HB 1751 2003
1	A bill to be entitled
2	An act relating to the staffing of health care facilities;
3	providing a popular name; providing legislative findings;
4	defining terms; prescribing facility staffing standards
5	relating to nurse-to-patient ratios, staffing plans, and
6	the minimum skill mix; allowing the implementation of
7	higher staffing levels; providing recordkeeping
8	requirements; prohibiting mandatory overtime and excessive
9	duty hours; allowing voluntary overtime work; providing a
10	statement of employee rights; providing for the Agency for
11	Health Care Administration to ensure compliance with the
12	act and to adopt rules; providing an effective date.
13
14	Be It Enacted by the Legislature of the State of Florida:
15
16	Section 1. Popular name.--This act shall be known by the
17	popular name “The Safe Staffing for Quality Care Act."
18	Section 2. Legislative findings.--The Legislature finds
19	that:
20	(1) The state has a substantial interest in assuring that
21	delivery of health care services to patients in health care
22	facilities located within this state is adequate and safe and
23	that health care facilities retain sufficient nursing staff so
24	as to promote optimal health care outcomes.
25	(2) Recent changes in our health care delivery system are
26	resulting in a higher acuity level among patients in health care
27	facilities.
28	(3) Extensive research indicates that inadequate
29	registered-nurse staffing in hospitals can result in increased
30	patient death rates, dangerous medical errors, and increased
31	length of stay.
32	(4) To ensure the adequate protection and care for
33	patients in health care facilities, it is essential that
34	qualified registered nurses be accessible and available to meet
35	the nursing needs of patients.
36	Section 3. Definitions.--As used in this act, the term:
37	(1) “Acuity system” means an established measurement
38	instrument that:
39	(a) Predicts nursing care requirements for individual
40	patients based on severity of patient illness, need for
41	specialized equipment and technology, intensity of nursing
42	interventions required, and the complexity of clinical nursing
43	judgment needed to design, implement, and evaluate the patient's
44	nursing care plan;
45	(b) Details the amount of nursing care needed, both in
46	number of registered nurses and in skill mix of nursing
47	personnel required daily for each patient in a nursing
48	department or unit; and
49	(c) Is stated in terms that can be readily used and
50	understood by direct-care nursing staff.
51	(2) “Assessment tool” means a measurement system that
52	compares the staffing level in each nursing department or unit
53	to actual patient nursing care requirements in order to review
54	the accuracy of an acuity system.
55	(3) “Documented staffing plan” means a detailed written
56	plan setting forth the minimum number, skill mix, and
57	classification of licensed nurses required in each nursing
58	department or unit in the health facility for a given year,
59	based on reasonable projections derived from the patient census
60	and average acuity level within each department or unit during
61	the previous year, the department or unit size and geography,
62	the nature of services provided, and any forseeable changes in
63	department or unit size or function during the current year.
64	(4) “Critical care unit” means a unit of a hospital which
65	is established to safeguard and protect patients the severity of
66	whose medical conditions requires continuous monitoring and
67	complex nursing intervention.
68	(5) “Declared state of emergency” means an officially
69	designated state of emergency which has been declared by a
70	federal, state, or local government official who has the
71	authority to declare that the state, county, municipality, or
72	locality is in a state of emergency, but does not include a
73	state of emergency which results from a labor dispute in the
74	health care industry.
75	(6) “Direct-care nurse” or “direct-care nursing staff"
76	means any registered nurse who has direct responsibility to
77	oversee or carry out medical regimens or nursing care for one or
78	more patients. Only registered nurses who have specific patient
79	care assignments shall be included in the calculation of the
80	registered nurse-to-patient ratio.
81	(7) “Health care facility” means an acute care hospital;
82	an emergency care, ambulatory, or outpatient surgery facility
83	licensed under section 395.003, Florida Statutes; or a
84	psychiatric facility licensed under chapter 394, Florida
85	Statutes.
86	(8) “Nurse” means a registered nurse.
87	(9) “Nursing care” means care that falls within the scope
88	of practice set forth in chapter 464, Florida Statutes, and
89	other laws and regulations or that is otherwise encompassed
90	within recognized professional standards of nursing practice,
91	including assessment, nursing diagnosis, planning, intervention,
92	evaluation, and patient advocacy.
93	(10) “Off-duty" means that the individual has no
94	restrictions placed on his or her whereabouts and is free of all
95	restraint or duty on behalf of the health care facility.
96	(11) “On-duty" means that the individual is required to be
97	available and ready to perform services on request within or on
98	behalf of the health care facility and includes any rest periods
99	or breaks during which the individual's ability to leave the
100	health care facility is restricted either expressly or by work-
101	related circumstances beyond the individual's control.
