The following perspective, “I’m Voting “No” on Question 1 – And Here’s Why” was sent to the Mass General community from President Peter L. Slavin, MD, in his monthly message. Dr. Slavin outlines a few of the potential impacts that Question 1 (on the Nov. 6 State Election ballot) will have on patient care and on health care in the state.
I’m Voting “No” on Question 1 – And Here’s Why
The confusion, controversy and concerns swirling around ballot Question 1 – mandated nurse staffing ratios – have intensified in recent weeks, a crescendo that will no doubt continue with the election only a month away. The issue of mandated ratios comes up in most meetings I attend these days and in conversations I have with colleagues, friends and family. I know many in the MGH community are hearing similar questions, and I want to share with you what I have learned about the potential impact of this initiative on patient care and on health care in Massachusetts.
Passage of Question 1 would impose rigid government-mandated nurse staffing ratios in every unit of every hospital – large or small, teaching or community, general or psychiatric – across the state 24 hours a day. On the surface, a prescribed maximum number of patients per nurse may seem like a reasonable idea, but in fact, this proposal would profoundly disrupt our entire health care system and erode access to the kind of high-quality care that patients in this state expect and deserve. This initiative would decimate many community hospitals – especially those struggling financially. It would force the closure of as many as 1,000 much-needed psychiatric beds. It would also have dire downstream consequences for home care, rehabilitation services, long-term care, community health centers, substance use disorder programs and hospice. This ballot proposal with its arbitrary ratios also will have significant negative effects here at the MGH.
Question 1 would disregard the professional judgment of our exceptional nurses.
In the three decades I have been privileged to work at the MGH, I have witnessed and experienced the skill, compassion and talent of nurses who deliver the excellent care that has long been a hallmark of this hospital. We trust our nurses here, and we count on their knowledge, judgment, critical thinking, specialized training and skill to assess, monitor and make the best possible care decisions at any given time. Like other hospitals, the MGH has a range of experience among its nurses. We have significant numbers of nursing students who are training on our units. We also hire many new graduates who are looking to build their careers and shape and develop their practices and competencies by working with and learning from experienced nurses. And we have extraordinary experienced nurses with knowledge and wisdom and the passion to share what they have learned about assessing, responding, managing and delivering compassionate care. Experience, training, competencies, acuity of patients – all these issues must be factored into staffing decisions. A one-size-fits-all approach strips away the flexibility nurses need to make the best decisions for patients. Indeed, every nurse, every patient, every unit and every hospital is different. Nurse staffing is not simply a numbers game. It’s an art – a careful, thoughtful, dynamic balance of ever-changing variables that requires awareness, judgment and experience. Clearly, staffing decisions are best made in the environment of care, in the moment.
Question 1 would exacerbate already-challenging capacity constraints.
If Question 1 passes, hospitals will face fines of $25,000 per day, per violation if they don’t meet the prescribed staffing ratios. Hospitals unable to afford or find the additional nurses required for compliance may choose instead to reduce inpatient bed and/or emergency department capacity to meet the ratios and avoid these fines. Massachusetts already has insufficient mental health and emergency department capacity. Question 1, if it passes, will likely make these capacity challenges worse and further limit patients’ ability to access the care they need.
Question 1 would require hospitals to hire far more nurses than are currently available.
The Massachusetts Health and Hospital Association estimates that hospitals will have to hire nearly 6,000 more nurses in this state to meet the staffing ratios – 4,700 new positions coupled with current statewide nurse vacancy totals of approximately 1,200. The MGH alone will need more than 170 new nurses to meet the required ratios. And because the mandated ratio requirement would go into effect Jan. 1, 2019, hospitals would have less than two months, only 37 business days, to hire, orient and train new nurses – nurses who, in fact, don’t exist in this state right now. Beds, units and perhaps even whole hospitals will have to close because they won’t be able to staff up to the required levels. And in the scramble to recruit more staff, hospitals will likely hire nurses currently employed at non-hospital-based community services and programs – long-term care, home care, substance use disorder programs, nursing homes – which will devastate these vital resources.
Question 1 would increase statewide health care costs.
Two independent research groups estimate the cost of the proposal to be an additional $1.3 billion in the first year and $900 million annually thereafter. Costs for the MGH are projected at $34.1 million a year, and for all Partners hospitals, $141.4 million. These additional expenses would come at a time when our state and our system have been focused on – and successful in – bringing down health care costs.
Those of us who work in health care will no doubt continue to be asked about this ballot question, and I encourage you to be engaged and informed and to understand both the direct impact as well as the unintended consequences of passage. We have created a special site on the MGH Apollo intranet (for MGH employees) with information, fact sheets, talking points, slide decks and reports regarding the ballot question, and we will continue to update this material in the weeks ahead. In addition, information is available at the Coalition to Protect Patient Safety website.
Keeping staffing decisions in the hands of nurses. Preserving access to excellent medical and mental health care in our state. Sustaining the great progress we have made in managing health care costs. That’s why I’m voting “No” on Question 1.
MASSACHUSETTS GENERAL HOSPITAL EMERGENCY DEPARTMENT TO SUFFER UNDER QUESTION 1
Proposal would critically impact emergency departments wait times and decrease access to care
BOSTON, MA – October 10, 2018 – Massachusetts General Hospital (MGH) announced today their opposition to mandated nurse staffing ratios, citing the devastating impacts these rigid government requirements would have on their ability to provide emergency care to patients. Slated to be Question 1 on the ballot this November, these unnecessary and unfounded staffing requirements will dramatically increase emergency room wait times and delay life-saving services in hospitals across the state.
The enormous costs and operational hurdles associated with the nurse staffing ballot question will set MGH back $9.4M in the emergency department alone, and will translate to severely negative impacts in emergency departments. Wait times in the emergency room will dramatically increase, causing delayed services throughout the hospital – including those that are time-sensitive and life-saving. Question 1 will limit capacity in the MGH emergency department by over 100 patients a day.
There are no exceptions to this mandate, even in the event of an unexpected influx of patients – such as a multi-car crash, large fire or tragedies such as the Boston Marathon bombing. According to an independent study by MassInsight and BW Research Partners, mandated nursing staffing requirements would exacerbate the current nursing shortage, which is currently highest in Psychiatric units (7.8%) and in Emergency Departments (7.5%).
The ballot question would require that hospitals across the state, no matter their size or specific needs of their patients, adhere to the same rigid nurse staffing ratios within all patient care areas at all times. The petition does not make allowances for rural or small community hospitals, holding them to the same staffing ratios as major Boston teaching hospitals.
The ballot question is opposed by the American Nurses Association - Massachusetts, Emergency Nurses Association - Massachusetts Chapter, Organization of Nurse Leaders, Infusion Nurses Society, Massachusetts Association of Colleges of Nursing, Academy of Medical-Surgical Nurses’ Greater Boston Chapter, the Western Massachusetts Nursing Collaborative, the Massachusetts College of Emergency Physicians, the Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Massachusetts Council of Community Hospitals, the Conference of Boston Teaching Hospitals, and other healthcare and business leaders across the state.