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A bill to be entitled

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An act relating to the staffing of health care facilities;

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creating ss. 395.051-395.057, F.S.; creating the Safe

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Staffing for Quality Care Act; providing a short title;

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providing legislative findings; defining terms;

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prescribing safe staffing standards for health care

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facilities; requiring licensed facilities to submit an

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annual staffing plan to the Agency for Health Care

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Administration; providing standards for the required skill

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mix; requiring compliance with the staffing plan;

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requiring recordkeeping; prohibiting mandatory overtime;

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providing applicability; permitting employees to refuse

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certain assignments and to report suspected violations of

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safe staffing standards; providing for the agency to

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enforce compliance with the act; requiring the agency to

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develop rules; providing an effective date.

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Be It Enacted by the Legislature of the State of Florida:

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     Section 1.  Section 395.051, Florida Statutes, is created to

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read:

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     395.051 Short title.--Sections 395.051-395.057 may be cited

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as the "Safe Staffing for Quality Care Act."

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     Section 2.  Section 395.052, Florida Statutes, is created to

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read:

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     395.052 Legislative findings.--The Legislature finds that:

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     (1) The state has a substantial interest in ensuring that

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delivery of health care services to patients in health care

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facilities located in this state is adequate and safe and that

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health care facilities retain sufficient nursing staff so as to

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promote optimal health care outcomes.

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     (2) Recent changes in our health care delivery system are

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resulting in a higher acuity level among patients in health care

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facilities.

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     (3) Registered nurses constitute the highest percentage of

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direct health care staff in acute care facilities and have a

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central role in delivering health care.

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     (4) Extensive research indicates that inadequate registered

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nurse staffing in hospitals can result in increased patient death

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rates, dangerous medical errors, and increased length of stay.

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     (5) To ensure adequate protection and care for patients in

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health care facilities, it is essential that qualified registered

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nurses who are trained and authorized to deliver nursing services

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be accessible and available to meet the nursing needs of

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patients.

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     Section 3.  Section 395.053, Florida Statutes, is created to

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read:

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     395.053 Definitions.--As used in this act, the term:

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     (1) "Acuity system" means an established measurement

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instrument that:

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     (a) Predicts nursing care requirements for individual

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patients based on the severity of patient illness, the need for

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specialized equipment and technology, the intensity of nursing

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interventions required, and the complexity of clinical nursing

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judgment needed to design, implement, and evaluate the patient's

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nursing care plan;

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     (b) Details the amount of nursing care needed, both in the

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number of registered nurses and in the skill mix of nursing

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personnel required daily for each patient in a nursing department

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or unit; and

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     (c) Is stated in terms that can be readily used and

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understood by direct-care nursing staff.

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     (2) "Assessment tool" means a measurement system that

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compares the staffing level in each nursing department or unit

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against actual patient nursing care requirements in order to

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review the accuracy of an acuity system.

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     (3) "Declared state of emergency" means an officially

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designated state of emergency which has been declared by a

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federal, state, or local government official who has the

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authority to declare that the state, county, municipality, or

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locality is in a state of emergency. The term does not include a

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state of emergency that results from a labor dispute in the

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health care industry.

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     (4) "Direct-care nurse" or "direct-care nursing staff"

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means any registered nurse who has direct responsibility to

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oversee or carry out medical regimens or nursing care for one or

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more patients. A nurse administrator, nurse supervisor, nurse

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educator, charge nurse, or other registered nurse who does not

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have a specific patient assignment may not be included in the

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calculation of the registered nurse-to-patient ratio.

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     (5) "Documented staffing plan" means a detailed written

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plan that sets forth the minimum number, skill mix, and

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classification of licensed nurses required in each nursing

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department or unit in the health care facility for a given year,

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based on reasonable projections derived from the patient census

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and average acuity level within each department or unit during

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the previous year, the department or unit size and geography, the

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nature of services provided, and any foreseeable changes in

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department or unit size or function during the current year.

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     (6) "Health care facility" means an acute care hospital; an

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emergency care, ambulatory, or outpatient surgery facility

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licensed under s. 395.003; or a psychiatric facility licensed

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under chapter 394.

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     (7) "Nurse" means a registered nurse.

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     (8) "Nursing care" means care that falls within the scope

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of practice set forth in chapter 464 and other laws and rules or

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care that is otherwise encompassed within recognized professional

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standards of nursing practice, including assessment, nursing

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diagnosis, planning, intervention, evaluation, and patient

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advocacy.

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     (9) "On-call time" means time spent by an employee who:

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     (a) Is not working on the premises of the place of

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employment but who is compensated for availability; or

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     (b) As a condition of employment, has agreed to be

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available to return to the premises of the place of employment on

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short notice if the need arises.

