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The official version of any departmental rulemaking activity (notices of proposal or adoption) are published in the New Jersey Register or New Jersey Administrative Code. Should there be any discrepancies between this document and the official version of the proposal or adoption, the official version will govern.
HEALTH AND SENIOR SERVICES
SENIOR SERVICES AND HEALTH SYSTEMS BRANCH
HEALTH FACILITIES EVALUATION AND LICENSING DIVISION
CERTIFICATE OF NEED AND HEALTHCARE FACILITY LICENSURE
PROGRAM
Hospital Licensing Standards
Mandatory Staff Level Posting and Reporting Standards; General
Provisions
Adopted New Rules: N.J.A.C. 8:43G-17A
Adopted Amendment: N.J.A.C. 8:43G-1.2
Proposed: April 16, 2007 at 39 N.J.R. 1363(a).
Adopted: , 2008 by __________________________,
Heather Howard, J.D., Commissioner, Department of Health
and Senior Services (with the approval of the Health Care
Administration Board and in consultation with the Quality
Improvement Advisory Committee).
Filed: , 2008, as R. 2008 d. , without changes.
Authority: N.J.S.A. 26:2H-1 et seq., specifically 26:2H-5h.
Effective Date: , 2008
Expiration Date: , 2010
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Summary of Public Comments and Agency Responses:
The Department of Health and Senior Services (Department)
received written comments prior to the June 15, 2007 close of the 60-day
public comment period from the following:
1. Robyn Begley, RN, MSN CNAA, BC, President, ONE/NJ
(Organization of Nurse Executives), Princeton, NJ
2. Jean Bronock-Zaccone, RN, MPA, Vice President and Chief
Nursing Officer, St. Clare’s Health System, Dover, NJ
3. Edna Cadmus, PhD, RN, CNAA, Sr. VP, Patient Care Services,
Englewood Hospital and Medical Center, Englewood, NJ
4. Ann Campbell, Chief Nursing Officer, Virtua Health Inc., Marlton,
NJ
5. Charlotte Crowe, RN, no address
6. Dr. Dorothy J. DeMaio, Dean and University Professor Emerita,
Rutgers College of Nursing, Far Hills, NJ
7. Geri L. Dickson, PhD, RN, Bloomfield, NJ
8. Lois Dornan, MSN, RN, CPHQ, Director, Clinical Integration,
Robert Wood Johnson Health Network, New Brunswick, NJ
9. Linda Flynn, PhD, RN, Director of Research, New Jersey
Collaborating Center for Nursing and Assistant Professor, Rutgers College
of Nursing, Newark, NJ
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10. Joan Gavin, RN, MS, CNAA, BC, Vice President of Nursing
and CNO, Shore Memorial Hospital, Somers Point, NJ
11. Bernie Gerard, Jr., Vice President, Health Professionals and
Allied Employees, Emerson, NJ
12. Barbara Holfelner, RN, MSN, CNAA, Vice-President, Patient
Care Services and Risk Management, Our Lady of Lourdes Medical
Center, Camden, NJ
13. Aline M. Holmes, Sr. VP, Clinical Affairs and Karen S. Ali,
Acting General Counsel, New Jersey Hospital Association, Princeton, NJ
14. Kim A. Kelly, RN, MS, CNAA, BC, Vice President, Clinical
Services, CentraState Healthcare System, Freehold, NJ
15. Thomas H. Kenney, Executive Secretary-Treasurer, Essex-
West Hudson Labor Council AFL-CIO, Newark, NJ
16. Felissa R. Lashley, RN, PhD, ACRN, FAAN, FACMG, Dean
and Professor, Rutgers College of Nursing, Newark, NJ
17. Carmen Manibo, RN, Christ Hospital, Jersey City, NJ.
18. Nancy Miller, Retirees Staff Liaison and Robert J. Cawley,
Retirees Chair, New Jersey State AFL-CIO Community Services Agency,
Clifton, NJ
19. Stephanie Orrico, RN, BSN, Fair Lawn, NJ
20. Lisa Romano, RN, New Jersey Nurses Union, Livingston, NJ
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21. Muriel M. Shore, EdD, RN, CNAA, Dean and Professor,
Division of Nursing and Health Management, Felician College, Lodi, NJ
22. Carolyn Torre, RN, MA, APN, C., Director of Practice, New
Jersey State Nurses Association, Trenton, NJ
23. Virginia C. Treacy, RN-Executive Director, District Council 1,
IUOE / AFL-CIO, New Brunswick, NJ
24. Susan Vilardi, RN, PHN, Bergenfield Health Department,
Bergenfield, NJ
25. Susanne Walther, APN, no address
26. David H. Weiner, President, Communications Workers of
America (CWA) Local 1081, Newark, NJ
27. Charles Wowkanech, President and Laurel Brennan, Secretary
and Treasurer, New Jersey State AFL-CIO, Trenton, NJ
Form Letters 28 through 38:
28. Carol Aiken, New Jersey Nurses Union, Livingston, NJ
29. Mary Barbes, New Jersey Nurses Union, Livingston, NJ
30. Anthony Caifano, Secretary-Treasurer, Amalgamated
Lithographers of America, New York, NY
31. Noel J. Christmas, President, Utility Workers Union of America
Local Number 601, Bloomfield, NJ
32. Chip Gerrity, President and Business Manager, International
Brotherhood of Electrical Workers Local Union 94, Hightstown, NJ
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33. Laura Korkes, Wayne, NJ
34. Reynaldo Massa, President, CWA Local 1023, Cranford, NJ
35. Charles Mattson, President, Bergen County Central Trades &
Labor Council, AFL-CIO, Paramus, NJ
36. Hetty Rosenstein, President, CWA Local 1037, Newark, NJ
37. Bill Trulby, Business Manager, International Association of
Heat and Frost Insulators and Asbestos Workers, Newark, NJ
38. John R. Wende, Business Manager and Financial Sec-Treas,
Building and Construction and Metal Trades Divisions Pipefitters Local
274, Ridgefield, NJ
Form Letters 39 through 43:
39. Ponciana Javier, RN, no address
40. Maria, RN, no address
41. Illegible name, no address
42. Illegible name, LPN, no address
43. Illegible name, LPN, no address
A summary of the comments and the Department’s responses
follows. The number(s) in parentheses after each comment identifies the
respective commenter(s) listed above.
