What This Bill Does
This bill requires hospitals to establish staffing plans that set minimum numbers of registered nurses assigned to patients during each shift. The bill also protects nurses who refuse unsafe assignments and creates a government process to investigate violations.
##
Who It Affects
* Hospital administrators and staff
* Registered nurses and licensed practical nurses
* Hospital patients
* Medicare and Medicaid programs
* Veterans Affairs, Department of Defense, and Indian Health Services hospitals
* The U.S. Department of Health and Human Services
##
Key Provisions
* Hospitals must implement staffing plans with specific nurse-to-patient ratios depending on hospital unit type. Examples include one nurse per patient in trauma units, two nurses per patient in intensive care units, and four nurses per patient in medical-surgical units. (Sec. 3401(b)(1))
* Hospitals cannot average nurse-to-patient ratios across shifts, cannot require mandatory overtime to meet ratios, and cannot use video monitors or technology to replace direct nurse observation of patients. (Sec. 3401(b)(4))
* Nurses have the right to refuse patient assignments if they believe the assignment violates staffing requirements or if they lack the training to safely care for those patients without being punished by the hospital. (Sec. 3405(c) and (d))
* The Secretary of Health and Human Services must establish a toll-free hotline where nurses and patients can report staffing violations, and hospitals must inform patients about this hotline. (Sec. 3405(g))
* Hospitals that violate these requirements can face civil penalties up to $25,000 for the first violation and $50,000 for later violations. Individuals working at hospitals who knowingly violate the law can face penalties up to $20,000. (Sec. 3406(d))
##
What Changes
If this bill becomes law, hospitals will be required to maintain specific numbers of registered nurses assigned directly to patient care based on the type of hospital unit. Hospitals currently without these specific staffing standards must create written staffing plans and update them annually. Hospitals will need to post information about actual nurse staffing in each unit where patients and staff can see it. Nurses gain new legal protections that prevent hospitals from firing or punishing them for refusing unsafe assignments. Medicare and Medicaid will adjust hospital payment amounts to cover the additional costs of meeting these new staffing requirements.
##
Important Definitions
* **Direct care registered nurse**: A person licensed by a state to practice as a registered nurse who provides bedside care to patients. (Sec. 3407(4))
* **Acuity level**: A measurement of how sick patients are and how much nursing care they need, based on the severity of illness, need for equipment, and intensity of nursing work required. (Sec. 3407(1))
* **Competence**: The ability to properly perform nursing duties for specific types of patients according to state nursing laws. (Sec. 3407(2))
* **State of emergency**: An unpredictable event requiring immediate medical care, but not including understaffing or labor disputes. (Sec. 3407(11))
##
Effective Date
Hospitals must implement staffing plans within one year of the law taking effect. Hospitals must meet the specific nurse-to-patient ratios within two years for most hospitals and four years for hospitals in rural areas (as defined in the Social Security Act). (Sec. 3401(a)(2))
II
118TH CONGRESS
1ST SESSION
S. 1113
To amend the Public Health Service Act to establish direct care registered
nurse-to-patient staffing ratio requirements in hospitals, and for other
purposes.
IN THE SENATE OF THE UNITED STATES
MARCH 30, 2023
Mr. BROWN (for himself, Ms. BALDWIN, Ms. WARREN, Mr. PADILLA, Ms.
STABENOW, Mr. MARKEY, and Mr. SANDERS) introduced the following
bill; which was read twice and referred to the Committee on Health, Edu-
cation, Labor, and Pensions
A BILL
To amend the Public Health Service Act to establish direct
care registered nurse-to-patient staffing ratio require-
ments in hospitals, and for other purposes.
Be it enacted by the Senate and House of Representa-
1
tives of the United States of America in Congress assembled,
2
SECTION 1. SHORT TITLE; TABLE OF CONTENTS; FINDINGS.
3
(a) SHORT TITLE.—This Act may be cited as the
4
‘‘Nurse Staffing Standards for Hospital Patient Safety
5
and Quality Care Act of 2023’’.
6
(b) TABLE OF CONTENTS.—The table of contents for
7
this Act is as follows:
8
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•S 1113 IS
Sec. 1. Short title; table of contents; findings.
