Each hospital in California will spend from $200,000 to $2.3 million per year to comply with the state's mandatory nurse-staffing ratios set to take effect next year, according to an analysis released late last month by the Public Policy Institute of California, San Francisco, a not-for-profit research group.
The ratios, required by a first-in-the-nation state law, have sparked fierce debate about the number of patients for whom each nurse can reasonably care. The dispute has intensified with the specter of a nursing shortage, which could threaten hospitals' ability to meet the required standards. However, some recent reports have questioned claims about the severity-or even the existence-of nurse shortages.
The California Healthcare Association, which lobbies on behalf of the state's 470 hospitals, has proposed a minimum standard of one nurse for every 10 patients in medical-surgical units. The California Nurses Association supports a ratio of one nurse for every three patients in such units, arguing that more people will be attracted to the nursing profession if nurses are not so overworked.
Earlier last month, Kaiser Permanente, with 26 hospitals and 6.1 million health-plan members in the state, broke ranks with hospitals and endorsed the standard backed by two unions: the United Nurses Association of California and the Service Employees International Union Nurses Alliance. Together, the unions represent about 10,000 of Kaiser's nurses in California. The unions back a standard of one nurse for every four patients in medical-surgical units.
According to the institute's analysis, which includes previously published data, implementing the nursing association's proposal could cost each hospital more than $2.3 million per year.
In a written statement to the media, CNA President Kay McVay criticized the policy institute's cost estimates as "based on data that are so misleading as to render them analytically worthless." Implementing the ratios may be cost-neutral for California hospitals, McVay argued, and will produce "an enormous public benefit."
There is a lack of evidence, however, supporting the notion that mandatory ratios enhance patient safety, according to a study released last month by the Agency for Healthcare Research and Quality (July 23, p. 4).
"The literature is insufficient to make a reasoned judgment about organization of the work environment of nurses," the report concluded.
After soliciting recommendations from the state's healthcare industry, the California Department of Health Services is expected in September to release draft regulations containing specific ratios. Once final, the regulations are scheduled to become effective Jan. 1, 2002.
Other states are closely following the debate surrounding the California law as they consider similar proposals. In June, Oregon became the second state to pass a law mandating staffing standards. That law requires Oregon's 62 acute-care hospitals to work with nurses to develop appropriate ratios. Oregon's law also limits the amount of overtime nurses can work.
With regard to the Public Policy Institute's cost assessment of California's law, "putting a price tag on various staffing options is a very important start, but we also need more information about the potential benefits of higher ratios on the quality of patient care," said Joanne Spetz, a research fellow at the policy institute. "It's important that we get this right. The rest of the nation is watching California."