SECTION 1: General Comments
1. COMMENT: The commenter stated that the proposed
requirements would place an additional burden on its hospital and
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estimated that it would need to add an additional two full time equivalent
positions. (10)
2. COMMENT: The commenter stated that, based on a study at
Lourdes, the proposed requirements would necessitate an estimated
minimum of 30 to 40 minutes of nursing time per day in 18 inpatient units.
The regulation would place additional demands on staff on the off-shift
and weekends when limited leadership is available. The commenter
states that it already incorporates nurse staffing levels in its performance
improvement and patient safety initiatives. (12)
3. COMMENT: The commenter stated that the onerous
regulations would require extensive “nursing/ancillary staff time” to
complete. A pilot study completed by the New Jersey Hospital
Association estimated that the cost to the commenter’s system would be
potentially $350,000 per year or more than one million dollars per year for
its four-hospital system. (2)
4. COMMENT: The commenter stated that the regulation’s burden
to the hospital far outweighs its benefits to the patients and families.
Currently, the facility posts staffing information on white boards on the
inpatient units and staff provides the information verbally when requested.
(3)
5. COMMENT: The commenter stated that its facility currently
posts staffing information at nursing stations and that the proposed
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calculations are meaningless. The compilation and reporting regulations
would require extensive nursing time to complete. Pilot study results
indicated, conservatively, an hour a day to complete forms multiplied by
30 or more nursing units every day of the year, translated into 10,950
hours a year, or approximately an additional five full-time employees. “At
an average annual nursing salary of $70,000, the proposed posting
regulations could result in $350,000 a year in additional hospital
expenditures.” (13) Another commenter supported this position. (12)
6. COMMENT: The commenters stated that the burden of this
unfunded mandate to the hospitals far outweighs the benefits to the
patients and families. Nursing resources could be better and more
appropriately utilized in direct patient care. Currently, on virtually every
nursing unit, the facility posts staffing information at the nursing stations.
(1, 8, 14)
RESPONSE TO COMMENTS 1 THROUGH 6: As stated in the
Notice of Proposal published in the New Jersey Register on April 16, 2007
at 39 N.J.R. 1363(a), the Department promulgated the new rules at
N.J.A.C. 8:43G-17A to implement N.J.S.A. 26:2H-5f, 5g and 5h. N.J.S.A.
26:2H-5g requires general hospitals to compile, post, and report certain
staffing information and the Department is without authority to change the
requirements of a statute.
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7. COMMENT: The commenter suggested reducing the inpatient
posting to one twenty-four hour posting, similar to the Post Anesthesia
Care Unit (PACU) and Emergency Department (ED) requirement. The
commenter also stated that a posting giving the actual staffing over a
period of time (week or month) would be more accurate and far less
cumbersome and costly for hospitals to provide. (10)
RESPONSE: As stated in response to the prior comments, the
proposed new rules implement N.J.S.A. 26:2H-5f, 5g and 5h, which
require “daily” posting of certain staffing information based on each “unit”
and “the end of the prevailing shift.” The Department is without authority
to make the revisions as suggested by the commenter because they
contradict the statute.
SECTION 2: Definitions
8. COMMENT: The commenter stated that in its definition, “direct
patient care” includes only registered nurses (RNs) and nursing
assistants. The commenter does not collect information about physical
therapists (PTs) or respiratory care practitioners (RCPs) within the
Department of Nursing. Because such caregivers float across the
institution and would be difficult to measure on a shift-by-shift basis, the
commenter recommended deleting physical therapists and respiratory
therapists from the definition and other sections of the regulation. (3)
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9. COMMENT: The commenter recommended the deletion of the
terms PT and RCP in the definition of “direct patient care.” The
commenter also recommended the deletion of the proposed regulation,
which requires reporting of staffing for PTs and RCPs because these
individuals may be assigned to inpatient units or to outpatient areas and,
therefore, the posting of those ratios would be meaningless. (13) Another
commenter supported this position. (12)
10. COMMENT: The commenters recommended the deletion of
the terms PT and RCP in the definition of “direct patient care.” The
commenters also recommended the deletion of the proposed regulation,
which requires reporting of the staffing of PTs and RCPs. The commenter
noted that since PTs and RCPs may be assigned to inpatient units or to
outpatient areas, posting those assignment areas would be meaningless.