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     (10) "Overtime" means the hours worked in excess of any of

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the following:

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     (a) An agreed-upon, predetermined, regularly scheduled

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shift;

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     (b) Twelve hours in a 24-hour period; or

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     (c) Eighty hours in a consecutive 14-day period.

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     (11) "Reasonable efforts," in reference to the prohibition

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on mandatory overtime, means that the employer is unable to

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obtain staff coverage even though the employer has:

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     (a) Sought, from among all available qualified staff who

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are working, individuals who would volunteer to work extra time;

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     (b) Contacted employees who have made themselves available

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to work extra time;

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     (c) Sought the use of per diem staff; and

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     (d) Sought personnel from a contracted temporary agency if

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such staffing is permitted by law or an applicable collective

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bargaining agreement.

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     (12) "Skill mix" means the differences in licensing,

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specialty, and experience among direct-care nurses.

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     (13) "Staffing level" means the actual numerical registered

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nurse-to-patient ratio within a nursing department or unit.

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     (14) "Unforeseeable emergent circumstance" means:

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     (a) An unforeseen declared national, state, or municipal

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emergency;

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     (b) A situation in which a health care disaster plan is

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activated; or

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     (c) An unforeseen disaster or other catastrophic event that

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substantially affects or increases the need for health care

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services.

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     Section 4.  Section 395.054, Florida Statutes, is created to

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read:

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     395.054 Facility staffing standards.--

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     (1) STAFFING PRINCIPLES.--The basic principles of staffing

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in health care facilities should be focused on patient health

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care needs and based on consideration of patient acuity levels

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and services that need to be provided to ensure optimal outcomes.

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Safe staffing practices recognize the importance of all health

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care workers in providing quality patient care. Establishing

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staffing standards for registered nurses does not justify

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providing an insufficient level of staffing by other critical

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health care workers, including licensed practical nurses, social

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workers, and other licensed or unlicensed assistive personnel.

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The availability of licensed practical nurses, social workers,

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and other licensed or unlicensed assistive personnel enables

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registered nurses to focus on the nursing care functions that

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only registered nurses, by law, are permitted to perform and

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thereby helps to ensure adequate staffing levels.

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     (2) SPECIFIC STANDARDS.--Health care facilities shall

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provide staffing by registered nurses in accordance with the

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minimum nurse-to-patient ratios that are set forth in this

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subsection. Staffing for care that does not require a registered

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nurse is not included within these ratios and must be determined

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pursuant to the patient classification system. Nurse-to-patient

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ratios represent the maximum number of patients that are assigned

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to one registered nurse during one shift. Only nurses providing

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direct patient care shall be included in the ratios. Nurse

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administrators, nurse supervisors, charge nurses, and other

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licensed nurses that do not have a specific patient care

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assignment may not be included in the calculation of the nurse-

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to-patient ratio. This section does not prohibit a registered

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nurse from providing care within the scope of his or her practice

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to a patient assigned to another nurse.

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     (a) No more than two patients may be assigned to each

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registered nurse, so that the minimum registered nurse-to-patient

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ratio in a critical care unit is 1 to 2 or fewer at any time. As

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used in this paragraph, the term "critical care unit" means a

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nursing unit of a general acute care hospital that provides one

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of the following services: an intensive care service, a

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postanesthesia recovery service, a burn center service, a

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coronary care service, or an acute respiratory service. In the

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intensive care newborn nursery service, no more than two patients

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may be assigned to each nurse.

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     (b) In the surgical service operating room, no more than

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one patient-occupied operating room may be assigned to each

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registered nurse.

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     (c) No more than two patients may be assigned to each

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registered nurse in a labor and delivery unit of the perinatal

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service, so that the registered nurse-to-patient ratio is 1 to 2

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or fewer at any time.

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     (d) No more than three mother-baby couplets may be assigned

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to each registered nurse in a postpartum area of the perinatal

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unit at any time. If multiple births have occurred, the total

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number of mothers plus infants which are assigned to a single

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registered nurse may not exceed six.

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     (e) In a hospital that provides basic emergency medical

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services or comprehensive emergency medical services, no more

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than three patients who are receiving emergency services may be

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assigned to each registered nurse, so that the registered nurse-

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to-patient ratio in an emergency department is 1 to 3 or fewer at

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any time patients are receiving treatment. No fewer than two

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registered nurses must be physically present in the emergency

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department when a patient is present.

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     (f) The nurse assigned to triage patients may not have a

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patient assignment, may not be assigned the responsibility for

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the base ratio, and may not be counted in the registered nurse-

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to-patient ratio.

