, regularly scheduled
20 shift;
21 (b) Twelve hours in a 24-hour period; or
22 (c) Eighty hours in a consecutive 14-day period.
23 (13) "On-call time" means time spent by an employee
24 who is not working on the premises of the place of employment
25 but who is compensated for availability or who, as a condition
26 of employment, has agreed to be available to return to the
27 premises of the place of employment on short notice if the
28 need arises.
29 (14) "Reasonable efforts" in reference to the
30 prohibition on mandatory overtime means that the employer does
31 all of the following but is unable to obtain staff coverage:
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1 (a) Seeks individuals to volunteer to work extra time
2 from all available qualified staff who are working;
3 (b) Contacts qualified employees who have made
4 themselves available to work extra time;
5 (c) Seeks the use of per diem staff; and
6 (d) Seeks personnel from a contracted temporary agency
7 if such staffing is permitted by law or an applicable
8 collective bargaining agreement.
9 (15) "Unforeseeable emergent circumstance" means:
10 (a) Any unforseen declared national, state, or
11 municipal emergency;
12 (b) A situation in which a health care facility
13 disaster plan is activated; or
14 (c) Any unforseen disaster or other catastrophic event
15 that substantially affects or increases the need for health
16 care services.
17 (16) "Skill mix" means the differences in licensing,
18 specialty, and experience among direct-care nurses.
19 (17) "Staffing level" means the actual numerical
20 registered nurse-to-patient ratio within a nursing department
21 or unit.
22 Section 4. Facility staffing standards.--
23 (1) SPECIFIC STANDARDS.--Hospitals shall provide
24 staffing by registered nurses in accordance with the following
25 maximum patient assignments in the units specified. Additional
26 registered nurse staffing, auxiliary staffing by nurses other
27 than registered nurses or staffing by other healthcare
28 professionals are not included in these ratios and shall be
29 determined pursuant to the patient classification system as
30 provided in paragraph (b). Nurse-to-patient ratios represent
31 the maximum number of patients which shall be assigned to one
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1 registered nurse during one shift. Only nurses providing
2 direct patient care shall be included in the ratios. This
3 section does not prohibit a registered nurse from providing
4 care within the scope of his or her practice to a patient who
5 is assigned to another nurse.
6 (a) There shall be a maximum of two patients assigned
7 to each registered nurse so that the minimum registered
8 nurse-to-patient ratio in a critical care unit must be 1:2 or
9 fewer at any time. As used in this paragraph, the term
10 "critical care unit" means a nursing unit of a general acute
11 care hospital which provides one of the following services: an
12 intensive care service, a burn center, a coronary care
13 service, or an acute respiratory service. In the intensive
14 care newborn nursery service, a maximum of two patients shall
15 be assigned to each registered nurse.
16 (b) The surgical service operating room shall have a
17 maximum of one patient-occupied operating room assigned to
18 each registered nurse.
19 (c) There shall be a maximum of two patients assigned
20 to each registered nurse in a labor and delivery suite of the
21 perinatal service so that the registered nurse-to-patient
22 ratio shall be 1:2 or fewer at any time.
23 (d) There shall be a maximum of two patients assigned
24 to each registered nurse in a labor/delivery unit.
25 (e) There shall be a maximum of three mother-baby
26 couplets assigned to each registered nurse in a postpartum
27 area of the perinatal unit at any time. In the event of
28 multiple births, the total number of mothers plus infants
29 assigned to a single registered nurse shall never exceed six.
30 (f) There shall be a maximum of two patients assigned
31 to each registered nurse in a postanesthesia recovery unit.
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1 (g) In a hospital providing basic emergency medical
2 services or comprehensive emergency medical services, there
3 shall be a maximum of three patients who are receiving
4 emergency treatment assigned to each registered nurse so that
5 the registered nurse-to-patient ratio in an emergency
6 department shall be 1:3 or fewer at any time patients are
7 receiving treatment. There shall be no fewer than two
8 registered nurses physically present in the emergency
9 department when a patient is present.
10 (h) The nurse assigned to triage patients shall not
11 have a patient assignment, shall not be assigned
12 responsibility for the base radio, and shall not be counted in
13 the registered nurse-to-patient ratio.
14 (i) When nursing staff are attending critical care
15 patients in the emergency department, there shall be a maximum
16 of two patients assigned to each registered nurse. When
17 nursing staff in the emergency department are attending trauma
18 patients, there shall be a maximum of one patient assigned to
19 each registered nurse at any time.
20 (j) There shall be a maximum of three patients
21 assigned to each registered nurse in a step-down unit so that
22 the minimum registered nurse-to-patient ratio shall be 1:3 or
23 fewer at any time. As used in this paragraph, the term:
24 1. "Artificial life support" means a system that uses
25 medical technology to aid, support, or replace a vital
26 function of the body which has been seriously damaged.
