1. A Toolkit for Implementing HB 346 (ORC § 3727.50 to 3727.57)
Nurse Staffing In Ohio
A Toolkit for Implementing HB 346
(ORC § to )

2. Learning Objectives
After attending this session the participant will be able to:
Describe the role of the Chief Nursing Officer (CNO) in implementing the requirements of HB 346.
Describe the duties of the staffing committee as required in HB 346.
Describe the role of direct care nurses in implementing HB 346 and contributing to the development and once a year review of the hospital-wide nursing services staffing plan.

3. Learning Objectives
Identify methods to aid in successful committee process.
Articulate key metrics and definitions for developing a nursing services staffing plan.

4. The California Experience
Mandatory RN to patient ratios implemented in 2004 after legislation passed and became law in 1999
Key provisions
Hospital must be in continuous compliance
Hospital must utilize patient classification system & staff to required ratios when system requires
Hospital must develop a written staffing plan for each patient care unit that specifies staffing levels for RNs and other licensed and unlicensed staff
The statute was signed by Gov Gray Davis in 1999.
Original implementation date of Jan 1, 2001.
After two delays ultimately implemented Jan. 1, 2004 after final regulations were issued by the California Department of Health Services in the Fall 2003.
Two other provisions:
No more than 50% of the nursing workforce can be comprised of LVNs
Only RNs can be assigned patients in ED, OR and Neonatal ICU.
22 CCR Sec 70217

5. The California Experience
Hospital must maintain detailed documentation of assigned nurses by licensure category on shift-by-shift basis
No more than 50% of licensed nurses can be comprised by LVNs
RN only in Neonatal ICU, ED and OR
22 CCR Sec 70217

6. California Ratios 22 CCR Sec 70217
The ratios highlighted in red have changed (as required under the statute) since the original implementation in 2004.
Earlier this year three changes occurred:
Step-down went from 1:4 to 1:3
Telemetry went from 1:4 to 1:3
Other specialty care went from 1:5 to 1: this includes oncology and dialysis units.
22 CCR Sec 70217

7. Reported California Outcomes
1st study - pre mandated ratios
A Response to California’s Mandated Nursing Ratios, Bolton, Jones, Aydia, Donaldson, Brown, Lowe, McFarland and Haims, in June 2001 J. Nursing Scholarship
2nd Study – 1st year after implementation
Impact of California Licensed Nurse-patient Ratios on Unit Level Nurse Staffing and Patient Outcomes; Donaldson, Bolton, Aydin, Brown, Elashoff, Sandhu in Aug 2005 Policy, Politics and Nursing Practice
3rd Study – 2 years post implementation
Mandated Nurse Staffing Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Post regulation; Bolton, Aydin, Donaldson, Brown, Sandhu, McFarland, & Aronow in November 2007 Policy, Politics and Nursing Practice
What has happened in terms of patient outcomes under the California plan?
Three studies have been conducted utilizing nurse sensitive outcome data derived from the California Nursing Outcomes Database Project. Cal NOC
Cal NOC is similar to the NDNQI database. It was formed as a collaborative by the Association of California Nurse Leaders and ANA/California in The formation was funded through an ANA quality grant (one of the first 6) and work is based on the ANA Nursing Care Report Card for Acute Care developed in 1996.
Participation is voluntary. Currently there are 139 hospitals participating including such large systems as Kaiser, Sutter, the VA and Catholic Healthcare West.
CalNOC vision is:
Building & sustaining a valid and reliable statewide outcomes database.
Conducting research to advance evidence-based interventions to achieve quality.
Synthesizing & disseminating data to shape public policy, practice, & education.
1st Study - A Response to California’s Mandated Nursing Ratios, Bolton, et al
Data on hospital nurse staffing, patient falls and hospital acquired pressure ulcers was collected from June 1998 – June 1999 from 257 nursing units including med-surg, step-down, critical care and observation (Cal NOC database) .
Data showed a wide variation in nurse staffing and patient outcomes indicating a need for additional research.
2nd Study – Impact of California Licensed Nurse-patient Ratios on Unit Level Nurse Staffing and Patient Outcomes; Donaldson,et al. in Aug 2005 Policy, Politics and Nursing Practice
Data from the California Nursing Outcomes Coalition indicated evidence of overall compliance with mandated ratios however data did not reveal significant changes in incidence of patient falls or prevalence of hospital acquired pressure ulcers.
3rd Study - Mandated Nurse Staffing Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Post regulation
Study authored by Bolton, et al.,
Policy, Politics, & Nursing Practice, Vol. 8, No. 4, Nov.(2007)
This article examines the impact of mandated nursing ratios in California on key measures of nursing quality among adults in acute care hospitals. This study is a follow-up and extension of our first analysis exploring nurse staffing and nursing-sensitive outcomes comparing 2002 pre-ratios regulation data to 2004 post-ratios regulation data.
For the current study we used post-regulation ratios data from 2004 and 2006 to assess trends in staffing and outcomes. Findings for nurse staffing affirmed the trends noted in 2005 and indicated that changes in nurse staffing were consistent with expected increases in the proportion of licensed staff per patient. RN hours increased by 20.8% while total direct care hours increased by 7.4%. However anticipated improvements in nursing-sensitive patient outcomes, patient falls and hospital acquired pressure ulcers were not observed.

