Minnesota Hospital Association

Policy & Advocacy

MNA's 2013 Nurse Staffing Quota Bill

This legislation isn’t about “standards of care” — it’s about government mandated staffing quotas.

  • Quotas are a one-size-fits-all approach that will move staffing decisions away from bedside and charge nurses who are most familiar with the nursing unit, staff members and patients, and place those decisions in the hands of elected officials and political appointees.
  • Just 64 of Minnesota’s 147 hospitals have MNA contracts, and the Minnesota Nurses Association represents just 20 percent of nurses in the state. Instead of using the bargaining process where the MNA has contracts, MNA is proposing a law that would impact all Minnesota hospitals.

This bill threatens access to care.

  • The union is pushing a one-size-fits-all approach that does not recognize the differences in staffing a 25-bed critical access hospital or a 700-bed Twin Cities hospital.
  • For example, during the flu outbreak this winter one Minnesota hospital devoted an entire floor to flu patients. This required health care professionals to be nimble and have flexibility in staff assignments.
  • What would have happened if quotas had been in place a few years ago when a school bus crash brought dozens of injured students to a hospital emergency room? It is possible those patients would have been diverted to another hospital miles away, putting their safety and care at risk.

The MNA bill will have unintended consequences.

  • Requiring hospitals to hire additional RNs may draw nurses away from positions in long-term care facilities, clinics or other health care settings.
  • A mandate to hire more RNs could mean layoffs or reduced hiring of other important members of the care team, such as LPNs or nursing assistants.That harms patient care and hospitals’ innovations to reduce the overall cost of health care.
  • A government-mandated nurse staffing ratio will increase health care costs across the continuum of care.
  • In California, the only state with a mandated nurse staffing quota, consequences of mandated quotas include: frustrations among nurses over a loss of autonomy; difficulty juggling the logistics of dealing with rigid ratios and other labor laws; the closing of some patient-care units; and diversion of emergency department patients.

We all agree: Minnesota patients deserve hospital care that is delivered to the nation’s highest standards …and Minnesota hospitals already are delivering on that commitment. The Minnesota Nurses Association/National Nurses United bill (SF 471/HF 588) would replace local decision-making by nurse leaders working with bedside nurses and other caregivers with government-imposed staffing quotas. Quotas don’t equal quality.

The American Nurses Association’s “Principles for Nurse Staffing” emphasizes the need for flexibility and to staff according to the acuity of patients as opposed to a fixed number.

  • Minnesota hospitals have processes in place to appropriately staff each unit based on individual patient needs and the training, experience and capabilities of their nurses, nursing assistants, caseworkers, nurse managers, physicians, and other caregivers.
  • To ensure safe, high quality care, hospital staffing models are developed and implemented to adjust and flex up or down on the basis of patient need and the experienced judgment of nurses on the floor.
  • 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.

Minnesota hospitals already deliver the highest quality care in the country at a low cost.

  • The respected federal Agency for Healthcare Research & Quality ranks Minnesota as having the best overall health care quality in the nation, with hospitals contributing to that number one ranking.
  • Minnesota already is ranked in the top quarter of states for its quality of health care and its affordable cost. According to the Centers for Medicaid and Medicare, on average Minnesota hospitals are 9 percent less costly than their national counterparts, while maintaining high quality.

The legislation is a solution in search of a problem. During the time of broad and important health reform, the last thing hospitals need is more government mandates replacing local decision-making.

SF 471/HF 588 is one national union’s drive toward a government-mandated staffing quota in Minnesota

The MNA claims this is not a “ratio” bill but rather sets minimum standards of care.

  • This is false. Professional organizations such as the four organizations cited in the MNA’s bill are not organizations that establish “standards of care” or a “national standard.” This is intentional. The Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) and Association of Operating Room Nurses (AORN) call for ratios. The other two, Emergency Nurses Association (ENA) and American Association of Critical Care Nurses (AACN) call for acuity-based models rather than ratios. The result of this is that — according to the legislation — “in the absence of an evidence based standard” the decision will be made by a “working group” with a super majority of RNs — appointed by the governor — who will ultimately recommend quotas as they said in their Feb. 13 news conference “per unit and per shift.”
  • Linda Hamilton, president of MNA said on Feb. 13 there is a need to staff to “standards of care that have been developed through professional judgment in every hospital, on every shift, in every unit across the state.” That is a quota.
  • The union does not mention the American Nurses Association Principles for Nurse Staffing which emphasizes the need for flexibility and to staff according to the acuity of patients as opposed to a fixed number.

