Minnesota Hospital Association

Policy & Advocacy

Hospitals and nurses share the same goal — delivering safe patient care

The Nurse Staffing Plan Disclosure Act

In 2012, the Minnesota Nurses Association (MNA), an affiliate of National Nurses United (NNU), introduced legislation that would have imposed a government mandated nurse-to-patient quota in every Minnesota hospital. The MNA and NNU continue to pursue government-mandated quotas in states throughout the country via legislation and ballot initiatives.

Staffing decisions are best made at your local hospital by health care professionals closest to the bedside

  • Minnesota legislators in 2013 rejected the idea of a government-imposed mandate, recognizing that health care staffing decisions should made by health care professionals closest to the bedside at their local hospitals. Instead, a compromise was reached among legislators, the Minnesota Hospital Association and the nurses’ union to provide for greater transparency and reporting of nurse staffing levels in Minnesota hospitals.
  • Required the public reporting of hospital staffing levels, and
  • A study by the Minnesota Department of Health on the correlation between nurse staffing levels and patient outcomes. 

Since the passage of this legislation, MHA staff and hospitals have been working hard to implement the provisions of the law — all without any state resources:

  • Preparation of individual hospital nurse staffing plans. This required statewide hospital agreement on how hospital units would be clearly and consistently defined and how to account for hospital swing beds and observation patients.  
  • Sharing those staffing plans with key hospital employees.
  • The annual nurse staffing plans are to be posted on the Minnesota Hospital Association's quality website, www.mnhospitalquality.org, beginning April 1, 2014.
  • Hospitals are required to, on a quarterly basis, report how their actual nurse staffing levels and patient census compared to their nurse staffing plans. This information has been posted online since July 1, 2014 and is updated quarterly.

The Minnesota Hospital Quality Report website displays the following data:

  • Each unit within each hospital and the name of the unit (such as 3 West); the type of unit (for example, medical or ICU). A list of types of units was developed using the descriptions of the Labor Management Institute as a guideline, while also allowing a hospital to write in a name of a unit if it is not on the list. In addition, a “Critical Access Hospital mixed unit” was included.
  • Today’s health care is delivered by a team to meet the needs of the patient. Though not required by law, MHA has included a list of other members of the patient care team who are available on the unit.
  • Full time equivalent/hours worked per 24-hour period split by: Nurses and other assistive personnel
  • Average number of patients per 24-hour period
  • Worked hours per patient day (calculated)

Minnesota Department of Health’s Nurse Staffing Patient Outcomes Study

The law describes the study this way:

“The Department of Health shall convene a workgroup to consult with the department as they study the correlation between nurse staffing levels and patient outcomes. This report shall be presented to the chairs and ranking minority members of the Health and Human Services Committees in the House of Representatives and the Senate by January 15, 2015.”

  • The Minnesota Department of Health convened a work group comprised of three hospital representatives, three MNA representatives and other individuals with backgrounds in higher education, patient safety, and one consumer representative. The work group held five public meetings.
  • From the beginning of the work group, MHA representatives stressed that MDH could do the study using already publicly reported quality information. Given the breadth and depth of quality data that is already publicly reported, MHA asked MDH not to seek additional data from hospitals. In an effort to collaborate with MDH, MHA communicated in persion with MDH staff and with the Commissioner and in writing on at least a half dozen occasions.
  • MDH asked 39 hospitals for data from 2013. After surveying its members about whether it was possible to collect the staffing data from 2013, MHA informed MDH that for many of its members it would be impossible to provide the data MDH was seeking because the new law went into effect in 2014 and therefore hospitals had not been collecting the staffing data MDH wanted in 2013. In addition, MHA informed MDH that conducting the study based on a subset of MN hospitals was not called for in the legislation.
  • MDH also sought to match patient outcomes to staffing levels, however, publicly available outcomes data are exclusively collected at the hospital level, not at the unit level. Obtaining more granular staffing data at the unit and even shift level does nothing to change the fact that reporting of quality outcomes are at the hospital level. In other words, even with staffing data by unit, MDH would not have outcome or quality data for the unit.

MDH's Nurse Staffing and Patient Outcomes report

  • As part of its study, MDH reviewed a number of studies on nurse staffing and patient outcomes. In his cover letter to legislators, Commissioner of Health Ed Ehlinger states:

“At this point, available studies do not prove causal relationship, or indicate that changes in patient outcomes are solely the result of nurse staffing decisions; they also do not identify points at which staffing levels become unsafe or begin to have negative effects on outcomes.”

Further, the report states:

“While the literature has demonstrated the correlation between nurse staffing volumes and certain outcomes, it has not yet established an increase in nurse volume will inevitable product [sic] changes in outcomes – or the pretense of a causal relationship. In addition, the published evidence doesn’t provide specific nurse staffing levels that will lead to certain patient outcomes, or suggest particular staffing models that might be more effective in improving patient outcomes. ” p. 4.

“…there have been no randomized controlled trials or studies using random assignment of nurse staffing levels to certain hospitals to study patient outcomes. Without this specific approach, it is not possible to determine the most appropriate staffing configuration or at which level nurse staffing is correlated with better or worse patient outcomes.” p. 5.