27 2. "Step-down unit" means a unit that is organized,
28 operated, and maintained to provide for the monitoring and
29 care of patients with moderate or potentially severe
30 physiologic instability requiring technical support but not
31 necessarily artificial life support.
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1 3. "Technical support" means specialized equipment or
2 personnel, or both, providing for invasive monitoring,
3 telemetry, and mechanical ventilation, for the immediate
4 amelioration or remediation of severe pathology for those
5 patients requiring less care than intensive care but more than
6 that which is available from medical/surgical care.
7 (k) There shall be a maximum of three patients
8 assigned to each registered nurse so that the minimum
9 registered nurse-to-patient ratio in a telemetry unit shall be
10 1:3 or fewer at any time. As used in this paragraph, the term
11 "telemetry unit" means a unit designated for the electronic
12 monitoring, recording, retrieval, and display of cardiac
13 electrical signals.
14 (l) There shall be a maximum of four patients assigned
15 to each registered nurse so that the minimum registered
16 nurse-to-patient ratio in medical/surgical care units shall be
17 1:4 or fewer at any time. A medical/surgical unit is a unit
18 with beds classified as medical/surgical in which patients who
19 require less care than that which is available in intensive
20 care units or step-down units receive 24-hour inpatient
21 general medical services, postsurgical services, or both
22 general medical and postsurgical services. Such a unit may
23 include mixed patient populations of diverse diagnoses and
24 diverse age groups.
25 (m) There shall be a maximum of four patients assigned
26 to each registered nurse so that the minimum registered
27 nurse-to-patient ratio in a specialty care unit shall be 1:4
28 or fewer at any time. A specialty care unit is a unit that is
29 organized, operated, and maintained to provide care for a
30 specific medical condition or a specific patient population,
31 is more comprehensive for the specific condition or disease
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1 process than that which is available on medical/surgical
2 units, and is not otherwise specifically covered in this
3 section.
4 (n) There shall be a maximum of four patients assigned
5 to each registered nurse so that the minimum registered
6 nurse-to-patient ratio in an acute care psychiatric unit shall
7 be 1:4 or fewer at any time.
8 (o) Identifying a unit by a name or term other than
9 those used in this subsection does not affect the requirement
10 to staff at the ratios identified for the level or type of
11 care described in this subsection.
12 (2) STAFFING PLAN.--To ensure that it is staffed in a
13 manner that provides sufficient, appropriately qualified
14 nursing staff of each classification in each department or
15 unit within the facility in order to meet the individualized
16 care needs of the patients therein and to meet the
17 requirements for registered nurse staffing set forth in
18 subsection (1), each health care facility licensed under this
19 statute shall annually submit to the Agency for Health Care
20 Administration a documented staffing plan, together with a
21 written certification that the staffing plan is sufficient to
22 provide adequate and appropriate delivery of health care
23 services to patients for the ensuing year. The staffing plan
24 must:
25 (a) Meet the minimum requirements set forth in
26 subsection (1);
27 (b) Be adequate to meet any additional requirements
28 provided by other laws or regulations;
29 (c) Employ and identify an approved acuity system for
30 addressing fluctuations in actual patient acuity levels and
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1 nursing care requirements requiring increased staffing levels
2 above the minimums set forth in the plan;
3 (d) Factor in other unit or department activity, such
4 as discharges, transfers and admissions, and administrative
5 and support tasks, which is expected to be done by direct-care
6 nurses in addition to direct nursing care;
7 (e) Identify the assessment tool used to validate the
8 acuity system relied on in the plan;
9 (f) Identify the system that will be used daily to
10 document actual staffing within each department or unit;
11 (g) Include a written assessment of the accuracy of
12 the previous year's staffing plan in light of actual staffing
13 needs;
14 (h) Identify each nurse staff classification
15 referenced therein together with a statement setting forth
16 minimum qualifications for each such classification; and
17 (i) Be developed in consultation with the direct-care
18 nursing staff within each department or unit or, if such staff
19 is represented, with the applicable recognized or certified
20 collective-bargaining representatives of the direct-care
21 nursing staff.
22 (3) MINIMUM SKILL MIX.--The skill mix reflected in a
23 staffing plan must assure that all of the following elements
24 of the nursing process are performed in the planning and
25 delivery of care for each patient: assessment, nursing
26 diagnosis, planning, intervention, evaluation, and patient
27 advocacy.
28 (a) The skill mix may not incorporate or assume that
29 nursing care functions required by licensing law or
30 regulations or accepted standards of practice to be performed
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1 by a registered nurse or licensed practical nurse are to be
2 performed by unlicensed assistant personnel.
3 (b) A nurse may not be assigned, or included in the
4 count of assigned nursing staff for purposes of compliance
5 with minimum staffing requirements, in a nursing department or
6 unit or a clinical area within the health facility unless the
7 nurse is qualified in the area of practice to which the nurse
8 is assigned.
