HB 0043B 2003
1	A bill to be entitled
2	An act relating to the staffing of health care facilities;
3	providing a popular name; providing legislative findings;
4	defining terms; prescribing facility staffing standards
5	relating to nurse-to-patient ratios, staffing plans, and
6	the minimum skill mix; allowing the implementation of
7	higher staffing levels; providing recordkeeping
8	requirements; prohibiting mandatory overtime and excessive
9	duty hours; allowing voluntary overtime work; providing a
10	statement of employee rights; providing for the Agency for
11	Health Care Administration to ensure compliance with the
12	act and to adopt rules; providing for construction of the
13	act in pari materia with laws enacted during the 2003
14	Regular Session or the 2003 Special Session A of the
15	Legislature; providing an effective date.
16
17	Be It Enacted by the Legislature of the State of Florida:
18
19	Section 1. Popular name.--This act shall be known by the
20	popular name “The Safe Staffing for Quality Care Act."
21	Section 2. Legislative findings.--The Legislature finds
22	that:
23	(1) The state has a substantial interest in assuring that
24	delivery of health care services to patients in health care
25	facilities located within this state is adequate and safe and
26	that health care facilities retain sufficient nursing staff so
27	as to promote optimal health care outcomes.
28	(2) Recent changes in our health care delivery system are
29	resulting in a higher acuity level among patients in health care
30	facilities.
31	(3) Extensive research indicates that inadequate
32	registered-nurse staffing in hospitals can result in increased
33	patient death rates, dangerous medical errors, and increased
34	length of stay.
35	(4) To ensure the adequate protection and care for
36	patients in health care facilities, it is essential that
37	qualified registered nurses be accessible and available to meet
38	the nursing needs of patients.
39	Section 3. Definitions.--As used in this act, the term:
40	(1) “Acuity system” means an established measurement
41	instrument that:
42	(a) Predicts nursing care requirements for individual
43	patients based on severity of patient illness, need for
44	specialized equipment and technology, intensity of nursing
45	interventions required, and the complexity of clinical nursing
46	judgment needed to design, implement, and evaluate the patient's
47	nursing care plan;
48	(b) Details the amount of nursing care needed, both in
49	number of registered nurses and in skill mix of nursing
50	personnel required daily for each patient in a nursing
51	department or unit; and
52	(c) Is stated in terms that can be readily used and
53	understood by direct-care nursing staff.
54	(2) “Assessment tool” means a measurement system that
55	compares the staffing level in each nursing department or unit
56	to actual patient nursing care requirements in order to review
57	the accuracy of an acuity system.
58	(3) “Documented staffing plan” means a detailed written
59	plan setting forth the minimum number, skill mix, and
60	classification of licensed nurses required in each nursing
61	department or unit in the health facility for a given year,
62	based on reasonable projections derived from the patient census
63	and average acuity level within each department or unit during
64	the previous year, the department or unit size and geography,
65	the nature of services provided, and any foreseeable changes in
66	department or unit size or function during the current year.
67	(4) “Critical care unit” means a unit of a hospital which
68	is established to safeguard and protect patients the severity of
69	whose medical conditions requires continuous monitoring and
70	complex nursing intervention.
71	(5) “Declared state of emergency” means an officially
72	designated state of emergency which has been declared by a
73	federal, state, or local government official who has the
74	authority to declare that the state, county, municipality, or
75	locality is in a state of emergency, but does not include a
76	state of emergency which results from a labor dispute in the
77	health care industry.
78	(6) “Direct-care nurse” or “direct-care nursing staff"
79	means any registered nurse who has direct responsibility to
80	oversee or carry out medical regimens or nursing care for one or
81	more patients. Only registered nurses who have specific patient
82	care assignments shall be included in the calculation of the
83	registered nurse-to-patient ratio.
