California's Minimum Nurse Staffing Legislation: Results from a Natural Experiment

Mark, Barbara A.; Harless, David W.; Spetz, Joanne; Reiter, Kristin L.; Pink, George H.

doi:10.1111/j.1475-6773.2012.01465.x

Cited by 57 publications

(78 citation statements)

References 23 publications

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“…27,28 Given concern that payment reductions may affect staffing levels at hospitals because hospitals cut back on labor inputs in response to financial pressure, 29–32 nine nursing-sensitive patient safety and inpatient quality indicators were created. The California legislature passed Assembly Bill 394 (AB394) mandating minimum licensed nurse-to-patient ratios in October 1999, but this law was not implemented until January 2004 33–35 and should not influence our findings. These nine indicators were death in low mortality DRGs (PSI02), pressure ulcer (PSI03), selected infections due to medical care (PSI07), postoperative hemorrhage or hematoma rate (PSI09), postoperative pulmonary embolism or deep vein thrombosis rate (PSI12), acute myocardial infarction mortality (IQI15), congestive heart failure mortality (IQI16), acute stroke mortality (IQI17), and pneumonia mortality (IQI20).…”

Section: Methodsmentioning

confidence: 91%

“…Thus, they may take actions to sustain quality of care despite DSH reductions. 47 Third, even though California implemented regulations requiring minimum levels of licensed nurse staffing after our study period (e.g., beginning in 2004), 33–35 hospitals may have anticipated this new regulation. Therefore, rather than cutting back on labor inputs in response to DSH payment reductions, hospitals may have maintained or increased their nurse staffing and as a result, quality of care was not affected.…”

Section: Discussionmentioning

confidence: 99%

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Did Budget Cuts in Medicaid Disproportionate Share Hospital Payment Affect Hospital Quality of Care?

et al. 2014

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Background Medicaid Disproportionate Share Hospital (DSH) payments are one of the major sources of financial support for hospitals providing care to low-income patients. However, Medicaid DSH payments will be redirected from hospitals to subsidize individual health insurance purchase through US national health reform. Objectives The purpose of this study is to examine the association between Medicaid DSH payment reductions and nursing-sensitive and birth-related quality of care among Medicaid/uninsured and privately insured patients. Research Design and Method Economic theory of hospital behavior was used as a conceptual framework, and longitudinal data for California hospitals for 1996–2003 were examined. Hospital fixed effects regression models were estimated. The unit of analysis is at the hospital-level, examining two aggregated measures based on the payer category of discharged patients (i.e., Medicaid/uninsured and privately insured). Principal Findings The overall study findings provide at best weak evidence of an association between net Medicaid DSH payments and hospital quality of care for either Medicaid/uninsured or the privately insured patients. The magnitudes of the effects are small and only a few have significant DSH effects. Conclusions Although this study does not find evidence suggesting that reducing Medicaid DSH payments had a strong negative impact on hospital quality of care for Medicaid/uninsured or privately insured patients, the results are not necessarily predictive of the impact national health care reform will have. Research is necessary to monitor hospital quality of care as this reform is implemented.

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Section: Methodsmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Did Budget Cuts in Medicaid Disproportionate Share Hospital Payment Affect Hospital Quality of Care?

et al. 2014

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“…One study found a significant decrease in failure to rescue rates in some Californian hospitals (Mark et al, 2012) but the pattern of difference was not clearly linked to staffing increases. The largest (and significant) decreases in failure to rescue were observed in both hospitals with the worst pre legislation staffing (which had the greatest increase in staffing levels) and in hospitals with the highest pre-legislation staffing levels (which had the smallest staffing increase).…”