The commenter stated that although such caregivers provide direct patient
care, they are not included in the direct care hours as calculated by all
hospitals in New Jersey and the gathering of such information would
require additional resources. (1, 8, 14)
11. COMMENT: The commenter, although not explicitly referring
to the definition of “direct patient care,” stated that it operates nursing units
with a nurse director, assistant manager, advanced practice nurse,
physicians, advanced nurse practitioners, and physician assistants, many
of whom aren’t captured by the regulations. (4)
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RESPONSE TO COMMENTS 8 THROUGH 11: The Department
acknowledges that several commenters recommended the deletion of PT
and RCP from the definition of “direct patient care” for one or more of the
following reasons: (1) such caregivers float across the institution and
would be difficult to measure on a shift by shift basis, (2) these individuals
may be assigned to inpatient or to outpatient areas and, therefore, the
posting of those ratios would be meaningless, and (3) they are not
included in the direct care hours as calculated by all hospitals in New
Jersey and the gathering of such information would require additional
resources. As noted previously, the proposed new rules implement
N.J.S.A. 26:2H-5f, 5g and 5h. More specifically, N.J.S.A. 26:2H-5g(a)4
requires “information detailing for each unit and for the end of the
prevailing shift, as appropriate. . .the number of other licensed or
registered health care professionals meeting State staffing
requirements….” Such health care professionals include PTs and RCPs,
both of which are appropriately included in the definition of “direct patient
care” in the rules. As the Department noted in the New Jersey Register of
Monday, April 16, 2007 (39 N.J.R. 1363(a)), “‘Other licensed health care
professionals’ means 1. ‘Physical therapist,’ which shall have the meaning
set forth in N.J.S.A. 45:9-37.13, and 2. ‘Respiratory care practitioner,’
which shall have the meaning set forth in N.J.S.A. 45:14E-3.” The
Department is without authority to make the revisions as suggested by the
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commenters because they contradict the statute. Therefore, the
Department declines to make any changes to the rules at N.J.A.C. 8:43G-
17A that would remove the requirements for the reporting of staffing for
PTs and RCPs. Furthermore, under the rules at N.J.A.C. 8:43G-17A.2
advanced practice nurses would be included in the definition of “direct
patient care” because they would be registered professional nurses, a
group about which the statute requires information. However, physicians
and physician assistants would not be included in the definition of “direct
patient care” because the statute does not require information about these
health care providers. Administrative nurses, such as nurse directors and
assistant managers, would be counted in the definition because they are
registered professional nurses, but only if they are functioning as direct
care providers rather than as administrators.
12. COMMENT: The commenter indicated her support for the
regulations, but stated that the reporting should be simplified to include
strictly full-time equivalents (FTEs) because the reporting of partial shift
workers would be confusing and might lead to inaccurate accounting of
ratios of staff to patients. (25)
13. COMMENT: The commenter recommended identifying the
number of staff on a shift and not including the actual hours. The
commenter added that calculating actual hours goes beyond the required
law and would create additional workload. (3)
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RESPONSE TO COMMENTS 12 AND 13: The Department
acknowledges the concerns of these commenters regarding the
methodology to be used for counting staff. The Department is required by
law to consult with the Quality Improvement Advisory Committee (QIAC) in
developing the rules at N.J.A.C. 8:43G-17A and held a number of
meetings with this broad-based stakeholder group. The QIAC was deeply
divided between union and hospital representatives on whether to use
FTEs or to count the actual number of staff. Although the law does not
specify one method or the other, the Department believes that using
methods for counting staff that are not standard could confuse the
consumer, defeating the purpose of the legislation. While recognizing the
potential additional burden of calculating FTEs, the Department has
concluded that this method is in keeping with the intent of the legislation at
N.J.S.A. 26:2H-5f through h to provide the public with clear and concise
numbers that can be compared across facilities. The term FTEs includes
“partial shift workers” and the Department believes that inclusion is
appropriate. Equally important, as noted by other commenters, numerous
employers, governments, research institutions, and professional
organizations around the world have adopted the use of FTEs for staffing
calculations.
14. COMMENT: The commenter stated that the process does not
account for the direct patient care provided by centralized care providers
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such as an “IV team” or wound care team. The commenter also stated
that although shifts end at a predictable time, true nursing hours are not as
predictable. Some nursing staff may stay beyond their shift and these
hours would not be captured in the posting. (10)
15. COMMENT: The commenter stated that the definition of “shift”
does not take into account the many and varied shifts its health system
uses. (2)
16. COMMENT: The commenter stated that it has numerous
facilities, each of which uses a variety of “shifts, ” including nine-hour
shifts, which comprise float nurses, rapid emit nurses, rapid response
nurses, nurse managers, on-call nurses, and Code Blue teams. The
commenter suggested that the Department should revise the definition of
“shift” to more accurately reflect these variations and to allow hospitals to
provide accurate data. (4)
17. COMMENT: The commenter stated that the proposed
definition of “shift” “does not take into account the variety of shifts currently
being offered in hospitals. . .It also does not address the times when,
because of patient census, transfers in or out, or patient acuity, additional
staff such as advanced practice nurses, nurse managers, or members of
rapid response teams are deployed to help out for a short period of time.
