HB0392ham001 95TH GENERAL ASSEMBLY

Health Care Availability and Access Committee

Adopted in House Comm. on Mar 06, 2007

09500HB0392ham001 LRB095 05277 DRJ 32282 a

AMENDMENT TO HOUSE BILL 392

AMENDMENT NO. ______. Amend House Bill 392 by replacing everything after the enacting clause with the following:

"Section 1. Short title. This Act may be cited as the Nursing Care and Quality Improvement Act.

Section 5. Findings. The Legislature finds and declares all of the following:

(1) The State of Illinois has a substantial interest in promoting quality care and improving the delivery of health care services to patients in health care facilities in the State.

(2) Recent changes in the health care delivery systems that have resulted in higher acuity levels among patients in health care facilities increase the need for improved safety measures in order to protect patient care and reduce adverse events.

(3) Inadequate and poorly monitored registered nurse staffing practices that result in too few registered nurses providing direct care jeopardize the delivery of quality health care.

(4) Numerous studies have shown that patient outcomes are directly correlated to direct care registered nurse staffing levels.

(5) Requirements for direct care registered nurse staffing ratios will help address the registered nurse shortage in Illinois by aiding in recruitment of new registered nurses and improving retention of registered nurses who are considering leaving direct patient care because of the demands created by inadequate staffing.

(6) Establishing adequate minimum direct care registered nurse-to-patient ratios that take into account patient acuity measures will improve the delivery of quality health care services and patient safety.

(7) Establishing safe staffing standards for direct care registered nurses is a critical component of assuring that there is adequate hospital staffing at all levels to improve the delivery of quality care and protect patient safety.

Section 10. Definitions. In this Act:

"Acuity system" means an established measurement tool that does all of the following:

(1) Predicts nursing care requirements for individual patients based on: the severity of the patient's illness; the need for specialized equipment and technology; the intensity and complexity of nursing interventions required; the complexity of clinical nursing judgment needed to design, implement, and evaluate the patient's nursing care plan; the ability for self-care, including motor, sensory, and cognitive deficits; and the licensure required for care.

(2) Details the amount and complexity of nursing care needed, both in number of nurses and in skill mix of nursing personnel required, on a daily basis for each patient in a nursing department or unit.

(3) Takes into consideration the patient care services provided not only by registered nurses but also by direct care licensed practical nurses and other health care personnel.

(4) Is stated in terms that can be readily used and understood by nurses.

"Department" means the Department of Public Health.

"Direct care registered nurse" means an individual who has been granted a license to practice as a registered nurse and who provides bedside care for one or more patients.

"Director" means the Director of Public Health.

"Employment" includes the provision of services under a contract or other arrangement.

"Hospital" means an entity licensed under the Hospital Licensing Act.

"Nurse" and "registered nurse" mean any person licensed as a registered nurse or a registered professional nurse under the Nursing and Advanced Practice Nursing Act.

"Staffing plan" means a staffing plan required under Section 15 of this Act.

Section 15. Staffing plan required. Not later than one year after the effective date of this Act, each hospital shall implement a written staffing plan that (i) provides for safe, therapeutic, and competent care services, (ii) protects patient safety, and (iii) is consistent with the requirements of this Act.

Section 20. Minimum direct care registered nurse-to-patient ratios.

(a) For the purposes of this Section:

"Assigned" means that the registered nurse has responsibility for the provision of care to a particular patient within his or her scope of practice.

"Declared state of emergency" means a state of emergency that has been declared by the federal government or the head of the appropriate State or local governmental agency having authority to declare that the State, county, municipality, or locality is in a state of emergency, but does not include consistent understaffing.

(b) A hospital's staffing plan shall provide that, during each shift within a unit of the hospital, a direct care registered nurse shall not be assigned to more than the following number of patients in that unit:

(1) One patient in operating room units, trauma emergency units, and for patients receiving conscious sedation, at all times.

(2) Two patients in critical care units, including emergency critical care and intensive care units, newborn intensive care units, labor and delivery units, and post-anesthesia units at all times.

(3) Three patients in ante-partum units, emergency room units, pediatrics units, step-down units, and telemetry units at all times.

(4) Four patients in intermediate care nursery units, specialty care units, medical/surgical units, postpartum (mothers only) units, and acute care psychiatric units at all times.

(5) Five patients in rehabilitation units, skilled nursing units, and well-baby nursery units at all times.

(6) Six patients in postpartum (3 couplets) units and well-baby nursery units at all times.