84	(7) “Health care facility” means an acute care hospital;
85	an emergency care, ambulatory, or outpatient surgery facility
86	licensed under section 395.003, Florida Statutes; or a
87	psychiatric facility licensed under chapter 394, Florida
88	Statutes.
89	(8) “Nurse” means a registered nurse.
90	(9) “Nursing care” means care that falls within the scope
91	of practice set forth in chapter 464, Florida Statutes, and
92	other laws and regulations or that is otherwise encompassed
93	within recognized professional standards of nursing practice,
94	including assessment, nursing diagnosis, planning, intervention,
95	evaluation, and patient advocacy.
96	(10) “Off-duty" means that the individual has no
97	restrictions placed on his or her whereabouts and is free of all
98	restraint or duty on behalf of the health care facility.
99	(11) “On-duty" means that the individual is required to be
100	available and ready to perform services on request within or on
101	behalf of the health care facility and includes any rest periods
102	or breaks during which the individual's ability to leave the
103	health care facility is restricted either expressly or by work-
104	related circumstances beyond the individual's control.
105	(12) “Overtime" means the hours worked in excess of any of
106	the following:
107	(a) An agreed-upon, predetermined, regularly scheduled
108	shift;
109	(b) Twelve hours in a 24-hour period; or
110	(c) Eighty hours in a consecutive 14-day period.
111	(13) “On-call time" means time spent by an employee who is
112	not working on the premises of the place of employment but who
113	is compensated for availability or who, as a condition of
114	employment, has agreed to be available to return to the premises
115	of the place of employment on short notice if the need arises.
116	(14) “Reasonable efforts" in reference to the prohibition
117	on mandatory overtime means that the employer does all of the
118	following but is unable to obtain staff coverage:
119	(a) Seeks individuals to volunteer to work extra time from
120	all available qualified staff who are working;
121	(b) Contacts qualified employees who have made themselves
122	available to work extra time;
123	(c) Seeks the use of per diem staff; and
124	(d) Seeks personnel from a contracted temporary agency if
125	such staffing is permitted by law or an applicable collective
126	bargaining agreement.
127	(15) “Unforeseeable emergent circumstance" means:
128	(a) Any unforeseen declared national, state, or municipal
129	emergency;
130	(b) A situation in which a health care facility disaster
131	plan is activated; or
132	(c) Any unforeseen disaster or other catastrophic event
133	that substantially affects or increases the need for health care
134	services.
135	(16) “Skill mix" means the differences in licensing,
136	specialty, and experience among direct-care nurses.
137	(17) “Staffing level" means the actual numerical
138	registered nurse-to-patient ratio within a nursing department or
139	unit.
140	Section 4. Facility staffing standards.--
141	(1) SPECIFIC STANDARDS.--Hospitals shall provide staffing
142	by registered nurses in accordance with the following maximum
143	patient assignments in the units specified. Additional
144	registered nurse staffing, auxiliary staffing by nurses other
145	than registered nurses or staffing by other healthcare
146	professionals are not included in these ratios and shall be
147	determined pursuant to the patient classification system as
148	provided in paragraph (b). Nurse-to-patient ratios represent the
149	maximum number of patients which shall be assigned to one
150	registered nurse during one shift. Only nurses providing direct
151	patient care shall be included in the ratios. This section does
152	not prohibit a registered nurse from providing care within the
153	scope of his or her practice to a patient who is assigned to
154	another nurse.
155	(a) There shall be a maximum of two patients assigned to
156	each registered nurse so that the minimum registered nurse-to-
157	patient ratio in a critical care unit must be 1:2 or fewer at
158	any time. As used in this paragraph, the term “critical care
159	unit" means a nursing unit of a general acute care hospital
160	which provides one of the following services: an intensive care
161	service, a burn center, a coronary care service, or an acute
162	respiratory service. In the intensive care newborn nursery
163	service, a maximum of two patients shall be assigned to each
164	registered nurse.