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     (g) When nursing staff are attending critical care patients

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in the emergency department, no more than two patients may be

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assigned to each registered nurse. When nursing staff in the

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emergency department are attending trauma patients, no more than

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one patient may be assigned to each registered nurse at any time.

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     (h) No more than three patients may be assigned to each

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registered nurse in a step-down unit, so that the minimum

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registered nurse-to-patient ratio in a step-down unit is 1 to 3

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or fewer at any time. As used in this paragraph, the term:

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     1. "Artificial life support" means a system that uses

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medical technology to aid, support, or replace a vital function

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of the body which has been seriously damaged.

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     2. "Step-down unit" means a unit that is organized,

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operated, and maintained to provide for the monitoring and care

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of patients who have moderate or potentially severe physiologic

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instability that requires technical support but not necessarily

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artificial life support.

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     3. "Technical support" means specialized equipment or

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personnel, or both, that provide for invasive monitoring,

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telemetry, and mechanical ventilation, for the immediate

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amelioration or remediation of severe pathology for those

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patients who require less care than intensive care but more care

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than can be provided in a medical surgical unit.

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     (i) No more than three patients may be assigned to each

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registered nurse, so that the minimum registered nurse-to-patient

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ratio in a telemetry unit is 1 to 3 or fewer at any time. As used

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in this paragraph, the term "telemetry unit" means a unit

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designated for the electronic monitoring, recording, retrieval,

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and display of cardiac electrical signals.

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     (j) No more than four patients may be assigned to each

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registered nurse, so that the minimum registered nurse-to-patient

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ratio in medical surgical care units is 1 to 4 or fewer at any

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time. As used in this paragraph, the term "medical surgical unit"

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means a unit that has beds classified as medical surgical in

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which patients who require less care than can be provided in

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intensive care units or step-down units receive 24-hour inpatient

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general medical services, post-surgical services, or both general

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medical and post-surgical services. These units may include mixed

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patient populations of diverse diagnoses and diverse age groups.

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     (k) No more than four patients may be assigned to each

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registered nurse, so that the minimum registered nurse-to-patient

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ratio in a specialty care unit is 1 to 4 or fewer at any time. As

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used in this paragraph, the term "specialty care unit" means a

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unit that is organized, operated, and maintained to provide care

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for a specific medical condition or a specific patient

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population, is more comprehensive for the specific condition or

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disease process than can be provided in a medical surgical unit,

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and is not otherwise covered in this section.

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     (l) No more than four patients may be assigned to each

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registered nurse, so that the minimum registered nurse-to-patient

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ratio in an acute care psychiatric unit is 1 to 4 or fewer at any

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time.

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Identifying a unit by a name or term other than those used in

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this subsection does not affect the requirement to provide staff

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for the unit at the ratio required for the level or type of care

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provided in the unit, as set forth in this subsection.

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     (3) STAFFING PLAN.--Each facility licensed under this

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chapter shall ensure that it provides sufficient, appropriately

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qualified nursing staff of each classification in each department

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or unit within the facility in order to meet the individualized

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care needs of the patients. To accomplish this goal, each health

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care facility licensed under this chapter shall submit annually

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to the agency a documented staffing plan together with a written

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certification that the staffing plan is sufficient to provide

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adequate and appropriate delivery of health care services to

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patients for the ensuing year. The staffing plan must:

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     (a) Meet the minimum requirements set forth in subsection

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(2);

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     (b) Meet any additional requirements provided by other laws

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or rules;

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     (c) Employ and identify an approved acuity system for

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addressing fluctuations in actual patient acuity levels and

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nursing care requirements that require increased staffing levels

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above the minimums set forth in the plan;

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     (d) Factor in other unit or department activity, such as

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discharges, transfers, and admissions and administrative support

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tasks that direct-care nurses are expected to perform in addition

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to providing direct nursing care;

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     (e) Identify the assessment tool used to validate the

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acuity system used in the plan;

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     (f) Identify the system that will be used to document

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actual daily staffing levels within each department or unit;

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     (g) Include a written assessment of the accuracy of the

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previous year's staffing plan based on actual staffing needs;

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     (h) Identify each nurse staff classification referred to in

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the staffing plan, together with a statement setting forth

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minimum qualifications for each classification; and

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     (i) Be developed in consultation with the direct-care

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nursing staff in each department or unit or, if such staff is

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covered by a collective bargaining agreement, with the applicable

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recognized or certified collective bargaining representatives of

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the direct-care nursing staff.

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     (4) MINIMUM SKILL MIX.--The skill mix reflected in a

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documented staffing plan must ensure that all of the following

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elements of the nursing process are performed in the planning and

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delivery of care for each patient: assessment, nursing diagnosis,

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planning, intervention, evaluation, and patient advocacy.

