No on Question #1 (Massachusetts)

This is the first of three posts that will examine and make recommendations relative to the three state-wide ballot questions that will be part of the 2018 midterms here in the Commonwealth of Massachusetts.

The Secretary of State’s office has information relative to all three ballot questions on the Secretary’s website. The following is the summary of the question from the Secretary of State:

Question #1: This proposed law would limit how many patients could be assigned to each registered nurse in Massachusetts hospitals and certain other health care facilities. The maximum number of patients per registered nurse would vary by type of unit and level of care, as follows:

  • In units with step-down/intermediate care patients: 3 patients per nurse;
  • In units with post-anesthesia care or operating room patients: 1 patient under anesthesia per nurse; 2 patients post-anesthesia per nurse;
  • In the emergency services department: 1 critical or intensive care patient per nurse (or 2 if the nurse has assessed each patient’s condition as stable); 2 urgent non-stable patients per nurse; 3 urgent stable patients per nurse; or 5 non-urgent stable patients per nurse;
  • In units with maternity patients: (a) active labor patients: 1 patient per nurse; (b) during birth and for up to two hours immediately postpartum: 1 mother per nurse and 1 baby per nurse; (c) when the condition of the mother and baby are determined to be stable: 1 mother and her baby or babies per nurse; (d) postpartum: 6 patients per nurse; (e) intermediate care or continuing care babies: 2 babies per nurse; (f) well-babies: 6 babies per nurse;
  • In units with pediatric, medical, surgical, telemetry, or observational/outpatient treatment patients, or any other unit: 4 patients per nurse; and
  • In units with psychiatric or rehabilitation patients: 5 patients per nurse.

The proposed law would require a covered facility to comply with the patient assignment limits without reducing its level of nursing, service, maintenance, clerical, professional, and other staff.

The proposed law would also require every covered facility to develop a written patient acuity tool for each unit to evaluate the condition of each patient. This tool would be used by nurses in deciding whether patient limits should be lower than the limits of the proposed law at any given time.

The proposed law would not override any contract in effect on January 1, 2019 that set higher patient limits. The proposed law’s limits would take effect after any such contract expired.

The state Health Policy Commission would be required to promulgate regulations to implement the proposed law. The Commission could conduct inspections to ensure compliance with the law. Any facility receiving written notice from the Commission of a complaint or a violation would be required to submit a written compliance plan to the Commission. The Commission could report violations to the state Attorney General, who could file suit to obtain a civil penalty of up to $25,000 per violation as well as up to $25,000 for each day a violation continued after the Commission notified the covered facility of the violation. The Health Policy Commission would be required to establish a toll-free telephone number for complaints and a website where complaints, compliance plans, and violations would appear.

The proposed law would prohibit discipline or retaliation against any employee for complying with the patient assignment limits of the law. The proposed law would require every covered facility to post within each unit, patient room, and waiting area a notice explaining the patient limits and how to report violations. Each day of a facility’s non-compliance with the posting requirement would be punishable by a civil penalty between $250 and $2,500.

The proposed law’s requirements would be suspended during a state or nationally declared public health emergency.

The proposed law states that, if any of its parts were declared invalid, the other parts would stay in effect. The proposed law would take effect on January 1, 2019.

A YES VOTE would limit the number of patients that could be assigned to one registered nurse in hospitals and certain other health care facilities.

A NO VOTE would make no change in current laws relative to patient-to-nurse limits.

 

This question is pretty clearly a result of the frustration that the Massachusetts Nurses Association has in its failed negotiations with various hospital groups in the Commonwealth. While I sympathize with their frustrations, and agree with the general principle that there should not be too many patients assigned to any one nurse, I fear that this is too blunt an instrument.  The opponents of this question have suggested that it could cost as much as a billion dollars annually, and even in the world of Massachusetts health care, that’s real money.

The only other place where something like this has been mandated is California, and there seems to be a lot of dispute whether these mandates have been effective. In the battle of the experts, there seem to be experts on both sides of the question who are sure they know the answers. Other commentators have noted that there are some very significant differences between what was enacted in California and what is being proposed here in Massachusetts.

People with greater expertise than me (Eugene Litvak of the Harvard School for Public Health, for example) have argued that the problem is less one of nurse staffing than one of patient variability, and that some of this can be solved with better management science.

Rather than setting hard and fast limits, I think it would be better to let an agency like the Health Policy Commission set flexible limits based on their own data analytics.  It’s also a question much better suited to study and analysis by the legislature, then to have the general public – with our complete lack of expertise in medical management issues – decide.

For this reason I recommend voting no on Question #1.

About a1skeptic

A disturbed citizen and skeptic. I should stop reading the newspaper. Or watching TV. I should turn off NPR and disconnect from the Internet. We’d all be better off.
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One Response to No on Question #1 (Massachusetts)

  1. Valerie says:

    Thanks Jurgen. From talking with several nurses and a couple of people on the administrative side, I’d also decided NO. Appreciate your thoughtful and expansive confirmation.

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