Maine Hospital Association,

MEMORANDUM

TO: Senator Ethan Strimling, Chair
Representative John Tuttle, Chair
Members of the Labor Committee

FROM: Mary Mayhew, Vice President

DATE: May 4, 2007

RE: Testimony in Opposition to LD 1538 - An Act To Increase the Safety of Hospital Patients

Maine's Community Hospitals
The Maine Hospital Association represents all 39 community-governed hospitals which include 36 non-profit general acute care hospitals, 2 private psychiatric hospitals, and 1 acute rehabilitation hospital. Maine is one of only a handful of states in which all of its general acute care hospitals are nonprofit. In addition to acute care hospital facilities, our hospitals represent 19 home health agencies, 19 skilled nursing facilities, 17 nursing facilities, 8 residential care facilities, and 200 physician practices.

Maine's hospitals have stepped in to bridge gaps in access to services to ensure access to primary care physicians and specialists, to provide access to continuing care services, mental health services, nursing facilities, and public health programs. Each day Maine's hospitals experience the reality of our fragmented health care system. Every day we are on the front lines with a mission to fulfill: To improve the health and welfare of the people in our communities. A mission that governs our every decision.

With more than 25,000 full and part-time employees, hospitals are vital to Maine's economy. Hospitals are most often the largest employer in their communities. We are one of the largest employment sectors in the state. An estimated 13,000 new jobs will be created in health care in Maine from 1998 - 2008.

The Maine Hospital Association is opposed to the establishment of state-mandated fixed nurse-staffing ratios. Our hospitals should be evaluated based on the care provided not on fixed nurse/patient ratios. Hospitals and our health care professionals must be able to use professional judgment to manage staffing based on patient needs and the skill, competencies, education and experience of their staff, other support staff within the existing framework of regulatory and accreditation standards.

Maine Hospital Quality - 3rd Best in the Country
Maine's hospitals provide quality health care 24 hours a day, seven days a week to all patients regardless of their ability to pay. Maine hospitals already deliver an exceptionally high level of quality care. In fact, our state's hospitals were rated third best in the entire nation in a study by the Centers for Medicare & Medicaid Services (CMS) that reported on 22 indicators of the quality of care given to Medicare beneficiaries (JAMA Jan. 15, 2003). Ironically, California - the first state to mandate minimum nurse-to patient ratios in hospitals - ranked 44th in this same study. If Maine's staffing were ineffective we simply could not have achieved this 3rd best ranking.

Maine's non-profit community-governed hospitals are committed to ensuring quality patient care 24 hours a day, seven days a week. Our nurses and other caregivers are the heart and soul of our hospitals. Mandatory staffing ratios fail to address the true challenges confronting the health care workforce. Even worse, mandating inflexible staffing ratios is a misguided proposal that will have severe negative consequences for both our caregivers and our patients.

Hospital Staffing Must Be Evaluated Based on Results & Must Ensure Needed Flexibility to Meet Ever-Changing Patient Needs
Staffing effectiveness must be based on results not on arbitrary numbers that ignore the day to day realities of ensuring access to quality care. Staffing decisions require the critical thinking, judgment and flexibility of nurses who best understand the patients and their health care needs. Staffing models are designed to assure the highest quality of care provided in the safest environment. Hospitals and nursing leaders must be able to staff to meet the complex and ever-changing needs of patients. Cookie cutter approaches to patient care staffing fail to recognize differences between hospitals, in patient needs over a 24-hour period, and the skills, experiences, and education of the nursing staff and other staff support. Patient needs are highly individual. They drive staffing patterns now and must continue to do so.

Staffing Ratios Will Negatively Impact Access to Health Care Services
We are extremely concerned about the impact this bill will have on access to vital health care services. We need only look at California's experiences with staffing ratios to understand the detrimental impact that law has had on access. The California law forced 32% of hospitals to take beds out of services and 38% of hospital emergency departments went on diversion in just the first 6 months following implementation of the law. This proposal if enacted will force hospitals to deny admissions and transfer patients. Time is not often a luxury many patients have when they need immediate care - forcing them to travel greater distances to receive services because of an arbitrary staffing law is not in the best interests of patient care.