Although these healthcare professionals are providing direct patient care,
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this information will not be captured through the proposed allocation of
shifts.” (13) Another commenter supported this position. (12)
18. COMMENT: The commenters stated that mandating the
reporting of these shifts into an arbitrary eight- or 12-hour period does not
reflect what is in fact occurring on the nursing unit. The commenters said
that today’s hospitals may have two-, four-, six-, or ten-hour shifts in an
attempt to be flexible in meeting patient needs and to address high acuity
and high census fluctuations while meeting the needs of their nursing
staffs. The commenter added that “the proposed reporting system would
not accurately reflect the dynamic composition of the nursing unit due to
the fluctuation in the patient census (patient transfers in and out of the
unit), patient acuity, additional staff such as advanced-practice nurses,
nurse managers or members of rapid-response teams who are deployed
to assist anywhere in the hospital for periods of time when emergent
situations occur.” The commenters stated that such variables will not be
captured through the proposed allocation of shifts, which may not be
reflective of the actual care provided. (1, 8, 14)
RESPONSE TO COMMENTS 14 THROUGH 18: The proposed
new rules at N.J.A.C. 8:43G-17A, which implement N.J.S.A. 26:2H-5f, 5g
and 5h, require that nursing hours be measured in shifts. The Department
is aware of the many and varied shifts currently being offered in hospitals
and, therefore, suggested eight- and 12-hour shifts in order to achieve
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standardization and to make the staff posting process more efficient for
both hospitals and Department staff. The Department decided to use
these two standardized shifts in order to provide understandable data for
the public and comparable data across all hospitals. Furthermore, as
noted in the response to comment numbers 8 through 11, the Department
would include advanced practice nurses in the definition of “direct patient
care” because they would be registered professional nurses, a group
about which the statute requires information. Similarly, the Department
would include centralized care providers, float nurses, rapid emit nurses,
rapid response nurses, on-call nurses, and Code Blue teams in the
definition of “direct patient care” whenever such providers are included in
one of the groups for which the statute requires information.
Administrative nurses, such as nurse directors and assistant managers,
would be counted in the definition because they are registered
professional nurses, but only if they are functioning as direct care
providers rather than as administrators. However, physicians and
physician assistants would not be included in the definition of “direct
patient care” because the statute does not require information about these
health care providers.
SECTION 3: Information Required to be Posted; Retention
19. COMMENT: The commenter stated “posting data one hour
before the end of or one hour after the beginning of the next shift only
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provides historic information, and not current staffing levels.” The
commenter added that such data would not provide any useful information
to patients and their families. (2)
20. COMMENT: The commenter stated that the “form is required
at the busiest time, change of shift, when the one nursing supervisor on
duty for evenings, nights, weekends and holidays is ensuring that changes
in staffing needs are addressed.” The commenter also said, “to implement
this for every unit would require either the hospital to hire additional staff
or more likely assign this task to the charge nurse on each unit thereby
detracting from patient care.” Finally, the commenter added that “time
could be better spent focusing on patient needs” during change of shifts.
(3)
21. COMMENT: The commenters stated that collecting data “one
hour before the end of the shift” diverts nursing resources and attention
from the priorities of “safe patient handoffs” and “communication” at the
change of shifts. The commenter recommended posting the staffing
numbers after the beginning of the shift, so that patients and visitors could
view what the current status is for the current shift. (1, 8, 14)
RESPONSE TO COMMENTS 19 THROUGH 21: The proposed
new rules at N.J.A.C. 8:43G-17A implement N.J.S.A. 26:2H-5f, 5g and 5h
which require, in part, that a general hospital licensed pursuant to P.L.
1971, c.136 (N.J.S.A. 26:2H-1 et seq.) must compile and post daily. .
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.information detailing for each unit and for the end of the prevailing shift.
While the Department acknowledges that the form is required at change of
shift, the busiest time on hospital units, the Department believes, following
extensive consideration, that the intent of the law is that staff shall post
staffing information at the end of each shift. The Department trusts that
hospital staff will first focus nursing resources and attention on “safe
patient handoffs” and secondly on the completion of the staff posting
forms. Finally, the Department acknowledges that posting information at
the end of the shift will not allow patients and visitors to view the current
status for the current shift. However, as noted above, the Department has
determined that the law intends and mandates that staff shall post staffing
information at the end of each shift and therefore, the Department makes
no change on adoption.
22. COMMENT: The commenter stated that the counting of
patients in the ED is an irrelevant function since the data is retrospective.
The commenter suggested posting the numbers of RNs and nurses aides
only and eliminating the number of patients on the form, and providing
patient census on a 24-hour basis. (3)
23. COMMENT: The commenter stated that the ED information to
be reported would not assist the general public in making informed
decisions. The commenter added that reporting such aggregate numbers
would not take into “account the acuity of the patients being treated” and
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various components of direct patient care. Therefore, the commenter
suggested that the Department delete the proposed reporting requirement
for EDs. (4)
24. COMMENT: The commenters stated that the reporting of the
total number of patients seen in the ED for the shift and the number of
staff is relatively useless information to the public. Such information does
not take into account the various shifts used in EDs to accommodate
swings in census during the day, the ability to open up prompt or urgent
care centers to respond to increased volume, and the utilization of rapid
response and admission teams to assist with patients when needed. The
commenter recommended that the Department delete the proposed
reporting requirement for EDs. (1, 8, 13, 14) Another commenter
supported this position. (12)
RESPONSE TO COMMENTS 22 THROUGH 24: The proposed
new rules at N.J.A.C. 8:43G-17A implement N.J.S.A. 26:2H-5f, 5g and 5h,
which require “daily” posting of certain staffing information based on each
“unit” and “the end of the prevailing shift.” The Department, with input
from the QIAC, agreed to consider the ED a “unit” and, as defined in the
law, staffing information, including the number of patients, must be posted
at “the end of the prevailing shift.” The Department acknowledges that ED
data is retrospective and that aggregate numbers do not take into account
“the acuity of the patients being treated.” Nevertheless, the Department is
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without authority to make the revisions as suggested by the commenter
because the Department believes those revisions are contrary to the intent
of the statute. Finally, as noted earlier, health care providers on rapid
response teams, admission teams, various shifts, and in urgent care
centers would be counted in the definition of “direct patient care”
whenever such providers are included in one of the groups for which the
statute requires information.