165	(b) The surgical service operating room shall have a
166	maximum of one patient-occupied operating room assigned to each
167	registered nurse.
168	(c) There shall be a maximum of two patients assigned to
169	each registered nurse in a labor and delivery suite of the
170	perinatal service so that the registered nurse-to-patient ratio
171	shall be 1:2 or fewer at any time.
172	(d) There shall be a maximum of two patients assigned to
173	each registered nurse in a labor/delivery unit.
174	(e) There shall be a maximum of three mother-baby couplets
175	assigned to each registered nurse in a postpartum area of the
176	perinatal unit at any time. In the event of multiple births, the
177	total number of mothers plus infants assigned to a single
178	registered nurse shall never exceed six.
179	(f) There shall be a maximum of two patients assigned to
180	each registered nurse in a postanesthesia recovery unit.
181	(g) In a hospital providing basic emergency medical
182	services or comprehensive emergency medical services, there
183	shall be a maximum of three patients who are receiving emergency
184	treatment assigned to each registered nurse so that the
185	registered nurse-to-patient ratio in an emergency department
186	shall be 1:3 or fewer at any time patients are receiving
187	treatment. There shall be no fewer than two registered nurses
188	physically present in the emergency department when a patient is
189	present.
190	(h) The nurse assigned to triage patients shall not have a
191	patient assignment, shall not be assigned responsibility for the
192	base radio, and shall not be counted in the registered nurse-to-
193	patient ratio.
194	(i) When nursing staff are attending critical care
195	patients in the emergency department, there shall be a maximum
196	of two patients assigned to each registered nurse. When nursing
197	staff in the emergency department are attending trauma patients,
198	there shall be a maximum of one patient assigned to each
199	registered nurse at any time.
200	(j) There shall be a maximum of three patients assigned to
201	each registered nurse in a step-down unit so that the minimum
202	registered nurse-to-patient ratio shall be 1:3 or fewer at any
203	time. As used in this paragraph, the term:
204	1. “Artificial life support" means a system that uses
205	medical technology to aid, support, or replace a vital function
206	of the body which has been seriously damaged.
207	2. “Step-down unit" means a unit that is organized,
208	operated, and maintained to provide for the monitoring and care
209	of patients with moderate or potentially severe physiologic
210	instability requiring technical support but not necessarily
211	artificial life support.
212	3. “Technical support" means specialized equipment or
213	personnel, or both, providing for invasive monitoring,
214	telemetry, and mechanical ventilation, for the immediate
215	amelioration or remediation of severe pathology for those
216	patients requiring less care than intensive care but more than
217	that which is available from medical/surgical care.
218	(k) There shall be a maximum of three patients assigned to
219	each registered nurse so that the minimum registered nurse-to-
220	patient ratio in a telemetry unit shall be 1:3 or fewer at any
221	time. As used in this paragraph, the term "telemetry unit" means
222	a unit designated for the electronic monitoring, recording,
223	retrieval, and display of cardiac electrical signals.
224	(l) There shall be a maximum of four patients assigned to
225	each registered nurse so that the minimum registered nurse-to-
226	patient ratio in medical/surgical care units shall be 1:4 or
227	fewer at any time. A medical/surgical unit is a unit with beds
228	classified as medical/surgical in which patients who require
229	less care than that which is available in intensive care units
230	or step-down units receive 24-hour inpatient general medical
231	services, postsurgical services, or both general medical and
232	postsurgical services. Such a unit may include mixed patient
233	populations of diverse diagnoses and diverse age groups.
234	(m) There shall be a maximum of four patients assigned to
235	each registered nurse so that the minimum registered nurse-to-
236	patient ratio in a specialty care unit shall be 1:4 or fewer at
237	any time. A specialty care unit is a unit that is organized,
238	operated, and maintained to provide care for a specific medical
239	condition or a specific patient population, is more
240	comprehensive for the specific condition or disease process than
241	that which is available on medical/surgical units, and is not
242	otherwise specifically covered in this section.