Hospitals agree that staffing is important to quality

  • Quality and safe patient care is delivered by a care team that includes more than nurses – physicians, nursing assistants, therapists such as PT or respiratory, dietitians, and more.
  • Conducting his own analysis of hospital quality measures and staffing, a health and quality expert from the University of St. Thomas showed that there is only a weak correlation, and it is not possible to determine the ideal mix or number of care providers -- including all of the other members of the care team such as physicians or nursing assistants -- for a given workload of patients.
  • The condition of the patient, the experience of the care team, and the mix of the care team has as much to do with patient outcomes – if not more – as the number of nurses.
  • There are hundreds of academic studies regarding nurse staffing that do not reach a definitive conclusion of the number of nurses needed to achieve the best patient outcomes. There are studies that also look at other factors such as the length of shifts, the experience and education level of the nurse, and the skill mix of the care team as having as much or more to do with patient outcomes.
  • However, despite multiple studies by academic researchers throughout the country, no one has identified a definitive staffing level required to ensure quality outcomes for patients. Instead, staffing is inherently dynamic and constantly adjusted based on factors such as: the particular needs of the individual patient; the experience level of the nursing staff, physicians and other members of the care team; the physical layout of the specific unit; and a whole host of other variables. Moreover, staffing levels are just one factor in a multitude of drivers that determine patient outcomes.

MNA/NNU continue to campaign for a government mandated quota

  • Hospital staffing,of course, plays a role in patient outcomes. However, despite multiple studies by academic researchers throughout the country, no one has identified a definitive staffing level required to ensure quality outcomes for patients.
  • There are many variables to consider in terms of what constitutes safe, efficient staffing for a particular hospital unit. Every patient care unit is different based upon the types of patients cared for on that unit, and the way in which care is organized and delivered.
  • Staffing for individual units can vary based on the education and experience level of the staff, support from nurse educators and nurse managers on a given unit, as well as on the unique characteristics and mission of the hospital.
  • Minnesota hospitals have processes in place to appropriately staff each unit. To ensure safe, high quality care, hospital staffing models are developed and implemented to adjust and flex up and down on the basis of patient needs and the experienced judgment of the nurses on the unit.
  • Staffing is a collaborative process; a mandated fixed quota doesn’t allow that flexibility and innovation in a care team.
  • Every day, nurse leaders work with bedside and charge nurses to appropriately staff units based on individual patient needs and on the training, experience and capabilities of the care team. 

Nurses empowered to improve whiteboards for better communication

Inpatient teams across Fairview have focused on implementing effective whiteboard communication. RNs Kay Rowles and  Nicky Breen have taken this work to a whole new level at University of Minnesota Medical Center, Fairview.  

After six months of research, discussions, tests and recommendations, new whiteboards are being put in place in units on the East and West banks.  

“We researched how other hospitals designed and used their whiteboards and gathered feedback from patients and their families as well as staff members,” Kay says. “There were a lot of ideas and drafts of what the whiteboards should look like and what they needed to have on them.”      

Communicating pain  

One of the issues they struggled with was the pain management section of the whiteboards. In the past, patients’ pain levels were noted on the boards by either smiling/frowning faces or a number scale.          

“Research shows that those tools are not necessarily helpful for all patients, and it isn’t a good method of pain management,” Kay explains.  

Working with  Deb Drew, advanced practice nurse leader in the Pain Management Center, Kay and Nicky learned that setting a pain management goal by asking the patient, “What is the pain stopping you from doing?” is a more realistic method. If a goal for the patient is to be up and walking and the pain is preventing that from happening, it needs to be noted and treated.      

Transforming care at the bedside  

Nicky and Kay’s work originated through their efforts with the Transforming Care at the Bedside (TCAB) team, a national 18-month initiative involving 23 hospitals in Minnesota and Wisconsin to find efficiencies that improve patient care and cut costs.  

“Embedded within the TCAB program is the basic concept that front-line staff know best regarding what can help them do their work more efficiently and, equally as important, have a positive impact on patients and families,” says  Marjorie Page, vice president of adult services.  

“We brainstorm—or go ‘snorkeling,’ as we call it—for ideas that make things better for patients, family members and staff,” Nicky continues. “These newly designed whiteboards give us multiple ways of communicating— between the nurses, between nurses and doctors, between staff and with our patients and family members.  

“It helps patients feel they have more control and they can see we’re making sure they are getting consistent attention and quality care,” adds Kay. “This was such exciting work since about 80 percent of the whiteboards will now look exactly the same across all non-ICU adult units,” Marge says. “This is an important tool to help care providers across disciplines enhance communications with the patient and family.”      

Across Fairview  

Across Fairview, inpatient teams are improving whiteboards to reduce anxiety, enhance communication and, ultimately, the patient experience. Though there are standard elements of the whiteboards across sites, they vary somewhat to meet the specific needs of the care setting.  

Fairview Ridges Hospital’s pediatric unit adopted the University of Minnesota Amplatz Children’s Hospital format, which represents best practices for communicating with children and families. In those rooms, the whiteboards flip, presenting the adult information on the opposite side for times when that format is needed.  

Whiteboards are installed or in the process of being installed at all Fairview hospitals, and we’re working to ensure they’re used consistently.

Thanks to Fairview Health Services and the University of Minnesota Amplatz Children's Hospital for contributing this story. © 2012 Farview Health Services.