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Nurse Staffing Ratios Already Exist in California. How's that Working?

flickr/Travis Wise

Advocates on both side of ballot Question 1 have pointed to California when making their cases for how voters should vote on November 6th. California was one of the first states to pass similar legislation, in 1999.

WCAI’s Kathryn Eident talked with Joanne Spetz, a professor at the Institute of Health Policy Studies at UC San Francisco. She was a consultant to the Massachusetts Health Policy Commission, an independent state agency that looked at the potential costs of the ballot question. Spetz has also studied the impacts of the law in California. Here's a transcript of their conversation, editted for broadcast. To hear an extended version of this conversation, click on the audio below.  

Kathryn Eident: What are some key pieces of the Massachusetts proposal that you think voters should keep in mind?

Joanne Spetz: There are a few differences between the Massachusetts proposal and what happened in California. One difference is that California's regulations were passed by the legislature and instructed the state agency to develop what the ratios would be, and the specific details of the regulations. The ballot question in Massachusetts specifies what the ratios would be in that proposition. For California, if there were to be, at some point, a belief that the ratio regulation should be changed in some way, there is a regulatory process. I'm not quite sure in the Massachusetts ballot question how those would be changed. My guess is it would be another ballot question, but I'm not sure.

Also, Massachusetts regulations are a little bit richer. In California, for example, in medical surgical units, it is one nurse to five patients. In ballot Question 1, it would be one nurse to every four medical surgical patients.

And then the Massachusetts ballot question also has very clear enforcement requirements and penalties for violation, which California does not have.

Kathryn Eident: You've got supporters saying this is going to improve patient safety, but the other side saying Massachusetts already has one of the highest quality of care outcomes. And I think a thing that a lot of us struggle with is, how those are quantified, and if they match as comparisons? Especially because you've looked in California at some of these very issues.

Joanne Spetz: Massachusetts overall does have very good patient outcomes, pretty comparable, or slightly better, than California.

You know in terms of what happened with the ratios in California, there are a few studies that have done pre/post comparisons. A couple of those were done in a project that I was involved in. And then one of them was done by Andrew Cook and Marty Gaynor.

The study by Cook and Gaynor did not find any systematic improvements in patient quality of care, using a whole variety of different measures. Those included things like pulmonary embolism, hospital acquired infections, and the death of a patient after a complication arises. The Cook and Gainer paper, and our papers, found some improvements for some, no improvements for others. A couple got worse. Really, in the end, it was no systematic evidence that, before-vs-after the ratios were implemented, there were improvements in the quality of care.

Kathryn Eident: So much of this conversation has been focused around the potential cost,and there's a range that the commission came up with. I guess it's kind of harder to compare to California, because the implementation took so much longer.

Joanne Spetz: Right yeah. We did not find in California any evidence that there were closures of hospitals or even significant curtailments of services. But California had a long ramp up time, so hospitals had a lot of time to prepare for it. There also was not any stipulation in the California regulations regarding non-registered nurse staff. So it was possible for a hospital to decide to reduce staffing in other departments, and that may be one of the reasons why in California we did not find systematic improvements in patient outcomes. In California, the possibility of laying off other personnel may also have been a reason that our hospitals were able to weather it. There were a couple of financial analysis, and one did suggest that there may have been less growth in the charity care provided by hospitals, and that hospitals that were more impacted by the ratios may have had bigger declines in their operating margins.

Also check out: What to Know About Ballot Question One