243	(n) There shall be a maximum of four patients assigned to
244	each registered nurse so that the minimum registered nurse-to-
245	patient ratio in an acute care psychiatric unit shall be 1:4 or
246	fewer at any time.
247	(o) Identifying a unit by a name or term other than those
248	used in this subsection does not affect the requirement to staff
249	at the ratios identified for the level or type of care described
250	in this subsection.
251	(2) STAFFING PLAN.--To ensure that it is staffed in a
252	manner that provides sufficient, appropriately qualified nursing
253	staff of each classification in each department or unit within
254	the facility in order to meet the individualized care needs of
255	the patients therein and to meet the requirements for registered
256	nurse staffing set forth in subsection (1), each health care
257	facility licensed under this statute shall annually submit to
258	the Agency for Health Care Administration a documented staffing
259	plan, together with a written certification that the staffing
260	plan is sufficient to provide adequate and appropriate delivery
261	of health care services to patients for the ensuing year. The
262	staffing plan must:
263	(a) Meet the minimum requirements set forth in subsection
264	(1);
265	(b) Be adequate to meet any additional requirements
266	provided by other laws or regulations;
267	(c) Employ and identify an approved acuity system for
268	addressing fluctuations in actual patient acuity levels and
269	nursing care requirements requiring increased staffing levels
270	above the minimums set forth in the plan;
271	(d) Factor in other unit or department activity, such as
272	discharges, transfers and admissions, and administrative and
273	support tasks, which is expected to be done by direct-care
274	nurses in addition to direct nursing care;
275	(e) Identify the assessment tool used to validate the
276	acuity system relied on in the plan;
277	(f) Identify the system that will be used daily to
278	document actual staffing within each department or unit;
279	(g) Include a written assessment of the accuracy of the
280	previous year's staffing plan in light of actual staffing needs;
281	(h) Identify each nurse staff classification referenced
282	therein together with a statement setting forth minimum
283	qualifications for each such classification; and
284	(i) Be developed in consultation with the direct-care
285	nursing staff within each department or unit or, if such staff
286	is represented, with the applicable recognized or certified
287	collective-bargaining representatives of the direct-care nursing
288	staff.
289	(3) MINIMUM SKILL MIX.--The skill mix reflected in a
290	staffing plan must assure that all of the following elements of
291	the nursing process are performed in the planning and delivery
292	of care for each patient: assessment, nursing diagnosis,
293	planning, intervention, evaluation, and patient advocacy.
294	(a) The skill mix may not incorporate or assume that
295	nursing care functions required by licensing law or regulations
296	or accepted standards of practice to be performed by a
297	registered nurse or licensed practical nurse are to be performed
298	by unlicensed assistant personnel.
299	(b) A nurse may not be assigned, or included in the count
300	of assigned nursing staff for purposes of compliance with
301	minimum staffing requirements, in a nursing department or unit
302	or a clinical area within the health facility unless the nurse
303	is qualified in the area of practice to which the nurse is
304	assigned.
305	(4) COMPLIANCE WITH PLAN.--As a condition of licensing, a
306	health care facility must at all times staff in accordance with
307	its staffing plan and the staffing standards set forth in this
308	section; however, this section does not preclude a health care
309	facility's implementing higher direct-care nurse-to-patient
310	staffing levels.
311	(5) RECORDKEEPING.--The facility shall maintain records
312	sufficient to allow the agency to determine the daily staffing
313	ratios and skill mixes that the facility maintained on each
314	unit.
315	Section 5. Mandatory overtime and excessive duty hours.--
316	(1) PROHIBITION OF MANDATORY OVERTIME.--An employee of a
317	health care facility may not be required to work overtime as
318	defined in section 3 of this act. Compelling or attempting to
319	compel an employee to work overtime is contrary to public policy
320	and is a violation of this section. The acceptance by any
321	employee of overtime work is strictly voluntary, and the refusal
322	of an employee to accept such overtime work is not grounds for
323	discrimination, dismissal, discharge, or any other penalty;
324	threats of reports for discipline; or employment decisions
325	adverse to the employee.