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     (a) The skill mix may not incorporate or assume that

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nursing care functions that are required by licensing law or

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rules or accepted standards of practice to be performed by a

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licensed nurse are to be performed by unlicensed assistant

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personnel.

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     (b) A nurse may not be assigned to or included in the count

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of assigned nursing staff for purposes of compliance with minimum

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staffing requirements in a nursing department or unit or a

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clinical area within the health care facility unless the nurse is

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qualified in the area of practice to which the nurse is assigned.

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     (5) COMPLIANCE WITH PLAN.--As a condition of licensing, a

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health care facility must at all times provide staff in

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accordance with its documented staffing plan and the staffing

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standards set forth in this section; however, this section does

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not preclude a health care facility from implementing higher

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direct-care, nurse-to-patient staffing levels.

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     (6) RECORDKEEPING.--The facility shall maintain records

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sufficient to allow the agency to determine the daily staffing

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ratios and skill mixes that the facility has maintained on each

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unit.

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     Section 5.  Section 395.055, Florida Statutes, is created to

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read:

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     395.055 Mandatory overtime.--

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     (1) An employee of a health care facility may not be

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required to work overtime as defined in s. 395.053. Compelling or

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attempting to compel an employee to work overtime is contrary to

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public policy and is a violation of this section. The acceptance

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by any employee of overtime work is strictly voluntary, and the

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refusal of an employee to accept such overtime work may not be

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grounds for discrimination, dismissal, discharge, or any other

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penalty; threats of reports for discipline; or employment

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decisions adverse to the employee.

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     (2) This section does not apply to work that occurs:

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     (a) Because of an unforeseeable emergent circumstance;

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     (b) During prescheduled on-call time if, as of July 1,

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2008, such prescheduled on-call time was a customary and

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longstanding practice in the unit or department of the health

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care facility; or

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     (c) Because of unpredictable and unavoidable occurrences

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relating to health care delivery that occur at unscheduled

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intervals and require immediate action, if the employer shows

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that the employer has exhausted reasonable efforts to comply with

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the documented staffing plan. An employer has not used reasonable

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efforts if overtime work is used to fill vacancies resulting from

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chronic staff shortages.

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     (3) This section does not prohibit a health care employee

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from voluntarily working overtime.

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     Section 6.  Section 395.056, Florida Statutes, is created to

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read:

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     395.056 Employee rights.--

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     (1) A health care facility may not penalize, discriminate

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against, or retaliate in any manner against a direct-care

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registered nurse for refusing an assignment that would violate

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requirements of this act.

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     (2) A health care facility may not penalize, discriminate

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against, or retaliate in any manner against an employee with

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respect to compensation for, or terms, conditions, or privileges

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of, employment if such an employee in good faith, individually or

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in conjunction with another person or persons:

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     (a) Reports a violation or suspected violation of this act

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to a regulatory agency, a private accreditation body, or

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management personnel of the health care facility;

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     (b) Initiates, cooperates in, or otherwise participates in

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an investigation or proceeding brought by a regulatory agency or

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private accreditation body concerning matters covered by this

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act;

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     (c) Informs or discusses with any other employee, any

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representative of the employee, a patient or a patient's

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representative, or with the public violations or suspected

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violations of this act; or

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     (d) Otherwise avails himself or herself of the rights set

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forth in this act.

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     (3) For purposes of this section, an employee is acting in

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good faith if the employee reasonably believes that the

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information reported or disclosed is true and that a violation

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has occurred or may occur.

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     Section 7.  Section 395.057, Florida Statutes, is created to

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read:

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     395.057 Implementation and enforcement.--

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     (1) The agency shall enforce compliance with the staffing

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plans and standards set forth in this act. The agency may adopt

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rules necessary to administer this act. At a minimum, the rules

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must provide for:

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     (a) Unannounced, random compliance site visits to licensed

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health care facilities subject to this act;

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     (b) An accessible and confidential system by which the

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public and nursing staff can report a health care facility's

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failure to comply with this act;

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     (c) A systematic means of investigating and correcting

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violations of this act;

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     (d) A graduated system of penalties, including fines,

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withholding of reimbursement, suspension of admission to specific

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units, and other appropriate measures, if violations are not

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corrected; and

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     (e) Public access to information regarding reports of

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inspections, results, deficiencies, and corrections.

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     (2) The agency shall develop rules for administering this

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act which require compliance with staffing standards for critical

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care units by July 1, 2009, and compliance with all provisions of

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this act by July 1, 2011.

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     Section 8.  This act shall take effect July 1, 2008.