Sec. 2. Minimum direct care registered nurse staffing requirement.
Sec. 3. Enforcement of requirements through Federal programs.
Sec. 4. Nurse workforce initiative.
(c) FINDINGS.—Congress finds the following:
1
(1) The Federal Government has a substantial
2
interest in promoting quality care and improving the
3
delivery of health care services to patients in health
4
care facilities in the United States.
5
(2) Recent changes in health care delivery sys-
6
tems that have resulted in higher acuity levels
7
among patients in health care facilities increase the
8
need for improved quality measures in order to pro-
9
tect patient care and reduce the incidence of medical
10
errors.
11
(3) Inadequate and poorly monitored registered
12
nurse staffing practices that result in too few reg-
13
istered nurses providing direct care jeopardize the
14
delivery of quality health care services.
15
(4) Numerous studies have shown that patient
16
outcomes are directly correlated to direct care reg-
17
istered nurse staffing levels, including a 2010
18
Health Services Research study that concluded that
19
implementation of minimum nurse-to-patient staff-
20
ing ratios in California has led to improved patient
21
outcomes and nurse retention and a 2014 Agency
22
for Healthcare Research and Quality study that con-
23
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•S 1113 IS
cluded increases in nurse staffing and skill mix lead
1
to improved quality and reduced length of stay at no
2
additional cost.
3
(5) Requirements for direct care registered
4
nurse staffing ratios will help address the registered
5
nurse shortage in the United States by aiding in re-
6
cruitment of new registered nurses and improving
7
retention of registered nurses who are considering
8
leaving direct patient care because of demands cre-
9
ated by inadequate staffing.
10
(6) Establishing adequate minimum direct care
11
registered nurse-to-patient ratios that take into ac-
12
count patient acuity measures will improve the deliv-
13
ery of quality health care services and guarantee pa-
14
tient safety.
15
(7) Establishing safe staffing standards for di-
16
rect care registered nurses is a critical component of
17
assuring that there is adequate hospital staffing at
18
all levels to improve the delivery of quality care and
19
protect patient safety.
20
SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE
21
STAFFING REQUIREMENT.
22
(a) MINIMUM DIRECT CARE REGISTERED NURSE
23
STAFFING REQUIREMENTS.—The Public Health Service
24
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•S 1113 IS
Act (42 U.S.C. 201 et seq.) is amended by adding at the
1
end the following new title:
2
‘‘TITLE
XXXIV—MINIMUM
DI-
3
RECT
CARE
REGISTERED
4
NURSE STAFFING REQUIRE-
5
MENT
6
‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT.
7
‘‘(a) STAFFING PLAN.—
8
‘‘(1) IN GENERAL.—A hospital shall implement
9
a staffing plan that—
10
‘‘(A) provides adequate, appropriate, and
11
quality delivery of health care services and pro-
12
tects patient safety; and
13
‘‘(B) is consistent with the requirements of
14
this title.
15
‘‘(2) EFFECTIVE DATES.—
16
‘‘(A)
IMPLEMENTATION
OF
STAFFING
17
PLAN.—Subject to subparagraph (B), the re-
18
quirements under paragraph (1) shall take ef-
19
fect on a date to be determined by the Sec-
20
retary, but not later than 1 year after the date
21
of the enactment of this title.
22
‘‘(B) APPLICATION
OF
MINIMUM
DIRECT
23
CARE
REGISTERED
NURSE-TO-PATIENT
RA-
24
TIOS.—The requirements under subsection (b)
25
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•S 1113 IS
shall take effect as soon as practicable, as de-
1
termined by the Secretary, but not later than—
2
‘‘(i) 2 years after the date of enact-
3
ment of this title; and
4
‘‘(ii) in the case of a hospital in a
5
rural
area
(as
defined
in
section
6
1886(d)(2)(D) of the Social Security Act),
7
4 years after the date of enactment of this
8
title.
