Establish Maximum patient-to-nurse Ratios in Minnesota Hospitals

 

This bill is intended to instate a legal mandate on nurse-patient ratios in MN. In doing so this body hopes to provide

higher quality patient care, better working situations for nurses, and ensure all MN hospitals are in line with national

and federal standards.

 

This bill is important as it will reduce nurse-patient ratios, leading to better patient outcomes, higher levels of

care, and better, safer conditions for patients and nurses. According to a review of 21 studies conducted in regards to

nurse-patient ratios and published by the NIH, higher nurse-patient ratios decrease the risk of patient mortality and

generally show improved patient outcomes.

The American Nurses Association supports “The American Nurses Association (ANA) supports enforceable ratios as an

essential approach to achieving appropriate nurse staffing”.

This bill is good for patients and nurses.

 

1. Various Units (ie. Med/Surg, ICU, Trauma, etc.): Which units fall under these areas within this bill shall be

determined by the MRD following established industry and legal precedent. These classifications will be based on the

nature of patients admitted to the unit, including their acuity, criticality, and degree of nursing care needed.

2. Ratio: As expressed throughout this bill, ratios denote the ratio of nurses to patients. As an example, a ratio of

1:4 would indicate 1 nurse per every 4 patients.

3. Out-of-ratio: This is a common term within the healthcare industry that denotes a provider, typically a nurse, who is

operating beyond normal ratios for one reason or another. For the purpose of this bill, situations in which a nurse is

given additional patients include: the nurse is briefly covering another nurse; the patients are low acuity and can

safely be managed out of ratio; or an unforeseeable and irreparable staffing gap that has required the nurse to operate

out of ratio. There may be other situations not here enumerated that may be deemed a reasonable use of the

“Out-of-Ratio” allowances within this bill. These cases are to be established based on decisions and precedents of the

MDH in the enforcement of this bill. These allowances shall not be used in a situation where the unit is understaffed

for some avoidable reason, such as in the event that other staff could be called in. No patient should be admitted into

a unit as Out-of-Ratio unless failure to admit said patient would constitute a greater harm than help to the patient.

4. Out-of-Ratio as standard practice: If a hospital has established a policy or system of operation whereby it typically

operates Out-of-Ratio, then this is considered as the institution using Out-of-Ratio as standard practice and falls

under Section V, subsection 3, part b. The MDH is given authority to enforce this within “the spirit of the rule.”

 

5. Hospital: Hospitals (places in which this bill will apply) shall refer to tertiary and secondary care facilities that

handle acute care situations. The MDH shall classify each individual facility for the purpose of enforcement of this

bill under these general guidelines.

 

 

The enforcement for this bill will to delegated to the Minnesota Department of Health (MDH), specifically the Health

Regulation Division (HRD) Office of Health Facility Complaints (OHFC). Funds for the enforcement of this bill will be

provided from broader HRD’s existing budget and subsidised by fines collected by the MDH in the enforcement of this

bill. Additional allocation of funds for the enforcement of this bill may be reviewed and implemented as needed 6 months

after the effective date of this bill.

 

1. Ratios established: The following ratios will be used as the maximum nurse-patient ratio in the subsequent unit. This

applies to all Minnesota Acute care Hospitals in units that treat adult (18+) patients. Hospital units that care

specifically for pediatric patients will not fall under these restrictions with the exception being NICU units, which

are classified in this bill. Additionally, in the event of a Postpartum unit dealing with attached pediatric care, the

pediatric care will be considered separate from Postpartum and shall not be governed under this bill.

a. Operating room/theater, Trauma patients: The nurse-to-patient ratio should be no greater than 1:1 in these areas.

Higher ratios shall incur penalties

b. ICU, NICU, L&D, Acute respiratory care, Burn Unit, Coronary Care: The nurse-to-patient ratio should be 1:1, with

select cases of lower acuity providing an exception that may allow for 1:2 but

such ratios shall be considered “out-of-ratio” and should not be standard procedure.

c. L&D, Antepartum, Combined L&D and Postpartum, ER, Telemetry: The ratio in these units should be 1:3

d. Psychiatric: The ratio in these units shall be 1:4

e. Medical Surgical (Med/Surg): The ratio in this unit is recommended to be 1:4, but may be allowed to reach but not

exceed 1:6. Anything above 1:4 shall be considered “out-of-ratio” for these

units.

2. Extraordinary circumstances: In the event of a Mass Casualty Incident or other similar extraordinary circumstance,

these ratios may be broken without penalty, but whether or not a situation qualifies as an extraordinary circumstance

will be determined by the MDH on an individual basis.

3. Penalties: The following penalties shall be established for all acute care

a. Units operating beyond safe ratios: Any Hospital found to be operating beyond safe limits shall be fined $250,000 and

provided with a period of 4 months to come into adherence with this bill.

If the unit or units that are out of regulation fail to meet requirements in this time frame, they may be closed at the

discretion of MDH. Hospital administrators determined responsible for

such lapses may face up to 1 million dollars in fines and jail time up to 10 years, along with the revocation of

certifications and licensures if applicable.

b. Units operating “Out-of-Ratio” as standard practice: Units determined to be operating within the defined

“Out-of-Ratio” limits as standard practice and not as special circumstances shall be

treated as operating beyond safe ratios and shall face all penalties detailed above.

c. Units operating “Out-of-Ratio” as allowed: Nurses working out of ratio for legally permissible reasons under this

bill shall be entitled to no less than a 0.5x differential per patient out of the

recommended ratio.

4. Special exemptions: Hospitals may receive exemptions for the following reasons:

a. Staffing: If a hospital has made all reasonable attempts to hire sufficient nurses and continues to actively seek new

nurses, but despite these efforts is unable to procure sufficient staff,

then they may exceed the established ratios with the exception of the following units: OR, Trauma, ICU, NICU, Burn Unit.

In the event that a unit cannot maintain at maximum the “Out-of-Ratio”

requirements despite active hiring attempts, then patient admission to that unit must be limited so that they fall

within the “Out-of-Ratio” requirements until additional nurses can be hired.

a2. The MDH shall be given the authority to circumvent these regulations stated in Section V.4.a in specific

circumstances where it deems that the closure of beds within a unit would

constitute a greater detriment to public health.

b. Financial: If a hospital is unable to monetarily support the hiring of sufficient nurses on any unit, then that

unit's capacity must be reduced to meet the ratio requirements in this bill. In this

situation, nurses on medical-surgical floors may be allowed to work at the “out-of-ratio” rate as standard practice

without penalty and without needing to pay the differential, but the hospital

should demonstrate legitimate attempts to remedy such a situation.

5. Enforcement: The OHFC shall conduct triannual inspections and inquiries. The MDH may also execute unannounced

inspections and inquiries at any time. The MDH shall also be prompted to enact an inspection and inquiry in the event of

a staff or patient complaint. The MDH is given authority to access staffing and patient number records as necessary for

the enforcement of this bill.

 

 

This bill will go into effect on January 1st, 2028.