Mandated Staffing Ratios

Why Mandated Staffing Ratios are Bad Health Policy

The priority for hospitals is to improve the health of patients as effectively, safely and cost-efficiently as possible. The priority for labor unions is to protect the jobs, compensation and work conditions of their members. These goals aren’t in conflict. In fact, on many core issues – for example, quality care and compensation for nurses – Twin Cities hospitals and nurses are a national role model. Twin Cities hospitals are recognized by objective, third-party experts as among the best in the country. Full-time nurses working in these hospitals are among the highest paid in the country.

So when Twin Cities hospitals and unions representing nurses disagree on a significant issue, it’s important to look at the facts to understand the differences. That’s the case with mandatory staffing. In the 2012 session of the Minnesota Legislature, the Minnesota Nurses Association (MNA) supported legislation that would establish mandatory staffing levels for hospitals. In other words, the government – not on-the-scenes care providers – would determine by law how many nurses are required on every shift and in every hospital unit. 

The MNA’s government mandated approach to staffing ratios is driven by National Nurses United (NNU), a strident union organization with which the MNA is aligned. The NNU has crafted a national strategy to achieve their union goals, including job security for their members. In cases around the country, the NNU approach is the same: Raise concerns about patient safety, accuse hospitals of shortchanging patient care for bottom-line profits and propose government-imposed, mandatory staffing ratios as the solution. 

That may be good union-organizing strategy. It is bad health policy. Here are the facts:

• California imposed mandatory staffing ratios in 2004. If the goal – as NNU states – is to improve high-quality, safe patient care, objective measures reinforce the failure of NNU’s cookie-cutter approach. The most recent evaluation of the Agency for Healthcare Research and Quality ranks Minnesota’s health system as the best in the country. Hospital care is a core strength, according to the report. California’s overall system of care is on the borderline of “weak” and “average,” dragged down by “weak” hospital care measures. Other studies show similar results.
• When cost is the measure, California loses to Minnesota on that count as well. According to Kaiser State Health Facts, hospital expenses per inpatient day are approaching $2,700 in California. They are $1,731 in Minnesota.
• There is so little evidence that mandatory staffing ratios improve the quality of patient care that the Joint Commission suspended its staffing effectiveness standard in 2009 because no correlation was found between staffing levels and patient safety concerns. The Joint Commission is a universally recognized commission that focuses on the evaluation of patient-care processes to assure the highest degree of patient safety and quality outcomes.
• Even the American Nursing Association supports the need for flexibility in setting staffing ratios. It calls for an approach that recognizes changing conditions in every hospital based on the number of patients and the severity of their illnesses, the skills of nurses on duty, the support staff available and the technology the hospital uses to enhance patient care.

Twin Cities hospitals consistently demonstrate that there are better ways to deliver high-quality, safe care while reducing the overall cost. As a chief nurse officer at one Twin Cities hospital said, “Staffing is complex and needs to be flexible to best meet the needs of patients. There are times patients need two full-time nurses. They are that sick. There are other times when one nurse can care for more than one patient. Quality patient care needs to be evidence-based and tailor-made to individual patient situations.”

A June 2010 Star Tribune editorial agreed that government-imposed, mandatory staffing ratios are not a good approach to maintaining quality care and reducing costs. The editorial criticized mandatory staffing ratios, saying the approach ignored “the substantial investments made by Minnesota taxpayers and private healthcare organizations to track outcomes, make measurements available to the public and focus shrinking resources on areas most in need of improvement.”

And the truth is, there are better solutions. Twin Cities hospitals are building patient-centered staffing models around four components: 

Expertise: First and foremost, safe staffing depends on expert staffing. Nurses and other professionals must have the training and knowledge to be able to make the right decision for every patient in every circumstance. That’s a high bar, but one that nurses and other caregivers in Twin Cities hospitals consistently meet.

Technology.  Patients benefit the most when a nurse has the time to interact directly with everyone in his or her care. The investments Twin Cities hospitals have made in technology can free nurses from routine activities and reduce errors while taking advantage of the expertise nurses bring to patient care. 

Teamwork.  Flexibility in staffing creates the opportunity for nurses to work as part of an efficient, effective care-giving inter-professional team. RNs working with physicians, nursing assistants, emergency medical technicians, social workers and case managers are best able to assess the needs of patients and deliver the best care. Teamwork and flexible staffing also allow hospitals to respond to emergencies, making sure that nurses are able to deliver care to the patients actually in the hospital and not just be assigned to units by some arbitrary staffing model.

Collaboration. Minnesota health care earns top ratings for its patient outcomes based on its tradition of collaboration among the entire healthcare community. By tracking outcomes, and sharing best practice information, Twin Cities hospitals determine what systems and procedures are most effective, saving time and money.

To remain a national leader in health care, Twin Cities hospitals will depend on well-compensated nurses to deliver cost-effective, high quality patient care in a dynamic environment. Helping nurses to best do their job means rejecting mandates that interfere with progress and embracing the people, innovation and collaboration that facilitate a level of care patients have to come to expect from Minnesota healthcare.