25. COMMENT: The commenter stated that the counting of
patients in the PACU is an irrelevant function since the data is
retrospective. The commenter suggested posting the numbers of RNs
and nurses aides only and eliminating the number of patients on the form,
and providing patient census on a 24-hour basis. (3)
26. COMMENT: The commenter stated that the proposed post-
anesthesia care unit regulation is duplicative as current Department
regulations require specific staffing ratios for PACU units throughout the
state. In addition, the commenter saw no reason to gather and post such
data, which would not impact patient care or consumer education.
Therefore, the commenter recommended that the Department delete the
proposed PACU regulation. (4)
27. COMMENT: The commenter stated that calculations for the
PACU are unnecessary given that current Department regulations require
specific staffing ratios for that department. The commenter added that
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N.J.A.C. 8:43G-35.3(b) states: “There shall be a ratio of at least one
registered professional nurse for every three patients in the post-
anesthesia care unit.” The commenter suggested that the Department
delete the provision regarding the PACU. (1, 8,13, 14) Another
commenter supported this position. (12)
RESPONSE TO COMMENTS 25 THROUGH 27: The proposed
new rules at N.J.A.C. 8:43G-17A implement N.J.S.A. 26:2H-5f, 5g and 5h,
which require “daily” posting of certain staffing information based on each
“unit” and “the end of the prevailing shift.” The Department considers the
post-anesthesia care unit as a “unit” and, as defined in the law, staffing
information, including the number of patients, must be posted at “the end
of the prevailing shift.” The Department acknowledges that PACU data is
retrospective and that existing Department rules require specific staffing
ratios for PACUs. However, the Department believes the required
reporting for PACUs meets the intent of the statute to provide as much
staffing information as possible to the public. The Department believes
the commenter’s proposed revisions are contrary to the intent of the
statute and therefore declines to make any change on adoption.
28. COMMENT: The commenter stated that if members of the
public are requesting staffing information, they should obtain quarterly
information from the Department or utilize the Department’s complaint line,
which is already available to the public. The commenter added that the
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hospitals would not be able to provide information to the public due to
limited resources. (3)
29. COMMENT: The commenter stated that the provision of a
copy of daily postings at no charge and at any time to any member of the
public upon request would be onerous and would require additional
funding in order for hospitals to comply. The commenter recommended
that one copy of the daily posting be made available to patients and
families through normal record copying procedures in every healthcare
organization. “All other requests by individuals or entities. . .should be
directed to the. . . Department and addressed through their normal record
request procedures.” (13) Another commenter supported this position.
(12)
30. COMMENT: The commenters stated that compliance with the
mandate that “all general hospitals shall establish procedures to provide a
copy of the daily postings at no charge to any member of the public upon
request” would have significant adverse impact upon the resources of all
institutions. The commenters recommended that all such requests should
be funneled through the Department. (1, 8, 14)
RESPONSE TO COMMENTS 28 THROUGH 30: The proposed
new rules at N.J.A.C. 8:43G-17A implement N.J.S.A. 26:2H-5f, 5g and 5h,
which require a general hospital to “provide upon request to a member of
the public, information detailing for each unit and for the end of the
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prevailing shift. . . .” Although the statute did not provide any funding, the
law requires compliance from facilities regarding the provision of
information upon request. In addition, hospitals would submit information
to the Department monthly and the Department would develop quarterly
numbers, which the public could easily retrieve from the Department
website. Hospitals may customize their procedures to allow sufficient time
for retrieval and copying.