9
‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE-
10
TO-PATIENT RATIOS.—
11
‘‘(1) IN GENERAL.—Except as provided in para-
12
graph (4) and other provisions of this section, a hos-
13
pital’s staffing plan shall provide that, at all times
14
during each shift within a unit of the hospital, and
15
with a full complement of ancillary and support
16
staff, a direct care registered nurse may be assigned
17
to not more than the following number of patients
18
in that unit:
19
‘‘(A) One patient in trauma emergency
20
units.
21
‘‘(B) One patient in operating room units,
22
provided that a minimum of 1 additional person
23
serves as a scrub assistant in such unit.
24
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•S 1113 IS
‘‘(C) Two patients in critical care units, in-
1
cluding neonatal intensive care units, emer-
2
gency critical care and intensive care units,
3
labor and delivery units, coronary care units,
4
acute respiratory care units, postanesthesia
5
units, and burn units.
6
‘‘(D) Three patients in emergency room
7
units, pediatrics units, stepdown units, telem-
8
etry units, antepartum units, and combined
9
labor, deliver, and postpartum units.
10
‘‘(E) Four patients in medical-surgical
11
units, intermediate care nursery units, acute
12
care psychiatric units, and other specialty care
13
units.
14
‘‘(F) Five patients in rehabilitation units
15
and skilled nursing units.
16
‘‘(G) Six patients in postpartum (3 cou-
17
plets) units and well-baby nursery units.
18
‘‘(2)
SIMILAR
UNITS
WITH
DIFFERENT
19
NAMES.—The Secretary may apply minimum direct
20
care registered nurse-to-patient ratios established in
21
paragraph (1) for a hospital unit referred to in such
22
paragraph to a type of hospital unit not referred to
23
in such paragraph if such type of hospital unit pro-
24
vides a level of care to patients whose needs are
25
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•S 1113 IS
similar to the needs of patients cared for in the hos-
1
pital unit referred to in such paragraph.
2
‘‘(3) APPLICATION
OF
RATIOS
TO
HOSPITAL
3
NURSING PRACTICE STANDARDS.—
4
‘‘(A) IN GENERAL.—A patient assignment
5
may be included in the calculation of the direct
6
care registered nurse-to-patient ratios required
7
in this subsection only if care is provided by a
8
direct care registered nurse and the provision of
9
care to the particular patient is within that di-
10
rect care registered nurse’s competence.
11
‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC
12
COMPETENCE.—A hospital shall not assign a di-
13
rect care registered nurse to a hospital unit un-
14
less that hospital determines that the direct
15
care registered nurse has demonstrated current
16
competence in providing care in that unit, and
17
has also received orientation to that hospital’s
18
unit sufficient to provide competent care to pa-
19
tients in that unit.
20
‘‘(C) DUTIES OF THE ASSIGNED DIRECT
21
CARE REGISTERED NURSE.—Each patient shall
22
be assigned to a direct care registered nurse
23
who shall directly provide the assessment, plan-
24
ning, supervision, implementation, and evalua-
25
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•S 1113 IS
tion of the nursing care provided to the patient
1
at least every shift and has the responsibility
2
for the provision of care to a particular patient
3
within his or her scope of practice.
4
‘‘(D) NURSE
ADMINISTRATORS
AND
SU-
5
PERVISORS.—A registered nurse who is a nurse
6
administrator, nurse supervisor, nurse manager,
7
charge nurse, case manager, or any other hos-
8
pital administrator or supervisor, shall not be
9
included in the calculation of the direct care
10
registered nurse-to-patient ratio unless that
11
nurse has a current and active direct patient
12
care assignment and provides direct patient
13
care in compliance with the requirements of this
14
section, including competency requirements.
15
The exemption in this subsection shall apply
16
only during the hours in which the individual
17
registered nurse has the principal responsibility
18
of providing direct patient care and has no ad-
19
ditional job duties as would a direct care reg-
20
istered nurse.
21
‘‘(E) OTHER
PERSONNEL.—Other per-
22
sonnel may perform patient care tasks based on
23
their training and demonstrated skill but may
24
not perform or assist in direct care registered
25
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•S 1113 IS
nurse functions unless authorized to do in ac-
1
cordance with State scope of practice laws and
2
regulations.