Registered nurse-to-patient ratios represent the maximum number of patients who may be assigned to one registered nurse at any one time. There shall be no averaging of the number of patients and the total number of registered nurses on the unit during any one shift nor over any period of time. The registered nurse-to-patient ratio must be maintained at all times throughout each shift. Only nurses providing direct patient care shall be included in the ratios.

Staffing for care not requiring a registered nurse is not included within these ratios. Additional staff in excess of these prescribed ratios, including non-licensed staff, shall be assigned in accordance with the hospital's documented patient acuity system for determining nursing care requirements, considering factors that include the severity of the illness, the need for specialized equipment and technology, the complexity of clinical judgment needed to design, implement, and evaluate the patient care plan, the ability for self-care, and the licensure of the personnel required for care.

Nurse administrators, nurse supervisors, nurse managers, charge nurses, and other licensed nurses shall be included in the calculation of the licensed nurse-to-patient ratio only when those licensed nurses are engaged in providing direct patient care. When a nurse administrator, nurse supervisor, nurse manager, charge nurse, or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the calculation of the ratio. Nurse administrators, nurse supervisors, nurse managers, and charge nurses who have demonstrated current competence to the hospital in providing care on a particular unit may relieve nurses during breaks, meals, and other routine, expected absences from the unit.

(c) The names used to identify clinical units in subsection (b) reflect common usage and understanding. Each identified unit provides care to distinct patient types and conditions; each unit provides nursing care in accordance with general direct care registered nursing practice standards and unit-specific standards and competency requirements; and direct care registered nurse staffing levels for each shift in each unit are determined on the basis of patient assessments performed by direct care registered nurses with demonstrated competency on the unit and in accordance with unit-specific standards regarding nursing care requirements for patients served by the unit. These unit-specific characteristics determine the applicable minimum direct care registered nurse-to-patient staffing ratio for each unit.

(d) Identifying a unit by a name or term other than those used in subsection (b) does not affect the requirement to staff at the direct care registered nurse-to-patient ratios identified for the level of intensity or type of care described in this Section.

(e) Patients shall be cared for only on units where the level of intensity, type of care, and direct care registered nurse-to-patients ratios meet the individual requirements and needs of each patient.

(f) Within one year after the effective date of this Act, the Department shall adopt rules providing specific guidance on the implementation of the minimum direct care registered nurse-to-patient ratios. The Department shall adopt these rules in accordance with the Department's licensing and certification rules and other professional and vocational rules under Illinois law.

(g) The Director may apply minimum direct care registered nurse-to-patient ratios established in subsection (b) of this Section to a type of hospital unit not referred to in that subsection (b) if that other unit performs a function similar to the function performed by the unit referred to in subsection (b).

(h) If necessary to protect patient safety, the Director may prescribe regulations that (i) increase minimum direct care registered nurse-to-patient ratios under this Section to further limit the number of patients that may be assigned to each direct care nurse or (ii) add minimum direct care registered nurse-to-patient ratios for units not referred to in subsections (b) and (d).

(i) The requirements established under this Section do not apply during a declared state of emergency if a hospital is requested or expected to provide an exceptional level of emergency or other medical services.

(j) Nursing personnel from temporary nursing agencies shall not be assigned to a patient care unit without having demonstrated clinical and supervisory competence.

(k) The Department shall adopt rules prescribing the time by which the requirements of this Section must be implemented. That time shall be as soon as practicable after the effective date of this Act, but in no event later that 2 years after the effective date of this Act.

Section 25. Development and reevaluation of staffing plan.

(a) In developing the staffing plan, a hospital shall provide for direct care registered nurse-to-patient ratios above the minimum direct care registered nurse-to-patient ratios required under Section 20 of this Act if appropriate, based upon consideration of the following factors:

(1) The number and individualized needs of patients and the acuity level of patients as determined by the application of an acuity system on a shift-by-shift basis.

(2) The anticipated admissions, discharges, and transfers of patients during each shift that impacts direct patient care.

(3) Specialized experience required of direct care registered nurses on a particular unit.

(4) Staffing levels and services provided by other health care personnel in meeting direct patient care needs not required by a direct care registered nurse.

(5) The level of technology available that affects the delivery of direct patient care.

(6) The level of familiarity with hospital practices, policies, and procedures by temporary agency direct care registered nurses used during a shift.

(7) Obstacles to efficiency in the delivery of patient care presented by physical layout.

(b) A hospital shall specify the system used to document actual staffing in each unit for each shift.

(c) A hospital shall annually evaluate (i) its staffing plan in each unit in relation to actual patient care requirements and (ii) the accuracy of its acuity system and shall update its staffing plan and acuity system to the extent appropriate based on that evaluation.

