Mandating nurse staffing ratios

Thompson and Diers (1991) relate: Most hospitals were charging less than their [nursing] costs for room and board.

Many theories have been advanced for this practice, the most likely one being that patients could compare the costs of a hospital ‘room’ with that of a hotel, not realizing the ‘room and board’ included many services not offered by hotels.

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An alternative approach would be to provide a market-based incentive to hospitals to optimize nurse staffing levels by unbundling nursing care from current room and board charges, billing for nursing care time (intensity) for individual patients, and adjusting hospital payments for optimum nursing care. Vol12No03Man01 Key words: nurse staffing; nursing minimum data set; diagnosis related group; cost of care; nursing intensity; health services research; nurse-to-patient staffing ratio; nursing workforce.

The revenue code data, used to charge for inpatient nursing care, could be used to benchmark and evaluate inpatient nursing care performance by case mix across hospitals. In the past several years, there has been a growing need for more registered nurses in hospitals due to rising acuity of patients and shorter lengths of stay.

Traditionally hospitals had used unpaid students to meet most of their staffing needs.

With the influx of more patients coming into hospitals for their nursing care, the hospitals were challenged to incorporate this new cost of registered nurses into their accounting systems.

The method is an adaptation of the original work by Thompson and colleagues who argued for a nursing intensity adjustment for the Diagnosis Related Group (DRG)-based prospective payments to hospitals, which were implemented in 1983 (Thompson, Averill, & Fetter, 1979; Thompson & Diers, 1991).

Incorporating nursing variable costs directly into the billing and reimbursement system could align payment with costs and also provide a new source of nursing data based within the national billing system.

The sicker patients who required these interventions dramatically increased the intensity of nursing care as well as the level of training and expertise needed to care for these more complex patients.

It became more difficult to know how to staff the commonly used, large wards of that era as nursing intensity began to fluctuate more significantly with each new admission.

This article will argue for the benefits of implementing a nursing intensity adjustment for nursing care by briefly reviewing the process by which nurses lost their economic independence; describing the gap between the supply and demand for registered nurses; presenting the arguments for and against mandatory, nurse-to-patient staffing ratios; offering a different approach for increasing the number of registered nurses at the bedside, namely nursing intensity billing; proposing sources of funding to pay for nursing intensity billing; and identifying limitations of nursing intensity billing. This situation has motivated some state legislatures to enact or consider regulatory measures to assure adequate staffing.

These regulatory measures assign some minimum level of staffing that all hospitals must meet regardless of the types and severity of patients.

The modern hospital was born soon after the First World War with the introduction of a myriad of new technologies, such as aseptic surgery, anesthesia, modern pharmaceuticals, x-rays, and laboratories to measure biological functions.

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