The MNA claims “troubling instances are not reported."

  • Nurses, as a matter of professional licensure, are obligated to report incidents involving unsafe conditions to hospitals as soon as possible. The Minnesota Department of Health can inspect a hospital for safety at any time.

MNA’s president Linda Hamilton said: “there are not enough nurses working on duty.”

  • The Minnesota Department of Health reported in Feb. 2013, that hospital admissions declined for the third straight year yet staffing increased. In fact, full-time equivalent positions grew by 4.2 percent. One-third of the new positions were filled by RNs.

The MNA claims that “minimum standards” would prevent hospital readmissions.

  • “Minimum standards” are quotas, and quotas in California have not been shown to cause an increase in quality.
  • Since 2011 — without this legislation — Minnesota hospitals have prevented 4,000 avoidable hospital readmissions. Members of the care team (which includes other health care professionals in addition to RNs) have focused on five key areas known to be main contributors to avoidable hospital readmissions: comprehensive discharge planning, medication management, patient and family engagement, transition care support, and transition communications.

At its press conference the MNA cited the Minnesota Department of Health’s adverse health events report as a reason for this bill. Are these events a result of inadequate nurse staffing?

  • Absolutely not. Nurse staffing was identified as the root cause in adverse events less than one percent of the time. In 2009, specific staffing questions were added to the Adverse Health Events reporting system to help hospitals identify whether staffing levels contributed to a reportable event. Adverse events are much more often related to failed communication among all team members or breakdowns in the system, such as processes or protocols not being followed.
  • For more information on staffing and adverse health events, see the Minnesota Department of Health’s information: http://www.health.state.mn.us/patientsafety/ae/staffingpatientsafety.pdf
  • In recent research in California, researchers concluded that higher registered nurse staffing per patient day had a limited impact on adverse events in California hospitals.

The MNA’s bill authors say that “Study after study shows proper staffing lowers health care cost.”

This is false. Two studies reported the following:

  • “The large wage increases for California nurses are important to any assessment of the overall impact of California’s staffing legislation and need to be considered by planners and policymakers in other states who are considering the implementation of such ratios. Furthermore, there are as yet unanswered questions about whether the minimum-nurse staffing legislation met the policy goal of improving quality of care.” (Health Affairs, Feb. 10, 2009)
  • “Although the practice is intended to address problems in hospital nurse staffing and quality of patient care, this commentary argues that staffing ratios will lead to negative consequences for nurses involving the equity, efficiency, and costs of producing nursing care in hospitals.” (Nursing Outlook, March/April 2009)

Further, Minnesota already is ranked in the top quarter of states for cost and quality of health care. According to the Centers for Medicare and Medicaid, on average Minnesota hospitals are 9 percent less costly than their national counterparts, while maintaining high quality.

The MNA claims that their bill will reduce health care costs.

  • Mandatory staffing quotas would increase hospital labor costs — TOTAL labor costs, not just nursing costs — by an average of 4 percent. Hospital reimbursement rates already are under pressure from every payer. This additional cost is unaffordable by hospitals and the employers, individuals and taxpayers who pay the cost of health care. It would have two immediate effects: health costs would increase and hospitals would be forced to lay off caregivers and other employees to accommodate the higher costs of registered nurses. Keep in mind, in Twin Cities union hospitals, for example, an MNA nurse earns $44 an hour in salary alone — not including benefits or pension costs. On a full-time basis, that’s $91,500 per year that will have to be found for every additional RN required by these quotas.
  • In addition, a mandated staffing quota will raise costs across the health care continuum because nurses will be drawn away from positions in long-term care facilities, clinics or other health care settings.
  • When California passed its mandated quota bill in 1999, it also appropriated $60 million to expand the supply of nurses at their state institutions of higher learning.

One of the bill’s authors said at the MNA’s press conference that this “legislation puts the decision at the bedside and not at the Capitol.”

This does the exact opposite. It takes decisions away from nurse leaders who work with bedside and charge nurses every day, hour by hour, to staff according to the needs of patients and the mix and skill of the care team and puts it in control of a politically appointed workgroup in St. Paul.