Legislation that attempts to reimagine the way hospitals track and enforce staffing levels is on its way to Gov. Jay Inslee's desk after state representatives voted it out of the House last week.
The issue of hospital staffing has remained one of the most difficult topics for the state's health care industry to come to an agreement on in the past few years, particularly during the worst of the pandemic. While both hospital administrators and health care labor unions agree health care systems don't have enough staff and are reaching a breaking point, they have largely disagreed on how best to solve the problem.
The debate has pitted employee burnout against strained hospital finances, while trying to keep patient safety at the center of the conversation.
Last week, state lawmakers officially landed on a compromise: a bill that includes stronger accountability for hospitals when it comes to implementing staffing plans, but doesn't go so far as to mandate strict ratios for how many nurses they should have on duty at any given time. In the United States, only California has approved such nurse-to-patient ratio laws.
"We're very excited this bill has passed overwhelmingly in both chambers [of the Legislature]," said David Keepnews, executive director of the Washington State Nurses Association. "These are issues that we've been working on for quite some time, and I think the bill represents real progress toward the goal of safe staffing."
Chelene Whiteaker, senior vice president of government affairs with the Washington State Hospital Association, called the agreement a "whole new regulatory structure for hospitals" and one the hospital association is ready to support.
The version that House representatives approved does not include specific language requiring statewide, standardized nurse-to-patient ratios — something hospitals adamantly opposed because they said stringent mandates could force them to stop accepting patients if they couldn't maintain the ratios. A nurse-to-patient ratio designates the number of patients a nurse is assigned to during one shift, depending on their department.
"We obviously would have strongly preferred having enforceable standards and ratios in the bill," Keepnews said. Many health care employees feel higher staffing levels mean they can devote more time to each patient, cut back on potential mistakes and take more breaks.
"But legislators wanted to see a compromise, so we and the hospitals entered into that in good faith," he added.
Instead, the bill that will land on Inslee's desk introduces a penalty system — which could include enforced ratios — for hospitals if they don't follow the staffing plans created by their own staffing committees at least 80% of the time.
Hospitals in Washington already have their own committees tasked with planning nurse staffing. But their recommendations are often ignored or vetoed by hospital management with no penalty or negotiation process, according to WA Safe + Healthy, a coalition of health care unions and staffers that has long advocated for strict ratios.
If Inslee approves the bill, hospitals will start tracking how often they're in compliance with their staffing plans, which they will submit annually to the state Department of Health. Per the bill, if a staffing plan is not adopted by a hospital, the hospital's CEO must provide reasons why and either change the plan prior to the hospital's adoption or prepare an alternative plan.
The extra reporting requirements would add work for hospitals, but Whiteaker said she doesn't see it as a "barrier to making this meaningful policy change."
Some hospitals, like smaller, rural ones with less administrative reporting capacity, won't face the same penalties.
Hospitals have until 2025 to create new staffing committees, half of whom are registered nurses who provide direct patient care, and establish final staffing plans.
The legislation does have some limits on when DOH officials can investigate complaints about failures to follow plans, but if DOH investigates and finds a violation, the hospital will be required to submit a corrective plan of action within 45 days. If a hospital doesn't submit a staffing plan, charter or corrective action plan within the designated time frame, it could be fined up to $10,000 per month, according to the bill.
"The new legislation is much clearer on what can trigger an investigation, what the processes are for making a complaint that goes to the staffing committee and really limits what the CEO can veto," Keepnews said.
The bill also includes policies for mandatory overtime and "uninterrupted" meal and rest breaks for staffers, which the state's health care unions have long argued are insufficient.
Now, if a hospital fails to provide appropriate meal and rest breaks more than 80% of the time, or fails to file a quarterly report to the state Department of Labor & Industries, it will be fined between $5,000 and $20,000, depending on the size of the hospital.
"No hospital wants to have to face a financial penalty and also the public image that may be associated with facing a fine," Keepnews said. "But the goal isn't to harm any hospitals financially at all, it's to raise the expectation of accountability."
It's not yet clear if the new requirements will significantly help close staffing gaps in hospitals, but Keepnews argued that the current staffing crisis is one of the main reasons many nurses have left the industry in Washington.
"Inadequate staffing is sort of a vicious cycle," he said. "The poorer that staffing is, the worse working conditions become and the more nurses leave. Improving staffing is going to bring many of those nurses back, but it's also going to mean that as new nurses graduate and go to work, they're going to be facing better working conditions."
Whiteaker, meanwhile, sees the new changes as "the ultimate social experiment," noting that additional work will continue to encourage more people to enter or rejoin the health care industry.
"We see this as a big step forward," Keepnews said. "It's not everything we had pushed for, but we're going to work on implementing this and making it work as well as possible. This is recognition by the Legislature and by everyone that there is a real problem going on and it's in need of solutions."