3
‘‘(F) TEMPORARY NURSING PERSONNEL.—
4
A hospital shall not assign any nursing per-
5
sonnel from temporary nursing agencies patient
6
care to any hospital unit without such personnel
7
having demonstrated competence on the as-
8
signed unit and received orientation to that hos-
9
pital’s unit sufficient to provide competent care
10
to patients in that unit.
11
‘‘(G) ANCILLARY AND ADDITIONAL STAFF-
12
ING.—The need for additional staffing of direct
13
care registered nurses, licensed vocational or
14
practical nurses, licensed psychiatric techni-
15
cians, certified nursing or patient care assist-
16
ants, or other licensed or unlicensed ancillary
17
staff above the minimum registered nurse-to-pa-
18
tient ratios shall be based on the assessment of
19
the individual patient’s nursing care require-
20
ment, the individual patient’s nursing care plan,
21
and acuity level.
22
‘‘(4) RESTRICTIONS.—
23
‘‘(A) PROHIBITION AGAINST AVERAGING.—
24
A hospital shall not average the number of pa-
25
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•S 1113 IS
tients and the total number of direct care reg-
1
istered nurses assigned to patients in a hospital
2
unit during any 1 shift or over any period of
3
time for purposes of meeting the requirements
4
under this subsection.
5
‘‘(B) PROHIBITION
AGAINST
IMPOSITION
6
OF MANDATORY OVERTIME REQUIREMENTS.—A
7
hospital shall not impose mandatory overtime
8
requirements to meet the hospital unit direct
9
care registered nurse-to-patient ratios required
10
under this subsection.
11
‘‘(C)
RELIEF
DURING
ROUTINE
AB-
12
SENCES.—A hospital shall ensure that only a
13
direct care registered nurse who has dem-
14
onstrated current competence to the hospital in
15
providing care on a particular unit and has also
16
received orientation to that hospital’s unit suffi-
17
cient to provide competent care to patients in
18
that unit may relieve another direct care reg-
19
istered nurse during breaks, meals, and other
20
routine, expected absences from a hospital unit.
21
‘‘(D) APPLICATION OF DIRECT CARE REG-
22
ISTERED
NURSE-TO-PATIENT
RATIOS
IN
PA-
23
TIENT-ACUITY
ADJUSTABLE
UNITS.—Patients
24
shall be cared for only on units or patient care
25
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•S 1113 IS
areas where the direct care registered nurse-to-
1
patient ratios meet the level of intensity, type
2
of care, and the individual requirements and
3
needs of each patient. Notwithstanding para-
4
graph (2), hospitals that provide patient care in
5
units or patient care areas that are acuity
6
adaptable or acuity adjustable shall apply the
7
direct care registered nurse-to-patient ratio re-
8
quired in this section for the highest patient
9
acuity level or level of care in that unit or pa-
10
tient care area, and shall comply with all other
11
requirements of this section.
12
‘‘(E) USE OF VIDEO MONITORS.—A hos-
13
pital shall not employ video monitors or any
14
form of electronic visualization of a patient as
15
a substitute for the direct observation required
16
for patient assessment by the direct care reg-
17
istered nurse or required for patient protection.
18
Video monitors or any form of electronic visual-
19
ization of a patient shall not be included in the
20
calculation of the direct care registered nurse-
21
to-patient ratio required in this subsection and
22
shall not replace the requirement of paragraph
23
(3)(D) that each patient shall be assigned to a
24
direct care registered nurse who shall directly
25
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•S 1113 IS
provide the assessment, planning, supervision,
1
implementation, and evaluation of the nursing
2
care provided to the patient at least every shift
3
and have the responsibility for the provision of
4
care to a particular patient within his or her
5
scope of practice.
6
‘‘(F) USE
OF
OTHER
TECHNOLOGY.—A
7
hospital shall not employ technology that sub-
8
stitutes for the assigned registered nurse’s pro-
9
fessional judgment in assessment, planning, im-
10
plementation, and evaluation of care.
11
‘‘(5) ADJUSTMENT OF RATIOS.—
12
‘‘
[Text truncated for display. Full text available on Congress.gov.]