September 15, 2023
More States Look to Mandate Staffing Ratios As Nurse Burnout Subsists
Implementing many aspects of President Biden’s Increasing Access to High-Quality Care Executive Order, CMS has released a rule mandating staffing ratios in skilled nursing facilities (SNFs). Across state and federal regulations, reducing nurse burnout has been prioritized this year. Burnout is a major threat to patient outcomes, contributing to staffing shortages that result in longer lengths of stay, higher rates of hospital-acquired infections, and additional, avoidable patient deaths. This summer, more states also announced new policy proposals mandating minimum nurse-to-patient staffing ratios, including the AHPA states of Georgia, Illinois and Ohio. While hospital associations argue that staffing laws impede their ability to provide care, lawmakers are hearing from nursing associations that inappropriate, hazardous staffing levels are “the main cause” driving nurses to “leave the bedside in record numbers.”
At the federal level, CMS hopes to reward health systems with lower turnover rates—a major factor for health systems fighting nurse-staffing difficulties. The Agency is adopting a new structural measure in the SNF Value-Based Purchasing program to collect and report on nursing staff turnover. Facilities will begin reporting this measure in FY 2024, to impact payments beginning in FY 2026.
A separate proposed rule on nursing staff ratios would also require nursing homes to provide 2.45 nurse aide hours per resident per day, meaning a ratio of about one aide for every 10 residents. The rule also calls for facilities to have an RN on staff 24 hours a day, every day. Current law requires only that nursing homes have “sufficient” staffing, but it leaves nearly all interpretation to states. CMS hopes this will “drive improvements in nursing staff turnover that are likely to translate into positive resident outcomes.” The American Health Care Association (AHCA) noted that the mandate “requires nursing homes to hire tens of thousands of nurses that are simply not there. It then penalizes us and threatens to displace hundreds of thousands of residents when we can’t achieve the impossible.”
Across the U.S., state policymakers are increasingly exploring mandated nursing staffing minimums. In New York, critical care units will now have to have at least one nurse assigned to every two patients at all 212 state-run hospitals. Georgia’s Safe Staffing Bill would set staffing minimum ratios anywhere from 1:1 for trauma emergency units to 1:6 for postpartum care. In Oregon, legislators are looking to codify specified ratios for 12 types of hospital units and end the “buddy system” that allows nurses to give patients to colleagues in excess of the hospital’s existing nurse-to-patient minimums. Maine administrators will have to navigate a bouquet of mandated minimum ratios, varying based on the setting of care; so might Pennsylvania, depending on whether these states finalize their proposals.
Finding and retaining nursing staff is a major challenge for health care leaders.
Turnover is expensive; the cost of replacing a single RN can be upwards of $60,000, depending on the local labor market. Nursing ratios are one way to reduce burnout, but some hospital administrators argue they increase labor costs to the point of hospital closures. Additionally, given the nationwide shortage of clinicians, it can be difficult to find the staff needed to meet these staffing ratio mandates. Other health system administrators report having actually seen hospital revenues increase dramatically despite mandated nurse-to-patient ratios. According to the California Health Care Foundation, nurse ratios made it easier for the hospital to secure funding.