102	(12) “Overtime" means the hours worked in excess of any of
103	the following:
104	(a) An agreed-upon, predetermined, regularly scheduled
105	shift;
106	(b) Twelve hours in a 24-hour period; or
107	(c) Eighty hours in a consecutive 14-day period.
108	(13) “On-call time" means time spent by an employee who is
109	not working on the premises of the place of employment but who
110	is compensated for availability or who, as a condition of
111	employment, has agreed to be available to return to the premises
112	of the place of employment on short notice if the need arises.
113	(14) “Reasonable efforts" in reference to the prohibition
114	on mandatory overtime means that the employer does all of the
115	following but is unable to obtain staff coverage:
116	(a) Seeks individuals to volunteer to work extra time from
117	all available qualified staff who are working;
118	(b) Contacts qualified employees who have made themselves
119	available to work extra time;
120	(c) Seeks the use of per diem staff; and
121	(d) Seeks personnel from a contracted temporary agency if
122	such staffing is permitted by law or an applicable collective
123	bargaining agreement.
124	(15) “Unforeseeable emergent circumstance" means:
125	(a) Any unforseen declared national, state, or municipal
126	emergency;
127	(b) A situation in which a health care facility disaster
128	plan is activated; or
129	(c) Any unforseen disaster or other catastrophic event
130	that substantially affects or increases the need for health care
131	services.
132	(16) “Skill mix" means the differences in licensing,
133	specialty, and experience among direct-care nurses.
134	(17) “Staffing level" means the actual numerical
135	registered nurse-to-patient ratio within a nursing department or
136	unit.
137	Section 4. Facility staffing standards.--
138	(1) SPECIFIC STANDARDS.--Hospitals shall provide staffing
139	by registered nurses in accordance with the following maximum
140	patient assignments in the units specified. Additional
141	registered nurse staffing, auxiliary staffing by nurses other
142	than registered nurses or staffing by other healthcare
143	professionals are not included in these ratios and shall be
144	determined pursuant to the patient classification system as
145	provided in paragraph (b). Nurse-to-patient ratios represent the
146	maximum number of patients which shall be assigned to one
147	registered nurse during one shift. Only nurses providing direct
148	patient care shall be included in the ratios. This section does
149	not prohibit a registered nurse from providing care within the
150	scope of his or her practice to a patient who is assigned to
151	another nurse.
152	(a) There shall be a maximum of two patients assigned to
153	each registered nurse so that the minimum registered nurse-to-
154	patient ratio in a critical care unit must be 1:2 or fewer at
155	any time. As used in this paragraph, the term “critical care
156	unit" means a nursing unit of a general acute care hospital
157	which provides one of the following services: an intensive care
158	service, a burn center, a coronary care service, or an acute
159	respiratory service. In the intensive care newborn nursery
160	service, a maximum of two patients shall be assigned to each
161	registered nurse.
162	(b) The surgical service operating room shall have a
163	maximum of one patient-occupied operating room assigned to each
164	registered nurse.
165	(c) There shall be a maximum of two patients assigned to
166	each registered nurse in a labor and delivery suite of the
167	perinatal service so that the registered nurse-to-patient ratio
168	shall be 1:2 or fewer at any time.
169	(d) There shall be a maximum of two patients assigned to
170	each registered nurse in a labor/delivery unit.
171	(e) There shall be a maximum of three mother-baby couplets
172	assigned to each registered nurse in a postpartum area of the
173	perinatal unit at any time. In the event of multiple births, the
174	total number of mothers plus infants assigned to a single
175	registered nurse shall never exceed six.
176	(f) There shall be a maximum of two patients assigned to
177	each registered nurse in a postanesthesia recovery unit.
178	(g) In a hospital providing basic emergency medical
179	services or comprehensive emergency medical services, there
180	shall be a maximum of three patients who are receiving emergency
181	treatment assigned to each registered nurse so that the
182	registered nurse-to-patient ratio in an emergency department
183	shall be 1:3 or fewer at any time patients are receiving
184	treatment. There shall be no fewer than two registered nurses
185	physically present in the emergency department when a patient is
186	present.
187	(h) The nurse assigned to triage patients shall not have a
188	patient assignment, shall not be assigned responsibility for the
189	base radio, and shall not be counted in the registered nurse-to-
190	patient ratio.
191	(i) When nursing staff are attending critical care
192	patients in the emergency department, there shall be a maximum
193	of two patients assigned to each registered nurse. When nursing
194	staff in the emergency department are attending trauma patients,
195	there shall be a maximum of one patient assigned to each
196	registered nurse at any time.
