By Michael Norton

State House News Service

BOSTON -- The trade group representing nurses is pledging to put the "sweat equity" of its 23,000 members behind a push to impose statutory nurse-to-patient ratios.

Hospital officials are decrying the proposal as running counter to the trend toward a health-care system in which providers are reimbursed based on the quality of care they deliver and patient satisfaction.

The Massachusetts Nurses Association on Monday outlined plans to press for passage of a 2014 ballot proposal if the Legislature does not act by the middle of next year to pass nurse-staffing legislation, which would apply to acute-care hospitals.

The proposal calls for one nurse for every four patients in medical-surgical units. In emergency departments, nurses could care for between one and three patients depending on patient conditions. Nurses in critical-care units would have one or a maximum of two patients, based on the needs of those patients. Hospitals would face a $25,000-per-day fine if they do not meet staffing standards.

According to Massachusetts Hospital Association President Lynn Nicholas, the initiative petition appears to be a "repeat of an arcane idea that has no merit."

"A law requiring a fixed staffing formula contradicts the very principle of patient-centered care," Nicholas said in a statement reacting to the ballot plan. "Making patient-care decisions on the political stage is never a good idea.


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Care focused on the needs of each and every patient means making care decisions at the patient's bedside by nurses, physicians and other members of a professional caregiving team. Patients want decisions about their care made at the bedside, not at the ballot box."

The nurses are indeed turning to the ballot box after failing to pass staffing legislation over the past 15 years. They say industry consolidation has led to reductions in staff and claim Massachusetts hospitals were among the most heavily penalized by Medicare last year for preventable readmission of patients.

According to Nicholas, mandated nurse-staffing ratios are "antithetical" to the movement toward integrated care models under which payments are based on quality of care and patient satisfaction. That movement was emphasized in the 2012 state law aimed at controlling the growth of health-care costs.

"Massachusetts hospitals' core objection to mandated nurse-staffing ratios is that patient care is best determined by the caregiving team at the bedside, not by a government-set fixed formula," she said. "Patient-care staffing decisions should always be based on the best interest of the patient -- not a number. Nurses don't treat numbers, they treat people. Hospitals shouldn't be required to staff by numbers, either."

While the hospital association noted that only one state, California, has prescribed staffing by "government fiat," the nurses association said dozens of studies underscore the need for limits on the number of patients assigned to nurses to avoid mistakes in patient care and preventable re-admissions.

"The research is clear and unequivocal: The most important factor contributing to the health and safety of patients while they are in the hospital is the number of patients your nurse is assigned to care for during his or her shift," said Donna Kelly-Williams, president of the MNA/NNU and one of the 10 original signers of the petition to establish the ballot initiative. "The fact is, patients in our hospitals are at greater risk because they are being forced to share their nurse with too many other patients at the same time."

While state lawmakers have been reluctant to order a solution to the dispute between nurses and hospitals, the nurses association said voters have supported their measure in previous public-opinion polls.

As news of the developing ballot fight spread this week, the Massachusetts Medical Society on Monday released results of a phone survey of 417 Massachusetts adults conducted in May by Anderson Robbins Research. The survey measures satisfaction with and access to health-care services. Findings include:

* Three quarters reported that accessing the care they need is not difficult. 

* Fifty-six percent said they were very satisfied with the health care they received last year, while 28 percent said they were somewhat satisfied. The medical society reported those numbers "have remained highly stable for the past eight years."

* Residents continue to rely on primary-care physicians for opinions about where to go for care, with less than a third having used data available online about health-care quality and cost and most residents unaware that such data is available online.

* Nearly nine in 10 residents have seen their primary-care physician in the past year.

* Two-thirds of respondents indicated they would rather see a medical doctor than a nurse practitioner or a physician's assistant, although two-thirds of respondents also indicated they were very or somewhat likely to make an appointment with a nurse practitioner or physician's assistant in the future. A new state law allows nurse practitioners and physician's assistants to serve as primary-care providers.

* Three in 10 residents reported visiting a hospital emergency department in the past year, up from one quarter in 2012. The survey found that younger residents and those with government-backed insurance were more likely than others to use the emergency department. One-third of those who used the emergency room said a major factor behind their decision was that it was the "easiest place to get care."

* More than six in 10 residents were unable to offer an opinion of accountable care organizations after hearing a brief, generic description. Reactions to limited and tiered health plans remained "generally unfavorable."