8. Ohio Safe Nurse Staffing Legislative History
Substitute HB 346 was introduced by Rep. Jim Hughes
HB 346 is a result of collaborative efforts between the founders of the Nursing 2015 initiative:
The Ohio Hospital Association
The Ohio Nurses Association
The Ohio Organization of Nurse Executives
Signed by Gov. Strickland on June 12, 2008
Statute effective date is September 10, 2008
I am preaching to the choir but it is important to underscore the historic collaboration that is taking place and has been the driving force behind this legislation. The state of Ohio has a most unusual hospital and nursing community that is being watched and admired by the rest of the country. And our collaborative work is just beginning. It is incumbent on all of us to make our best good faith efforts to not just implement this statute but to use it as a way to advance safe patient care and the highest quality patient outcomes in the nation.
The next slide has more information about the key target dates.

9. Statute Implementation Timeline
Statute effective date
September 10, 2008
Nursing care committee convenes within 90 days after statute becomes effective or within 90 days after hospital begins treating patients
December 9, 2008
Written nursing services plan shall be implemented within 90 days after nursing care committee convenes or on first day of FY if FY begins within 180 days after nursing care committee convenes
March 9, 2009 or
up to June7, 2009 if FY begins within days of nursing care committee being convened

10. Statute § Definitions
“Direct patient care” – care provided by a nurse with direct responsibility to carry out medical regimens or nursing care for one or more patients.
“Inpatient care unit” - hospital unit, including operating room or other inpatient care are, in which nursing care is provided to patients who have been admitted to the hospital.
“Nurse” – a person who is licensed to practice as a registered nurse under Chapter of the ORC or, if hospital employs LPNs, a person licensed to practice as a licensed practical nurse under that chapter.

11. §3727.51 Establishment of hospital-wide nursing care committee
Convene committee within 90 days of statute effective date ( )
Hospital will select committee members
CNO shall be a member
Minimum 50% of members shall consist of direct care nurses
All types of nursing care services must be represented by direct care nurses
CNO must have mechanism for obtaining input from all direct care inpatient nurses
Role of the CNO:
Be a member of the committee
Provide a mechanism for obtaining input from all direct care inpatient nurses.
Provide leadership within the hospital to establish process for determining types of nursing care services that must be represented and selecting direct care nurses to serve on the committee.
Role of direct care nurses:
Direct care nurses can be called upon to offer their feedback in identifying the types of inpatient nursing care services that require representation and potential nurse representatives to the committee.
Direct care nurses will be asked to participate in providing input via the mechanism established by the CNO.

12. Sample Nursing Care Committee Composition
The statute does not indicate any representatives except the 50% direct care nurses and the CNO.
The hospital has the responsibility to convene the committee and name the committee members.
This is only a sample.

13. Obtaining Input from Direct Care Nurses
Surveys
Pencil and paper
Online
Utilize committee members to design
Unit specific staff meetings
Open staff forums
Open office hours
Solicit s from nurses
Unit rounds
Post drafts online for nurses to review and respond to
Ask members of committee to hold unit meetings to discuss plan development
Seek suggestions from Public Relations, Communications or Human Resources
Role of the CNO
Establish and communicate the mechanism(s) for obtaining feedback from inpatient direct care nurses regarding the nursing services staffing plan recommendations.
Role of direct care nurses
Provide feedback to the CNO
Attend meetings or complete surveys
Discuss staffing with peers and colleagues

14. § Committee Charge
Evaluate hospital’s current nursing services staffing plan if one exists or
Recommend a nursing services staffing plan consistent with current standards established by private accreditation organizations or governmental entities and addresses all of the following:
Selection, implementation and evaluation of minimum staffing levels for all inpatient units that ensure that the hospital has a staff of competent nurses with specialized skills needed to meet patient needs in accordance with evidence-based safe nurse staffing standards;
This section of the statute articulates the role and responsibility of the nursing care committee.

15. §3727.52 Committee Charge The complexity of complete care,
assessment on patient admission,
volume of patient admissions,
discharges and transfers,
evaluation of the progress of a patient’s problems,
the amount of time needed for patient education,
ongoing physical assessments,
planning for a patient’s discharge,
assessment after a change in patient condition, and
assessment of the need for patient referrals;

16. § Committee Charge
Patient acuity and the number of patients for whom care is being provided;
The need for ongoing assessments of a unit’s patients and its nursing staff levels;
The hospital’s policy for identifying additional nurses who can provide direct patient care when patients’ unexpected needs exceed the planned workload for direct care staff.
In order for the committee to function effective and complete it’s initial work of reviewing or recommending a nursing services staffing plan it must work as a team and have a common base of knowledge to work from. Good committee work is essential. Good committee work doesn’t just happen, it requires cultivation and intention.
This will be discussed in more detail later in the program.
A sample committee charter is included in the toolkit. It won’t be discussed during this session but it is available for hospitals to use and modify to meet their needs.