9 (4) COMPLIANCE WITH PLAN.--As a condition of
10 licensing, a health care facility must at all times staff in
11 accordance with its staffing plan and the staffing standards
12 set forth in this section; however, this section does not
13 preclude a health care facility's implementing higher
14 direct-care nurse-to-patient staffing levels.
15 (5) RECORDKEEPING.--The facility shall maintain
16 records sufficient to allow the agency to determine the daily
17 staffing ratios and skill mixes that the facility maintained
18 on each unit.
19 Section 5. Mandatory overtime and excessive duty
20 hours.--
21 (1) PROHIBITION OF MANDATORY OVERTIME.--An employee of
22 a health care facility may not be required to work overtime as
23 defined in section 3 of this act. Compelling or attempting to
24 compel an employee to work overtime is contrary to public
25 policy and is a violation of this section. The acceptance by
26 any employee of overtime work is strictly voluntary, and the
27 refusal of an employee to accept such overtime work is not
28 grounds for discrimination, dismissal, discharge, or any other
29 penalty; threats of reports for discipline; or employment
30 decisions adverse to the employee.
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1 (2) APPLICABILITY.--This section does not apply to
2 work that occurs:
3 (a) Because of any unforeseeable emergent
4 circumstance;
5 (b) During prescheduled on-call time if, as of July 1,
6 2003, such prescheduled on-call time was a customary and
7 longstanding practice in the unit or department of the health
8 care facility; or
9 (c) Because of unpredictable and unavoidable
10 occurrences relating to health care delivery which occur at
11 unscheduled intervals and require immediate action, if the
12 employer shows that the employer has exhausted reasonable
13 efforts to obtain staffing. An employer has not used
14 reasonable efforts if overtime work is used to fill vacancies
15 resulting from chronic staff shortages.
16 (3) This section does not prohibit a health care
17 employee from voluntarily working overtime.
18 Section 6. Employee rights.--
19 (1) RIGHT TO REFUSE ASSIGNMENT UNDER CONDITIONS THAT
20 WOULD VIOLATE STANDARDS.--A health facility covered by this
21 act shall not penalize, discriminate against, or retaliate in
22 any manner against a direct-care registered nurse for refusing
23 an assignment that would violate requirements set forth in
24 this act.
25 (2) RIGHT TO REPORT VIOLATIONS OF SAFE STAFFING
26 STANDARDS.--A health facility covered by this act shall not
27 penalize, discriminate against, or retaliate in any manner
28 against an employee with respect to compensation, terms, or
29 conditions or privileges of employment if such an employee in
30 good faith, individually or in conjunction with another person
31 or persons:
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1 (a) Reports a violation or suspected violation of this
2 act to a public regulatory agency, a private accreditation
3 body, or management personnel of the health care facility;
4 (b) Initiates, cooperates, or otherwise participates
5 in an investigation or proceeding brought by a regulatory
6 agency or private accreditation body concerning matters
7 covered by this act;
8 (c) Informs or discusses with other employees, with
9 representatives of the employees, with patients or patient
10 representatives, or with the public violations or suspected
11 violations of this act; or
12 (d) Otherwise avails himself or herself of the rights
13 set forth in this act.
14 (3) For purposes of this section, an employee is
15 acting in good faith if the employee reasonably believes that
16 the information reported or disclosed is true and that a
17 violation has occurred or may occur.
18 Section 7. Implementation and enforcement.--
19 (1) The Agency for Health Care Administration shall
20 ensure general compliance with the staffing plans and
21 standards set forth in this act. The agency may adopt such
22 rules as are necessary to implement this act. At a minimum,
23 the rules must provide for:
24 (a) Unannounced, random compliance site visits to
25 licensed health care facilities that are covered by the act;
26 (b) An accessible and confidential system by which the
27 public and nursing staff can report a health facility's
28 failure to comply with this act;
29 (c) A systematic means for investigating and
30 correcting violations of the act;
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1 (d) A graduated system of penalties, including fines,
2 withholding of reimbursement, suspension of admission to
3 specific units, and other appropriate measures, if violations
4 are not corrected;
5 (e) Public access to information regarding reports of
6 inspections, results, deficiencies, and corrections.
7 (2) The agency shall develop rules to administer this
8 act which require compliance with the staffing standards for
9 critical care units by July 1, 2004, and compliance with all
10 provisions of this act by July 1, 2006.
11 Section 8. This act shall take effect July 1, 2003.
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14 SENATE SUMMARY
15 Creates "The Safe Staffing for Quality Care Act,"
relating to staffing in health care facilities. Provides
16 facility staffing standards. Prohibits mandatory overtime
and excessive duty hours. Allows voluntary overtime
17 hours. Provides a statement of employee rights. Requires
the Agency for Health Care Administration to ensure
18 compliance with the act and to adopt rules for
administering the act.
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