197	(j) There shall be a maximum of three patients assigned to
198	each registered nurse in a step-down unit so that the minimum
199	registered nurse-to-patient ratio shall be 1:3 or fewer at any
200	time. As used in this paragraph, the term:
201	1. “Artificial life support" means a system that uses
202	medical technology to aid, support, or replace a vital function
203	of the body which has been seriously damaged.
204	2. “Step-down unit" means a unit that is organized,
205	operated, and maintained to provide for the monitoring and care
206	of patients with moderate or potentially severe physiologic
207	instability requiring technical support but not necessarily
208	artificial life support.
209	3. “Technical support" means specialized equipment or
210	personnel, or both, providing for invasive monitoring,
211	telemetry, and mechanical ventilation, for the immediate
212	amelioration or remediation of severe pathology for those
213	patients requiring less care than intensive care but more than
214	that which is available from medical/surgical care.
215	(k) There shall be a maximum of three patients assigned to
216	each registered nurse so that the minimum registered nurse-to-
217	patient ratio in a telemetry unit shall be 1:3 or fewer at any
218	time. As used in this paragraph, the term "telemetry unit" means
219	a unit designated for the electronic monitoring, recording,
220	retrieval, and display of cardiac electrical signals.
221	(l) There shall be a maximum of four patients assigned to
222	each registered nurse so that the minimum registered nurse-to-
223	patient ratio in medical/surgical care units shall be 1:4 or
224	fewer at any time. A medical/surgical unit is a unit with beds
225	classified as medical/surgical in which patients who require
226	less care than that which is available in intensive care units
227	or step-down units receive 24-hour inpatient general medical
228	services, postsurgical services, or both general medical and
229	postsurgical services. Such a unit may include mixed patient
230	populations of diverse diagnoses and diverse age groups.
231	(m) There shall be a maximum of four patients assigned to
232	each registered nurse so that the minimum registered nurse-to-
233	patient ratio in a specialty care unit shall be 1:4 or fewer at
234	any time. A specialty care unit is a unit that is organized,
235	operated, and maintained to provide care for a specific medical
236	condition or a specific patient population, is more
237	comprehensive for the specific condition or disease process than
238	that which is available on medical/surgical units, and is not
239	otherwise specifically covered in this section.
240	(n) There shall be a maximum of four patients assigned to
241	each registered nurse so that the minimum registered nurse-to-
242	patient ratio in an acute care psychiatric unit shall be 1:4 or
243	fewer at any time.
244	(o) Identifying a unit by a name or term other than those
245	used in this subsection does not affect the requirement to staff
246	at the ratios identified for the level or type of care described
247	in this subsection.
248	(2) STAFFING PLAN.--To ensure that it is staffed in a
249	manner that provides sufficient, appropriately qualified nursing
250	staff of each classification in each department or unit within
251	the facility in order to meet the individualized care needs of
252	the patients therein and to meet the requirements for registered
253	nurse staffing set forth in subsection (1), each health care
254	facility licensed under this statute shall annually submit to
255	the Agency for Health Care Administration a documented staffing
256	plan, together with a written certification that the staffing
257	plan is sufficient to provide adequate and appropriate delivery
258	of health care services to patients for the ensuing year. The
259	staffing plan must:
260	(a) Meet the minimum requirements set forth in subsection
261	(1);
262	(b) Be adequate to meet any additional requirements
263	provided by other laws or regulations;
264	(c) Employ and identify an approved acuity system for
265	addressing fluctuations in actual patient acuity levels and
266	nursing care requirements requiring increased staffing levels
267	above the minimums set forth in the plan;
268	(d) Factor in other unit or department activity, such as
269	discharges, transfers and admissions, and administrative and
270	support tasks, which is expected to be done by direct-care
271	nurses in addition to direct nursing care;
272	(e) Identify the assessment tool used to validate the
273	acuity system relied on in the plan;
274	(f) Identify the system that will be used daily to
275	document actual staffing within each department or unit;
276	(g) Include a written assessment of the accuracy of the
277	previous year's staffing plan in light of actual staffing needs;
278	(h) Identify each nurse staff classification referenced
279	therein together with a statement setting forth minimum
280	qualifications for each such classification; and
281	(i) Be developed in consultation with the direct-care
282	nursing staff within each department or unit or, if such staff
283	is represented, with the applicable recognized or certified
284	collective-bargaining representatives of the direct-care nursing
285	staff.
286	(3) MINIMUM SKILL MIX.--The skill mix reflected in a
287	staffing plan must assure that all of the following elements of
288	the nursing process are performed in the planning and delivery
289	of care for each patient: assessment, nursing diagnosis,
290	planning, intervention, evaluation, and patient advocacy.
291	(a) The skill mix may not incorporate or assume that
292	nursing care functions required by licensing law or regulations
293	or accepted standards of practice to be performed by a
294	registered nurse or licensed practical nurse are to be performed
295	by unlicensed assistant personnel.