17. §3727.53 Evidence-based staffing plan
Each hospital shall create an evidence-based written staffing plan guiding the assignment of nurses hospital-wide.
Staffing plan must be implemented within 90 days after the hospital-wide nursing care committee is convened, except
If hospital’s next fiscal year starts within 180 days after date committee was convened the plan can be delayed in implementation until the next fiscal year starts.
The role of the CNO:
Providing leadership in the creation of an evidence-based written staffing plan that is a reflection of the work of the nursing care committee and is consistent and in concert with the hospital budget and goals of the hospital and its board of trustees.
Overseeing implementation of the staffing plan within the time frame required in the statute.
The role of the staffing committee:
Assist with the implementation of the staffing plan as needed.
Facilitate peer education about the plan and seek input and feedback from peers before and after the plan is implemented.

18. §3727.53 Evidence-based staffing plan
Staffing plan created under this provision shall, at a minimum, reflect current standards established by private accreditation organizations or governmental entities;
The plan shall be based on multiple nurse and patient considerations that yield minimum staffing levels for inpatient care units that ensure that the hospital has a staff of competent nurses with specialized skills needed to meet patient needs including:
Recommendations of the committee shall be given significant considerations;
The toolkit includes many resources and references including JC standards, other Ohio statutes that impact nurse staffing such as mental health and various professional standards and position statements related to nurse staffing.
These resources are in your toolkit hard copy and will be briefly touched on later in the program.

19. § Annual Review
At least once per year the hospital-wide nursing care committee shall do the following:
Review how the most current nursing services staffing plan does all of the following:
Affects inpatient care outcomes;
Affects clinical management;
Facilitates a delivery system that provides, on a cost-effective basis, quality nursing care consistent with acceptable and prevailing standards of safe nursing care and evidenced-based guidelines established by national nursing organizations.
Make recommendations, based on the most recent review conducted, regarding how the most current nursing services staffing plan should be revised, if at all.
Role of the CNO
Convene the hospital wide nursing care committee in order to conduct the annual review.
Work with the committee to identify and define the metrics, measures and processes that will be utilized by the committee to conduct the annual review consistent with the requirements of the statute.
Role of the nursing care committee
Work collaboratively with the CNO and hospital leadership to identify and define the metrics, measures and process that will be utilized by the committee to conduct the annual review consistent with the requirements of the statute.
Provide feedback

20. §3727.55 Adjusting Staffing Plan
To provide flexibility to meet patient needs, every hospital shall identify a model for adjusting the nursing services staffing plan for each inpatient care unit.
Short term Flexibility
Shift-to-shift or day-to-day
Voluntary overtime
Float Pools
In-house per diem staff
Short term agency
Staff floating
Longer term flexibility
New services or changes in patient types, expansion of beds
What process would be used to evaluate staffing levels to determine if staffing resources require adjustment
This section has generated many questions. This is the exact wording within the statute.
The key to keep in mind with this section, even though it is not as specific as some would like is the first phrase: to provide flexibility to meet patient needs.
That can mean flexibility on a shift to shift or day to day basis as patient volume and workload flucuates. What model is used for these short term fluctuations?
Many hospitals use a variety of methods to respond: voluntary overtime, float pools, in house per diem pools, short term agency or traveler nurses, staff floating.
It can also mean flexibility as patient characteristics, workload and care delivery changes over a longer period of time. And as that happens how is the staffing plan adjusted in response.
For example; if a new approach to glucose control and monitoring is implemented requiring an increase in RN care to diabetic patients, what would be the model for determining if the nursing services staffing plan is in need of adjustment?

21. § Plan distribution
Hospital shall provide copies of its nursing services staffing plan in accordance with both of the following:
A copy of the staffing plan and subsequent changes to the plan shall be provided to each member of the hospital’s nursing staff free of charge.
The staffing plan shall be provided to any person who requests it for a fee not to exceed actual copying costs.
A notice shall be posted In a conspicuous location in the hospital informing the public of the availability of the staffing plan that specifies the appropriate person, office or department to be contacted to review or obtain a copy of the staffing plan.
Role of the CNO
Provide leadership to establish a mechanism for distribution of the staffing plan and subsequent changes to the hospital’s nursing staff.
The plan could be made available on the hospital’s web page so it could be accessed at any time by the nursing staff. This might be the most economical method.
Provide leadership to create and post a conspicuous public notice, identify person or department to assume responsibility for distributing copies of the staffing plan when requested.
Role of the nursing care committee
Share information about the plan and answer questions from peers when possible.
Assist peers in obtaining the staffing plan when needed.
Role of the direct care nurses
Read and review the staffing plan.

22. §3727.57 Collective Bargaining
Nothing in these sections shall be construed to limit, alter, or modify any of the terms, conditions, or provisions of a collective bargaining agreement entered into by a hospital.

23. Questions