326	(2) APPLICABILITY.--This section does not apply to work
327	that occurs:
328	(a) Because of any unforeseeable emergent circumstance;
329	(b) During prescheduled on-call time if, as of July 1,
330	2003, such prescheduled on-call time was a customary and
331	longstanding practice in the unit or department of the health
332	care facility; or
333	(c) Because of unpredictable and unavoidable occurrences
334	relating to health care delivery which occur at unscheduled
335	intervals and require immediate action, if the employer shows
336	that the employer has exhausted reasonable efforts to obtain
337	staffing. An employer has not used reasonable efforts if
338	overtime work is used to fill vacancies resulting from chronic
339	staff shortages.
340	(3) This section does not prohibit a health care employee
341	from voluntarily working overtime.
342	Section 6. Employee rights.--
343	(1) RIGHT TO REFUSE ASSIGNMENT UNDER CONDITIONS THAT WOULD
344	VIOLATE STANDARDS.--A health facility covered by this act shall
345	not penalize, discriminate against, or retaliate in any manner
346	against a direct-care registered nurse for refusing an
347	assignment that would violate requirements set forth in this
348	act.
349	(2) RIGHT TO REPORT VIOLATIONS OF SAFE STAFFING
350	STANDARDS.--A health facility covered by this act shall not
351	penalize, discriminate against, or retaliate in any manner
352	against an employee with respect to compensation, terms, or
353	conditions or privileges of employment if such an employee in
354	good faith, individually or in conjunction with another person
355	or persons:
356	(a) Reports a violation or suspected violation of this act
357	to a public regulatory agency, a private accreditation body, or
358	management personnel of the health care facility;
359	(b) Initiates, cooperates, or otherwise participates in an
360	investigation or proceeding brought by a regulatory agency or
361	private accreditation body concerning matters covered by this
362	act;
363	(c) Informs or discusses with other employees, with
364	representatives of the employees, with patients or patient
365	representatives, or with the public violations or suspected
366	violations of this act; or
367	(d) Otherwise avails himself or herself of the rights set
368	forth in this act.
369	(3) For purposes of this section, an employee is acting in
370	good faith if the employee reasonably believes that the
371	information reported or disclosed is true and that a violation
372	has occurred or may occur.
373	Section 7. Implementation and enforcement.--
374	(1) The Agency for Health Care Administration shall ensure
375	general compliance with the staffing plans and standards set
376	forth in this act. The agency may adopt such rules as are
377	necessary to implement this act. At a minimum, the rules must
378	provide for:
379	(a) Unannounced, random compliance site visits to licensed
380	health care facilities that are covered by the act;
381	(b) An accessible and confidential system by which the
382	public and nursing staff can report a health facility's failure
383	to comply with this act;
384	(c) A systematic means for investigating and correcting
385	violations of the act;
386	(d) A graduated system of penalties, including fines,
387	withholding of reimbursement, suspension of admission to
388	specific units, and other appropriate measures, if violations
389	are not corrected;
390	(e) Public access to information regarding reports of
391	inspections, results, deficiencies, and corrections.
392	(2) The agency shall develop rules to administer this act
393	which require compliance with the staffing standards for
394	critical care units by July 1, 2004, and compliance with all
395	provisions of this act by July 1, 2006.
396	Section 8. If any law amended by this act was also amended
397	by a law enacted at the 2003 Regular Session of the Legislature
398	or at the 2003 Special Session A of the Legislature, such laws
399	shall be construed as if they had been enacted at the same
400	session of the Legislature, and full effect shall be given to
401	each if possible.
402	Section 9. This act shall take effect July 1, 2003, or
403	upon becoming law, whichever occurs later.