Hospitals know when they can't accept additional patients - that's part of the professional judgment that occurs every minute of every day now. Right now hospitals work with other hospitals to make sure that they can transfer patients when it is appropriate. We do not have excess bed capacity in Maine - so it can be a problem now to transfer patients - especially in peak tourist season for those hospitals that see increased patient volume or in peak flu season - this bill will grossly exacerbate those challenges and unnecessarily require patients to be transferred. Recently, during the last big storm, several hospitals in the Portland area needed to accept numerous patients from other facilities because of power outages and flooding. Had this law been in effect, those hospitals would not have been able to rise to the challenge to assist and provide care to those individuals.

Legislature Has Addressed this Issue Several Times Over the Last Few Years - Requiring Staffing Rule Changes & Mandating Submission of Quality Data by Hospitals
There are many who have argued that hospitals need to do something to address this issue. It is imperative that this Committee understand the numerous initiatives that have been undertaken over the last several years to comprehensively address the care provided to hospital patients as well as the myriad of regulations at the state and federal level that govern hospital staffing. In 2002, as a result of proposed staffing ratio legislation, the Department of Health & Human Services' Division of Licensing & Certification conducted a survey of hospital staffing plans and concluded that hospitals were staffing effectively based on state regulations. At the directive of the Legislature's Health & Human Services Committee, the Division and other interested parties, including the Maine State Nurses union, worked on revisions to hospital regulations to ensure that staffing plans included broad input and adequately addressed contingency planning. Those regulatory changes were adopted in January 2003.

In 2004 the Maine Quality Forum (MQF) was asked by the Legislature to study the issue. The MQF reported back to the Legislature in 2005 that there is insufficient data to support the use of staffing ratios throughout the hospital. The MQF did conclude that data should be collected on hospital quality measures relative to nursing sensitive indicators. Following adoption of a major substantive rule promulgated by the Maine Health Data Organization, hospitals began submitting the requested nursing sensitive data to the MQF in 2006. The MQF is currently working on the first public release and analysis of that data.

Existing State & Federal Regulations; Requirements of Accrediting Organization
The Department of Human Services state hospital regulations require that a system be in place to determine staffing requirements, which reflect the needs of patients. Individual staffing patterns must be developed for each patient care unit. Those staffing patterns must be based on the volume and care needs of patients. A registered professional nurse must appropriately assign the nursing care of each patient to nursing personnel in accordance with the patient's needs. At the federal level, CMS requires that an adequate number of licensed registered nurses, licensed practical nurses and other personnel be available to provide nursing care to all patients as needed. A registered nurse must supervise and evaluate the nursing care for each patient, and assign the nursing care of each patient to nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff.

And finally, the Joint Commission the voluntary accrediting organization for hospitals requires that nursing leaders develop organization-wide patient care programs, policies and procedures that describe how patient's nursing care needs are assessed, evaluated and met. Hospitals in the State of Maine are surveyed to monitor compliance with these standards at least every 18 months, sometimes more. The Joint Commission and DHS survey each accredited hospital every three years on alternating schedules. The Joint Commission also conducts random, unannounced surveys every 18 months. In addition, DHS randomly surveys hospitals six weeks following their Joint Commission survey. For those hospitals that choose not to seek Joint Commission accreditation, DHS surveys annually.
Hospitals meet these requirements in the following ways:

Each unit determines its core-staffing pattern annually, based on anticipated volume and patient care needs or severity of illness;
Unit schedules are developed monthly, based on these patterns;
Each unit, each shift is evaluated for their current volume of patients, and each patient is assessed for their level of severity (or acuity);
Staffing is based on these two assessments;
Patient assignments are determined by the registered nursing staff on duty;
The preceding shift makes an initial determination of what the next shift assignment will be. This is verified by the oncoming shift during change of shift report.

Given the extensive requirements that Maine hospitals must adhere to now, we do not understand the intent of this bill. We believe that every hour of each day nurses deliver quality patient care. The real concern that should be the focus of legislative deliberations should be the future supply of nurses and other healthcare professional in order to meet the needs of our rapidly aging population. Those future demands are real - that is where our attention and resources must be in order to ensure that we can meet those demands for healthcare services in the future.

Health Care Affordability
Maine's hospitals and the dedicated healthcare professionals are providing high quality care 24 hours a day 7 days a week, 365 days a year. Maine's hospitals are effectively staffing and work constantly to ensure that patient needs are being met. At a time when everyone is concerned about the cost of health care, this unneeded bill will cost millions to comply with, will jeopardize access to local health care, and significantly increase the cost of health care in Maine.

I appreciate your consideration of our concerns. We would strongly urge the committee to vote Ought Not to Pass on this legislation. I would be pleased to respond to any questions you may have.

Advocacy