Section: E F F E C T I V E a P P R O A C H E S F O R I D E N T I F Y mentioning

confidence: 99%

Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development

Griffiths

Ball

Drennan

et al. 2016

International Journal of Nursing Studies

207

216

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What is already known? A number of high quality reviews establish an association between lower registered nurse staffing levels, increased mortality rates and other adverse outcomes  Careful analysis of this evidence suggests that it is consistent with a causal relationship  Translation of this evidence into practice is disputedWhat this paper adds  This paper summarises and extends a recent systematic review on nurse staffing and outcomes undertaken for England's National Institute for Health and Care Excellence  Methodological limitations mean that existing studies may not give unbiased estimates of the benefits from increased nurse staffing, with over and underestimation of benefit both possible, which makes it difficult to directly translate evidence into guidance for practice. We identify avenues for progressing this important research so that future studies might be better able to provide the evidence needed to inform policy and practice, and provide a checklist to aid future study development AbstractA large and increasing number of studies have reported a relationship between low nurse staffing levels and adverse outcomes, including higher mortality rates. Despite the evidence being extensive in size, and having been sometimes described as "compelling" and "overwhelming", there are limitations that existing studies have not yet been able to address. One result of these weaknesses can be observed in the guidelines on safe staffing in acute hospital wards issued by the influential body that sets standards for the National Health Service in England, the National Institute for Health and Care Excellence (NICE), which concluded there is insufficient good quality evidence available to fully inform practice.In this paper we explore this apparent contradiction. After summarising the evidence review that informed the NICE guideline on safe staffing and related evidence, we move on to discussing the complex challenges that arise when attempting to apply this evidence to practice. Among these, we introduce the concept of endogeneity, a form of bias in the estimation of causal effects. Although current evidence is broadly consistent with a cause and effect relationship, endogeneity means that estimates of the size of effect, essential for building an economic case, may be biased and in some cases qualitatively wrong. We expand on three limitations that are likely to lead to endogeneity in many previous studies: omitted variables, which refers to the absence of control for variables such as medical staffing and patient case mix; simultaneity, which occurs when the outcome can influence the level of staffing just as staffing influences outcome; and common-method variance, which may be present when both outcomes and staffing levels variables are derived from the same survey.Thus while current evidence is important and has influenced policy because it illustrates the potential risks and benefits associated with changes in nurse staffing, it may not provide operational solutions. We conclude by posing a ser...

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“…At an international level, research on the association between the workload of the nursing team and patient safety outcomes includes in the discussion the number of patients assigned to each nurse or nursing assistant and the conditions of the working environment (1,(3)(4)(8)(9)(10)(11) . In Brazil, there is still a long way to go before subsidizing the implementation of the minimum parameters for adequate staffing, as it is established by nursing official organizations in the country (12) with the objective of balancing the number of patients per nursing professional in health institutions.…”

Section: Introductionmentioning

confidence: 99%

Association between workload of the nursing staff and patient safety outcomes

Magalhães

Costa

Riboldi

et al. 2017

Rev. esc. enferm. USP

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Objective:To describe the workload of the nursing team and relate it with patient safety outcomes in clinical and surgical inpatient units of a university hospital. Method: Crosssectional study, carried out from October 2013 to September 2015. The factor under study was the workload, expressed as the ratio between the mean number of patients and the number of nursing professionals in 24 hours and in the day shifts. Results: The sample consisted of 157,481 patients, 502 nursing professionals and 264 observations of safety outcomes. The ratios of patients per nurse and per nursing technician in day shifts indicate a mean estimate of 14-15 and 5-6 patients per professional, respectively. There was a significant association between the workloads in the inpatient units and average length of stay, urinary infection related to invasive procedure and the satisfaction of patients with nursing care. Conclusion: The increase in the workload of the nursing team had an impact on quality of care and safety for patients. An adequate staffing promotes a safer care environment.

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California's Minimum Nurse Staffing Legislation: Results from a Natural Experiment

Cited by 57 publications

References 23 publications

Did Budget Cuts in Medicaid Disproportionate Share Hospital Payment Affect Hospital Quality of Care?

Did Budget Cuts in Medicaid Disproportionate Share Hospital Payment Affect Hospital Quality of Care?

Nurse staffing and patient outcomes: Strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development

Association between workload of the nursing staff and patient safety outcomes

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