31. COMMENT: The commenter stated that since reports will be
submitted to the Department on a “to-be-developed” web-based interface,
the most efficient and expeditious method of three-year storage would be
at the State level in an electronic archiving system, which the Department
should develop. (2)
32. COMMENT: The commenter stated that the three-year storage
of daily postings would involve a tremendous amount of paper, “3
sheets/day x 365 days/unit,” as well as the non-productive time of
retrieving the form each shift from every unit. The commenter
recommended that the Department develop an electronic form to enter
and aggregate data in an efficient manner. (3)
33. COMMENT: The commenter stated that the requirement to
have hospitals maintain data separately is superfluous because hospitals
must send the data to the Department’s web-based reporting system. The
commenter added that maintaining thousands of essentially duplicate
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reports would be an expense to its non-profit organization. The
commenter recommended that because the Department will store data on
an electronic database, the Department should require hospitals to
maintain the “shift/daily” specific reports only until they submit that data
electronically to the Department website in the monthly reports. (4)
34. COMMENT: The commenter stated that the proposed
regulation seems to mandate “a redundancy in effort and a very expensive
one, in terms of paper, storage costs and manpower time” since the
Department will include the same data on a monthly basis on a web-based
system, which will be available to the public. The commenter, therefore,
recommended that the Department delete the proposed regulation
regarding three-year storage of daily postings. (13) Another commenter
supported this position. (12)
35. COMMENT: The commenters stated that a 15-unit hospital
would generate an additional 49,275 reports for a three-year period. The
commenters recommended that the Department develop and test an
electronic archiving system prior to implementation of posting and
reporting rules. (1, 8, 14)
RESPONSE TO COMMENTS 31 THROUGH 35: The proposed
new rules at N.J.A.C. 8:43G-17A implement N.J.S.A. 26:2H-5f, 5g and 5h,
which states that hospital patients “are entitled to have access to the
information that is required to be posted. . . .” While the Department
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acknowledges that hospitals find data retention burdensome and
superfluous, the Department has determined that the intent of the law is
that hospitals should maintain and have available for a reasonable amount
of time, such as the required three-year period, the daily staff posting
information to which patients, their families, and the public are entitled.
Furthermore, hospitals would be responsible for keeping daily shift
reports, paper or computerized copies, for three years in case of audits or
the need for verification. In addition, the Department would give hospitals
an Excel spreadsheet to aggregate information in an efficient manner.
The hospitals would input all the data from their calculations and give the
Department only aggregate information monthly. The Department would
archive monthly reports and make public quarterly reports. The
Department does not believe it is necessary for the Department to develop
an electronic archiving system and declines to make any changes on
adoption.
SECTION 4: Posting Locations
36. COMMENT: The commenter stated that there is an
inconsistent standard for posting. The commenter recommended that all
information be posted on the unit in a visible location or all posted in
waiting rooms. (3)
37. COMMENT: The commenters stated that based on their
recommendation to delete proposed regulations regarding the collection of
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staff information in the ED and PACU, the Department should delete the
regulation about posting in the ED and PACU waiting areas. (1, 4, 8,13,
14) Another commenter supported this position. (12)
RESPONSE TO COMMENTS 36 AND 37: The proposed new
rules at N.J.A.C. 8:43G-17A implement N.J.S.A. 26:2H-5f, 5g and 5h,
which require general hospitals to “post daily. . .information detailing for
each unit. . . .” As noted previously under “Response to Comments 22
through 24 and 25 through 27,” the Department believes the commenter’s
proposed revisions to delete the rule about posting in the ED and PACU
waiting areas are contrary to the intent of the statute and therefore
declines to make any change on adoption. Posting is required by law and
the posting areas stated in the rule vary due to the different types of units
and factors such as accessibility and infection control.
SECTION 5: Reporting Requirements
38. COMMENT: The commenter stated that the proposed
reporting requirements would be costly and an undue burden to the
hospital. The commenter recommended that the Department should
develop and test an electronic tool, which the Department could make
available to each institution. Such a tool should automatically aggregate
the daily shift information. (3)
RESPONSE: The proposed new rules at N.J.A.C. 8:43G-17A
implement N.J.S.A. 26:2H-5f, 5g and 5h, which require general hospitals
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to “report the information compiled to the commissioner on a monthly
basis.” The Department acknowledges that this reporting requirement
may be costly and burdensome to hospitals. As a result, the Department
is working to develop a web-based monthly reporting submission tool.
After considering issues of compatibility that may exist at some hospitals,
the Department will provide all hospitals with a basic Excel spreadsheet to
assist hospital staff with preliminary calculations. Although this tool will
not automatically aggregate information, it will assist hospitals in
complying with the statute and the rules without incurring undue cost and
burden.
39. COMMENT: The commenter stated that the hospitals should
validate the Department’s information for accuracy before the Department
releases such information to the public. The commenter added that
hospitals currently perform such validation regarding other data they
submit to the Department. (3)
40. COMMENT: The commenter recommended that staffing
information should not be publicly reported until validated by the individual
facility. (1, 8, 14)
RESPONSE TO COMMENTS 39 AND 40: The Department does
not have the staff or funds for independent validation of data. Therefore,
just as hospitals validate other data, they should also verify their staffing
information prior to submitting such data to the Department. In addition,
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the Department will give hospitals the opportunity to review reports before
releasing them to the public.
SECTION 6: Penalty
41. COMMENT: The commenter recommended “that a one-year
time period should be given to work out any issues of data collection or
accuracy before fines are instituted since this model has not been tested.”
(3)
42. COMMENT: The commenters recommended that no fines be
issued until the system is fully implemented and tested. (1, 8, 14)
RESPONSE TO COMMENTS 41 AND 42: N.J.S.A. 8:43G-17A will
become effective upon publication of the Notice of Adoption in the New
Jersey Register. However, the Department will consider allowing a period
without instituting fines, as the model for staff posting and reporting is
new.
