Published in the October 19, 2018 edition

This is the first of three parts examining the referendum questions on the November election ballot.

By DAN TOMASELLO

The debate over nurse staffing ratios is currently raging due to a proposed law appearing on the Nov. 6 ballot.

Question 1 seeks to limit how many patients could be assigned to each registered nurse in Massachusetts hospitals and certain other health care facilities. A yes vote would limit the number of patients that could be assigned to one registered nurse in hospitals and other health care facilities. A no vote would make no change in state law.

Supporters say the proposed initiative will improve health care and safety for patients and opponents claim it will send costs soaring higher while removing the discretion of hospital managers. The question has been the focus of heavy spending by both sides, with opponents accusing the Massachusetts Nurses Association of trying to force its union agenda on the state while supporters say hospital executives are bankrolling an anti-Question 1 campaign steeped in scare tactics and frivolous claims that they can’t afford to hire more nurses.

According to the proposed ballot question, “the maximum number of patients per registered nurse would vary by type of unit and level of care.” The following breakdown illustrates how the proposed law would work:

• In units with step-down/intermediate care patients: Three patients per nurse;

• In units with post-anesthesia care or operating room patients: One patient under anesthesia per nurse; two patients post-anesthesia per nurse;

• In the emergency services department: One critical or intensive care patient per nurse (or two if the nurse has assessed each patient’s condition as stable); two urgent non-stable patients per nurse; three urgent stable patients per nurse; or five non-urgent stable patients per nurse;

• In units with maternity patients: (a) active labor patients: One patient per nurse; (b) during birth and for up to two hours immediately postpartum: One mother per nurse and one baby per nurse; (c) when the condition of the mother and baby are determined to be stable: One mother and her baby or babies per nurse; (d) postpartum: Six patients per nurse; (e) intermediate care or continuing care babies: Two babies per nurse; (f) well-babies: six babies per nurse;

• In units with pediatric, medical, surgical, telemetry, or observational/outpatient treatment patients, or any other unit: Four patients per nurse;

• In units with psychiatric or rehabilitation patients: Five patients per nurse.

If approved, Question 1 would require health care facilities 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,” reads Question 1. “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 that is in effect on Jan. 1, 2019. The proposed law would take effect after those contracts expire.

“The state Health Policy Commission would be required to promulgate regulations to implement the proposed law,” reads Question 1. “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.”

Question 1 would also require the Health Policy Commission to establish a toll-free telephone that would be used to monitor complaints. A website would also be established, “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,” reads Question 1. “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.”

Question 1’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 Jan. 1, 2019.

Supporters

The Committee to Ensure Safe Patient Care, which was established by the Massachusetts Nurses Association, is the organization that supports Question 1.

“Today in Massachusetts hospitals, there is no law and no limit to guide the number of patients that can be assigned to a nurse at one time, aside from the ICU,” the Committee to Ensure Safe Patient Care states on its website. “Massachusetts hospitals are facing deteriorating patient care conditions, leading to more complications, readmissions and errors, as well as longer hospital stays and real life-threatening risks. The Patient Safety Act will dramatically improve patient safety in Massachusetts hospitals by setting a safe maximum limit on the number of patients assigned to a nurse at one time, while providing flexibility to adjust nurses’ patient assignments based on specific patient needs.”

Opponents

The Coalition to Protect Patients’ Safety is the organization that opposes Question 1. The coalition, which has primarily been funded by the Massachusetts Health and Hospital Association, calls Question 1 “a misguided and dangerous proposal to impose rigid, costly and unproven staffing mandates for registered nurses at every hospital in Massachusetts.”

“It makes no sense to weaken our healthcare system by overriding the professional judgment of nurses and doctors at the bedside,” the Coalition to Protect Patients’ Safety writes on its website. “Staffing decisions should be made by experienced medical professionals, not by government mandate.”

Dispute over costs

According to a recent study by the Health Policy Commission (HPC), Question 1 would have a price tag between $676 million and $949 million. According to the HPC’s website, the independent state agency is “charged with monitoring health care spending growth in Massachusetts” and provides “data-driven policy recommendations.”

“Consistent with this role, we conducted an independent analysis of the potential costs related to mandated nurse-to-patient staffing ratios,” said HPC Chairman Stuart H. Altman in a statement. “Our analysis raises significant questions about the impacts of these ratios on health care costs and spending in the commonwealth.”

Question 1 supporters criticized the HPC’s report and raised questions about the data that was used and the process involved.

“This guess on costs by the HPC is irresponsible and inconsistent and resembles nothing that the HPC has ever done before,” said Massachusetts Nurses Association Executive Director Julie Pinkham in a statement. “This estimates a cost of $300K per nurse FTE, per year, and — like the inflated numbers disputed by hospital executives — there is no independent data source or transparency in these cost estimates.”

— The State House News Service contributed to this report.