(d) A hospital's staffing plan shall be developed, and subsequent reevaluations shall be conducted, under this Section by a review committee. At least half the members of the review committee shall be unit-specific direct care registered nurses who provide direct patient care. If direct care registered nurses are represented under a collective bargaining agreement, the appointment of those nurse members shall be made by the authorized collective bargaining agent.

(e) A hospital shall submit to the Director its staffing plan and any annual updates under subsection (c).

(f) Nothing in this Act shall be construed to permit conduct prohibited under the National Labor Relations Act or under the Federal Labor Relations Act.

Section 30. Protection of nurses and other individuals.

(a) A nurse may refuse to accept an assignment as a nurse in a hospital if either of the following conditions apply:

(1) the assignment would violate the provisions of Section 15, 20, or 25; or

(2) the nurse is not prepared by education, training, or experience to fulfill the assignment without compromising the safety of any patient or jeopardizing his or her license.

The requirements of this subsection (a) shall apply to refusals occurring on or after the effective date of this Act, except that the requirements of paragraph (2) of this subsection (a) shall not apply to refusals in any hospital before the requirements of Section 15 of this Act apply to that hospital.

(b) A hospital may not discharge, discriminate, or retaliate in any manner with respect to any aspect of employment, including discharge, promotion, compensation, or terms, conditions, or privileges of employment, against a nurse based on the nurse's refusal of a work assignment under subsection (a). The requirements of this subsection (b) shall apply to refusals occurring on or after the effective date of the Act.

(c) A hospital may not file a complaint or a report against a nurse with the appropriate State professional disciplinary agency because of the nurse's refusal of a work assignment under subsection (a). The requirements of this subsection (c) shall apply to refusals occurring on or after the effective date of this Act.

(d) Any nurse who has been discharged, discriminated against, or retaliated against in violation of this Section may bring an action in the circuit court seeking relief as authorized in items (1) through (5) of this subsection. A nurse who prevails in such an action shall be entitled to one or more of the following:

(1) Reinstatement.

(2) Reimbursement of lost wages, compensation, and benefits.

(3) Attorney's fees.

(4) Court costs.

(5) Other damages.

The requirements of this subsection (d) shall apply to refusals occurring on or after the effective date of this Act.

(e) A nurse or other individual may file a complaint with the Director against a hospital that violates the provisions of this Act. For any complaint filed under this subsection, the Director shall do all of the following:

(1) Receive and investigate the complaint.

(2) Determine whether a violation of this Act as alleged in the complaint has occurred.

(3) If such a violation has occurred, issue an order that the complaining nurse or individual shall not suffer any retaliation in accordance with subsection (b), (c), or (f).

(f) A hospital may not discriminate or retaliate in any manner with respect to any aspect of employment, including hiring, discharge, promotion, compensation, or terms, conditions, or privileges of employment, against any individual who, individually or in conjunction with another person or persons, does any of the following:

(1) Reports a violation or a suspected violation of this Act to the Director, a public regulatory agency, a private accreditation body, or the management personnel of the hospital.

(2) Initiates, cooperates, or otherwise participates in an investigation or proceeding brought by the Director, a public regulatory agency, or a private accreditation body concerning matters covered by this Act.

(3) Informs or discusses with other individuals or with representatives of hospital employees a violation or suspected violation of this Act.

The requirements of this subsection (f) shall apply to those actions set forth in paragraphs (1) through (3) of this subsection (f) and occurring on or after the effective date of this Act. The requirements of this subsection (f) shall apply to initiation, cooperation, or participation in an investigation or proceeding on or after the effective date of this Act.

(g) Beginning 18 months after the effective date of this Act, a hospital shall post in an appropriate location in each unit a conspicuous notice in a form specified by the Director that does each of the following:

(1) Explains the rights of nurses and other individuals under this Section.

(2) Includes a statement that a nurse or other individual may file a complaint with the Director against a hospital that violates the provisions of this Act, and provides instructions on how to file such a complaint.

Section 35. Penalties. The Director may impose administrative penalties or suspend, revoke, or place conditional provisions upon a license of a hospital for a violation of any provision of this Act. The Department shall adopt by rule a schedule establishing the amount of an administrative penalty that may be imposed for any violation of Section 15, 20, 25, or 30 of this Act when there is a reasonable belief that safe patient care has been or may be negatively impacted. Each violation of a staffing plan shall be considered a separate violation of this Act. Before imposing a penalty under this Section, the Director shall afford the hospital an opportunity to request a hearing and present evidence on the matter.

In addition to other moneys set aside and appropriated to the Department for nursing scholarships awarded pursuant to the Nursing Education Scholarship Law, revenues collected from administrative penalties imposed under this Act shall be allocated to the Department for that same purpose.".