The signature of California Gov. Gray Davis on a bill mandating minimum nurse-to-patient ratios in the state's hospitals sets in motion a complicated two-year process to write and implement regulations.
That's cold comfort, however, for the state's embattled hospitals, which fought desperately to keep the bill from passing the Legislature, and fought again to stop the governor from signing it.
Defeated and demoralized, California's 475 hospitals must now hope that the state's Department of Health Services takes a reasonable approach to determining how many nurses should be scheduled to work each shift in each unit for each case mix.
The law, the first of its kind in the U.S., extends the state's regulatory power into a new realm in an already highly regulated sector (Sept. 20, p. 3).
Although the American Nurses Association doesn't favor mandated staffing ratios, the California law is bound to elicit interest from other state nurses' groups and regulators.
As the California Nurses Association likes to remind voters and legislators, the state has the second-lowest nurse-population ratio in the U.S. The Dartmouth Atlas of Health Care gives the ratio for California as 2.27 nurses per 1,000 residents. The national average is 3.22.
Davis, a Democrat elected last year with strong union support, signed the bill on Oct. 10, the last day he could. At the same time, he vetoed another bill that would have more heavily regulated nursing homes, saying it was too expensive.
The CNA, which proposed the measure, was ecstatic that Davis signed it. The association predicted that it would play a strong role in its implementation.
"We will go into every hospital in California and see what's appropriate and adequate staffing, and what's not working," said CNA Executive Director Rose Ann DeMoro. "We haven't negotiated a process for implementation. I assume we'll have some form of joint work, either with the Bureau of Registered Nursing or the Department of Health Services."
Health services department spokeswoman Lea Brooks confessed, "There's not too much to say right now. Our department hasn't started the analysis yet."
She produced a timeline showing that the process, including public notice, comment, hearings and legal reviews, will last at least 322 days after the first draft regulations are presented.
In addition, the governor asked that the implementation be delayed a year to give the health services department more time. All parties, including the CNA, have agreed to support a follow-up bill authorizing the delay.
What the nurse-staffing bill means for hospitals is a bit of a hot-potato question, and hospital officials weren't eager to talk about it. Catholic Healthcare West, the largest operator in the state, with 45 hospitals, referred questions to the California Healthcare Association, the state's hospital association.
Jim Lott, executive vice president of the Hospital Association of Southern California, said his members "don't like to come out and speak on the record on this."
Confirming Lott's assertion, spokeswoman Alicia Gonzalez at 396-bed Glendale Adventist Hospital in suburban Los Angeles, referred questions to Lott.
Nathan Nayman, regional vice president of the Hospital Council of Northern and Central California, said hospitals aren't able to talk about specific implications of the law.
"We just know that it is going to increase costs. It will vary hospital to hospital," he said.
Many hospitals put extra money in their 1999-2000 budgets to cover the anticipated costs, he said.
An earlier version of the same legislation that would have mandated specific ratios without going through a regulatory process would have cost the state's hospitals $700 million per year, the CHA estimated.
Nayman called the new law "another unfunded mandate, which the hospital community has had to deal with over and over and over again."
Nayman pointed out that the governor vetoed a bill that would have increased staffing ratios in nursing homes, granted a 5% wage increase and improved worker education, because it would have cost the state's Medicaid program too much money.
"(The nurse staffing) bill would not take money out of the general fund, but there is no money for it, given the financial difficulties that hospitals now face," Nayman said. Further, there aren't any more nurses to be had since the supply of qualified nurses tightened up in Northern California a couple of years ago.
Lott agreed: "If you prescribe more nurses, where are we going to find them in California?"
A little-noticed provision forbids the use of unlicensed personnel to do medically related tasks, he said. "For example, the law would outlaw the use of phlebotomy technicians to draw blood. They're not licensed. We have a class of employees come Jan. 1 whom we won't be able to employ and use."
The prohibition on use of unlicensed personnel still goes into effect on Jan. 1, even though the staffing ratios will be delayed.
The state's hospital association and its regional partners are also likely to play a strong role in formulating the rules, Lott said. They'll work to make sure a "one-size-fits-all" approach isn't adopted, he said.
"There aren't any indications what the administration wants to do on the ratio regulations," he said. "There aren't any specified numbers in the law. It depends on just how tough it wants to be."