APPENDIX A
43. COMMENT: The commenter recommended the elimination of
all areas “already regulated for staffing such as the ICUs, PACU, NICU
and Mother/Baby.” The commenter added that the Department already
has the ability to monitor these areas or address concerns. (3)
44. COMMENT: The commenters stated that the “unit type”
section on the form includes many units for which there are already State
staffing guidelines and so the collection of additional data in these areas
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would be redundant. Also, because Virtua utilizes mixed units, the results
could be misleading. The commenter recommended (1) that the draft
proposed forms should be eliminated for the units already covered by the
State guidelines; (2) that only medical surgical units should report data
regarding their direct patient caregivers; and (3) that hospitals should be
able to label the units more accurately on the forms. (1, 4, 8, 14)
45. COMMENT: The commenter stated that the Department
currently has staffing requirements in place for “adult intensive care unit /
critical care unit, normal newborn nursery, neonatal intensive and neonatal
intermediate bassinets, pediatric intensive care unit, and psychiatric
services.” The commenter added that since the Department has the
ability to monitor staffing in said units, the collection of additional staffing
information would not be useful. (13) Another commenter supported this
position. (12)
RESPONSE TO COMMENTS 43 THROUGH 45: The proposed
new rules at N.J.A.C. 8:43G-17A implement N.J.S.A. 26:2H-5f, 5g and 5h,
which does not allow for the exclusion of units based on current staffing
requirements. Therefore, the Department does not have the authority to
eliminate units and will not make any changes regarding the proposed
form and unit types on adoption.
46. COMMENT: The commenter stated “actual hours worked”
should be eliminated because this requirement appears to go beyond the
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intent of the law. According to the commenter, calculating actual worked
hours would require the charge nurse to add or subtract hours depending
on whether the nurse took her or his meal time and breaks. The
commenter recommended that the Department only require hospitals to
calculate the number of nurses. (1, 3, 8, 14)
47. COMMENT: The commenter stated that given contractual
language regarding staff pay for eight hours, including time for meals, the
Department’s use of the phrase “actual hours worked” might result in
confusion and result in inaccurate reporting. (13) Another commenter
supported this position. (12)
RESPONSE TO COMMENTS 46 AND 47: The national standard
for calculating worked hours is “hours worked per patient day.” In the
absence of consensus from the QIAC, the Department relies on its
interpretation of the intent of the legislation (N.J.S.A. 26:2H-5f, 5g and 5h)
and will consider “actual hours worked” rather than counting staff at the
end of the shift. The Department would not count lunchtime, but would
count breaks.
48. COMMENT: The commenters recommended the elimination of
the proposed reporting forms. The commenters suggested that the
posting of staffing information should be required only on medical surgical
units and that the Department should use data it currently collects on the
cost reports to determine actual hours worked per patient day. Other
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commenters stated that an electronic system for reporting staffing
information to the Department should be developed and tested prior to full
implementation of the regulations. (1,8,13,14) Alternatively, NJHA stated
that it is prepared to work with hospitals to develop a system similar to that
developed in Massachusetts which requires publicly reported staffing
plans and an update, reflecting actual hours worked, on an annual basis.
(13) Another commenter supported this position. (12)
RESPONSE: The rules at N.J.A.C. 8:43G-17A do not include a
“reporting form.” The Department includes a “daily posting form” to
capture the staffing information required by N.J.S.A. 26:2H-5f, 5g and 5h.
The Department will develop a web-based system for monthly reporting by
the hospitals. Although the Department appreciates NJHA’s willingness to
work with hospitals to develop a system similar to that used in
Massachusetts, the Department believes the Massachusetts system is not
in keeping with New Jersey law because the reporting requirements are
different.
SUPPORTIVE COMMENTS
49. COMMENT: The commenters “strongly” supported the
Department’s proposal and methodology for determining nurse staffing
calculations based on worked hours. They stated, “giving the public the
right to know staffing levels at hospitals provides our patients, their
families, and our communities with some of the information they want and
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deserve when they are making critical health care decisions and facing
frightening health crises.” The commenters stated that federal regulations
recently went into effect requiring staff posting in nursing homes and
added that access to staffing information will also benefit hospitalized
patients and their families. They added that the regulations “will enable
the public to make more informed choices when selecting a health care
facility and will enable the Department to evaluate staffing in relationship
to other quality indicators.” (28 through 43)
50. COMMENT: The comments stated that as nurses in a
subacute and long-term care facility, they need to enforce safe nurse to
patient ratios. The commenters added that their patients are “medically
fragile and require more than custodial care.” Finally, they stated,
“Facilities are for profit, we need to make sure at least adequate care is
given.” (39 through 43).”
51. COMMENT: The commenter stated support for the proposed
regulations and noted, “in addition to public protection, these new rules will
be consistent with the requirements of the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) Staffing Effectiveness
Standards that should streamline the data collection and reporting
requirements of hospitals.” (21)
52. COMMENT: The commenter stated that since nurses provide
the majority of care to patients in acute care hospitals, they “support the
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proposal and method chosen by the Department of Health and Human
[Senior] Services in determining nurse staffing calculations based on
worked hours.” The commenter stated that the proposed regulations will
help patients and their families make decisions, enhance safe and
effective patient care, and improve the Department’s ability to evaluate
and manage staffing levels. (18)
53. COMMENT: The commenter stated that the Department’s
choice “for using a standardized method of calculation of the number of
worked hours to determine staffing is strongly supported. Without a
standard, the information reported to the public and the Department of
Health would have no consistency and defeat the purpose of comparison.”
The commenter added, “these provisions will enable the public to make
more informed choices when selecting a health care facility and will
enable the Department to evaluate staffing in relationship to other quality
indicators.” (15)
54. COMMENT: The commenter stated that this public disclosure
“will enable the patients and their families to choose the healthcare facility
with the sufficient numbers of staff who can provide them better care. . .”
and will motivate facilities “to improve and implement a safe staffing ratio.”