296	(b) A nurse may not be assigned, or included in the count
297	of assigned nursing staff for purposes of compliance with
298	minimum staffing requirements, in a nursing department or unit
299	or a clinical area within the health facility unless the nurse
300	is qualified in the area of practice to which the nurse is
301	assigned.
302	(4) COMPLIANCE WITH PLAN.--As a condition of licensing, a
303	health care facility must at all times staff in accordance with
304	its staffing plan and the staffing standards set forth in this
305	section; however, this section does not preclude a health care
306	facility's implementing higher direct-care nurse-to-patient
307	staffing levels.
308	(5) RECORDKEEPING.--The facility shall maintain records
309	sufficient to allow the agency to determine the daily staffing
310	ratios and skill mixes that the facility maintained on each
311	unit.
312	Section 5. Mandatory overtime and excessive duty hours.--
313	(1) PROHIBITION OF MANDATORY OVERTIME.--An employee of a
314	health care facility may not be required to work overtime as
315	defined in section 3 of this act. Compelling or attempting to
316	compel an employee to work overtime is contrary to public policy
317	and is a violation of this section. The acceptance by any
318	employee of overtime work is strictly voluntary, and the refusal
319	of an employee to accept such overtime work is not grounds for
320	discrimination, dismissal, discharge, or any other penalty;
321	threats of reports for discipline; or employment decisions
322	adverse to the employee.
323	(2) APPLICABILITY.--This section does not apply to work
324	that occurs:
325	(a) Because of any unforeseeable emergent circumstance;
326	(b) During prescheduled on-call time if, as of July 1,
327	2003, such prescheduled on-call time was a customary and
328	longstanding practice in the unit or department of the health
329	care facility; or
330	(c) Because of unpredictable and unavoidable occurrences
331	relating to health care delivery which occur at unscheduled
332	intervals and require immediate action, if the employer shows
333	that the employer has exhausted reasonable efforts to obtain
334	staffing. An employer has not used reasonable efforts if
335	overtime work is used to fill vacancies resulting from chronic
336	staff shortages.
337	(3) This section does not prohibit a health care employee
338	from voluntarily working overtime.
339	Section 6. Employee rights.--
340	(1) RIGHT TO REFUSE ASSIGNMENT UNDER CONDITIONS THAT WOULD
341	VIOLATE STANDARDS.--A health facility covered by this act shall
342	not penalize, discriminate against, or retaliate in any manner
343	against a direct-care registered nurse for refusing an
344	assignment that would violate requirements set forth in this
345	act.
346	(2) RIGHT TO REPORT VIOLATIONS OF SAFE STAFFING
347	STANDARDS.--A health facility covered by this act shall not
348	penalize, discriminate against, or retaliate in any manner
349	against an employee with respect to compensation, terms, or
350	conditions or privileges of employment if such an employee in
351	good faith, individually or in conjunction with another person
352	or persons:
353	(a) Reports a violation or suspected violation of this act
354	to a public regulatory agency, a private accreditation body, or
355	management personnel of the health care facility;
356	(b) Initiates, cooperates, or otherwise participates in an
357	investigation or proceeding brought by a regulatory agency or
358	private accreditation body concerning matters covered by this
359	act;
360	(c) Informs or discusses with other employees, with
361	representatives of the employees, with patients or patient
362	representatives, or with the public violations or suspected
363	violations of this act; or
364	(d) Otherwise avails himself or herself of the rights set
365	forth in this act.
366	(3) For purposes of this section, an employee is acting in
367	good faith if the employee reasonably believes that the
368	information reported or disclosed is true and that a violation
369	has occurred or may occur.
370	Section 7. Implementation and enforcement.--
371	(1) The Agency for Health Care Administration shall ensure
372	general compliance with the staffing plans and standards set
373	forth in this act. The agency may adopt such rules as are
374	necessary to implement this act. At a minimum, the rules must
375	provide for:
376	(a) Unannounced, random compliance site visits to licensed
377	health care facilities that are covered by the act;
378	(b) An accessible and confidential system by which the
379	public and nursing staff can report a health facility's failure
380	to comply with this act;
381	(c) A systematic means for investigating and correcting
382	violations of the act;
383	(d) A graduated system of penalties, including fines,
384	withholding of reimbursement, suspension of admission to
385	specific units, and other appropriate measures, if violations
386	are not corrected;
387	(e) Public access to information regarding reports of
388	inspections, results, deficiencies, and corrections.
389	(2) The agency shall develop rules to administer this act
390	which require compliance with the staffing standards for
391	critical care units by July 1, 2004, and compliance with all
392	provisions of this act by July 1, 2006.
393	Section 8. This act shall take effect July 1, 2003.