(17)
55. COMMENT: The commenter stated its organization’s strong
support for “the proposed methodology for determining nurse staffing
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calculations based on worked hours.” The commenter added that the
proposed rules will help the Department “evaluate existing staffing levels
in our facilities in an accurate and objective manner. A myriad of
reputable national organizations support or have adopted the same
concept.” (23)
56. COMMENT: The commenter stated support for the
Department’s position that nurse staffing calculations per unit per shift
would be calculated based on “the total actual hours of staff providing
direct care worked during the shift.” The FTE methodology “indicated in
the proposed rules is universally recognized as the ‘standard’ for staffing
calculation by many groups and disciplines.” (16)
57. COMMENT: The commenter stated its wholehearted
concurrence with “the Department’s proposal to utilize the accepted
standard of Full-Time Equivalents (FTEs) as a means of reporting staffing
information.” (27)
58. COMMENT: The commenter “finds the rule clear and believes it
achieves the intent of the statute.” In addition, the commenter agrees with
the Department that the methodology employed for counting the number
of staff will provide a calculation that can be used for “inter-hospital
comparison of data.” (22)
59. COMMENT: The commenter stated that the FTE methodology
indicated in the proposed rules is universally recognized as the “standard”
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for staffing calculations across occupational groups because it “accurately
quantifies actual time worked; facilitates comparisons between units and
organizations; and is easy to calculate.” The commenter added that the
methodology has been adopted by employers, governments, research
institutions, and professional organizations worldwide. The commenter
also noted that “recognizing the importance of having an accurate and
standard methodology for calculating nurse staffing, the Center for
Medicare and Medicaid Services require that Skilled Nursing Facilities
report staffing levels of Registered Nurses, Licensed Practical Nurses, and
Certified Nursing Assistants in Full-Time Equivalents (FTEs), based on
actual hours worked.” (9)
60. COMMENT: The commenter stated that the proposed new
rules requiring hospitals and nursing homes to provide staffing information
to the public are similar to their examples of New Jersey hospitals
reporting infection rates to the public. The commenter added that its
“Union members and their family members frequent the Skilled Nursing
Facilities and Nursing Facilities and they would find significant succor
were staffing information regarding these facilities made public.” Finally,
the commenter “fervently supports the regulations as proposed.” (26)
61. COMMENT: The commenter stated that nurse staffing
calculations based on worked hours will enable inter-hospital comparisons
of data and may provide a means for researchers to develop methods of
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analysis of staffing data to develop indicators of “safe / quality care.” In
addition, the numbers can be studied in relation to such variables as nurse
satisfaction, burn out, and intent-to-leave, thus benefiting patients, nurses,
and institutions alike. (7)
62. COMMENT: The commenter stated that the proposed rules will
improve the Department’s ability to asses the existing staffing levels and
measure the facilities’ attempts to provide safe staffing. In addition, the
commenter stated that staff posting would help patients and their families
to make informed decisions regarding their health care choices. The
commenter also strongly supports the Department’s “methodology for
determining nurse staffing calculations based on actual hours worked.”
(5)
63. COMMENT: The commenter stated that the proposed staff
posting regulations are a beginning. With over 40 years experience
ranging from a practicing RN to Dean of Rutgers College of Nursing, the
commenter had a recent hospital stay and wrote from the perspective of
both professional and patient. She noted that the primary reason for
nursing shortages is the shortage of decent working conditions for nurses.
She added that the Institute of Medicine has consistently reported that
one’s life depends upon the hospital they select—and the two main criteria
are the number of Board Certified Physicians and the number of
Registered Nurses. She also quoted the January / February 2006 issue of
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the Journal of Health Affairs as follows: “Increasing the number of RNs
and the number of hours of care RNs devote to patients would save 6,700
lives and four million days of patient care in hospitals each year.” (6)
64. COMMENT: The commenters stated that the proposed rules
will improve the Department’s ability “to evaluate existing staffing levels in
our health care facilities, as well as the measures hospitals use to provide
safe staffing.” The commenters added that the provisions will enable the
Department to evaluate staffing in relationship to other quality indicators.
The commenters also stated their strong support of the Department’s “way
of determining nurse staffing calculations based on actually worked
hours.” (19, 24)
65. COMMENT: The commenters stated their strong support for
the proposed regulations and agree that staffing levels should be
calculated using FTEs. The commenters also stated that a number of
nationally recognized organizations support this concept as well. Finally,
the commenters support these regulations, which will help provide the
public with the number of caregivers per patient in a clear and concise
manner that could be compared across facilities. (11, 20)
RESPONSE TO COMMENTS 49 THROUGH 65: The Department
appreciates the support of the above commenters and thanks them for
their informative and insightful comments. The Department also
appreciates comments, which stated, “Union members and their family
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members frequent the Skilled Nursing Facilities and Nursing Facilities and
they would find significant succor were staffing information regarding
these facilities made public.” The Department reminds the commenters
that the rules at N.J.A.C. 8:43G-17A apply to general hospitals. As the
Department stated in the Notice of Proposal at 39 N.J.R. 1363(a), “the
Department anticipates future rulemaking to fulfill the statutory
requirement for licensed nursing homes.”