Rules; Patients' Rights

Establishes a commission to assist the insurance commissioner to
adopt rules to ensure patients' rights to nursing care.

HOUSE OF REPRESENTATIVES                H.B. NO.           
TWENTIETH LEGISLATURE, 2000                                
STATE OF HAWAII                                            

                     A BILL FOR AN ACT



 1      SECTION 1.  The legislature finds that the President's
 2 Advisory Commission on Consumer Protection and Quality in the
 3 Health Care Industry (Advisory Commission) was created to make
 4 recommendations to the President on how to address the compelling
 5 data that suggested the quality of health care nationally had
 6 declined radically with the onset of unregulated managed care.
 7 On March 31, 1998, the Advisory Commission suggested that, "The
 8 purpose of the health care system must be to continuously reduce
 9 the impact and burden of illness, injury and disability, and to
10 improve the health and functioning of the people of the United
11 States."  The Advisory Commission also suggested that an initial
12 set of national aims should include the following:
13      (1)  Reducing the underlying causes of illness, injury, and
14           disability;
15      (2)  Expanding the research on new treatment and evidence of
16           effectiveness;
17      (3)  Assuring the appropriate use of health care services;
18      (4)  Reducing health care errors;
19      (5)  Addressing oversupply and undersupply of health care
20           resources; and

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 1      (6)  Increasing patients' participation in their care.
 2      Hawaii's health care system is undergoing a dramatic
 3 transformation.  Contributing factors to the transformation are:
 4      (1)  An increased emphasis on managed care;
 5      (2)  Changes in health care financing;
 6      (3)  Deregulation of the industry resulting in unprecedented
 7           competition and consolidation among providers; and
 8      (4)  The emergence of for-profit health care providers. 
 9 These trends have resulted in an increased focus by many Hawaii
10 providers on market competition and financial performance,
11 blurring their mission of providing accessible, high quality
12 health care.  The impact of these changes has been significant.
13 As a result of the pressures of cost containment in the health
14 care industry since 1992, Hawaii nurses have had increasing
15 difficulty in providing a professional standard of care to
16 patients, which is the patient's right and the licensed nurses'
17 responsibility.  Hawaii's licensed nurses have commented that
18 their patient load is so busy that they are not able to provide
19 quality care.  The negative effects of health care system changes
20 on patients and patient care has been documented in the
21 literature.  Lewin-VHI, Inc., a health care consulting firm based
22 in Fairfax, Virginia, prepared a report for the American Nurses'
23 Association exploring the nature and strength of the linkages of

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 1 nursing care and patient outcomes.  Their report indicates that
 2 hospitals who employ fewer registered nurses or who "short staff"
 3 their units have longer lengths of stay than hospitals who employ
 4 registered nurses to provide all or most patient care or who have
 5 higher nurse to patient ratios.  These longer lengths of stay are
 6 associated with poor patient monitoring, omissions or delays in
 7 certain treatments, and an increase in medication errors and
 8 accidents.  The report also indicates that mortality rates are
 9 indeed related to the quality of nursing care, as measured by the
10 ratio of registered nurses to all nursing staff.  This
11 relationship appears to stem from both the positive effect of a
12 more qualified nursing staff on direct patient care and the
13 organizational changes that often correspond to a larger
14 proportion of registered nurses.  While this does not imply a
15 causal relationship between mortality and nurse satisfaction, it
16 does appear to have some effect on mortality.
17      As a matter of public policy as evidenced by the passage of
18 Act 178, Session Laws of Hawaii 1998, Hawaii, as the "Health
19 State", is committed to continuously reducing the impact and
20 burden of illness, injury, and disability, and to improve the
21 health and functioning of the people of Hawaii and ensuring that
22 the people who seek care through Hawaii's health care system have
23 access to cost-effective and quality health care.  Hawaii is also

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 1 committed to implementing actions to attain the national goals as
 2 set forth by the Advisory Commission.
 3      The legislature finds that patients in health care
 4 environments who do not have sufficient nursing care are at risk
 5 for inadequate assessment of their condition, increased infection
 6 rates, skin breakdown, medication errors, inadequate pain
 7 management, falls, and inadequate preparation for discharge.
 8 These risk factors often contribute to increased length of stay,
 9 readmissions, and increased cost to the patient, family,
10 taxpayer, and the health care system.  The legislature further
11 finds that there is a positive correlation between increased
12 nursing staffing and positive outcome for patients and that
13 Hawaii's patients have a right to nursing care across the health
14 care continuum and calls upon the health care industry, the
15 nursing profession, and state agencies to adopt rules that afford
16 Hawaii's patients the right to sufficient nursing care.
17      The purpose of this Act is to assist Hawaii's citizens to
18 receive the highest quality of nursing care, by requiring
19 development of rules by the insurance commissioner through
20 patients' rights to nursing care commission.
21      SECTION 2.  For the purpose of this Act:
22      "Board" means the board of nursing.
23      "Commissioner" means the insurance commissioner.

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 1      "Health care facility" means a health care facility or
 2 service as defined in section 323D-2, Hawaii Revised Statutes.
 3      "Nurse" means a person licensed under chapter 457, Hawaii
 4 Revised Statutes.
 5      "Patient or resident" means an individual or family
 6 receiving nursing care within a health care facility.
 7      SECTION 3.  The commissioner shall adopt rules in accordance
 8 with chapter 91, Hawaii Revised Statutes to assure that every
 9 patient or resident of any health care facility in Hawaii during
10 admission, and duration of stay for emergency, ambulatory,
11 inpatient, or resident services, shall be assured of sufficient
12 nursing care to provide for the patient's or resident's safety
13 and to implement a plan of nursing care based on applicable
14 professionally recognized standards of nursing practice.  The
15 rules shall include:
16      (1)  A requirement that a registered nurse executive/leader
17           be designated by the facility to be involved in the
18           overall allocation of resources to assure that
19           patients' rights to nursing care is attained;
20      (2)  A registered nurse be designated by the health care
21           facility to be responsible for the overall quality
22           assurance for nursing care provided;
23      (3)  A registered nurse to be designated by the health care
24           facility at all times during a patient's or resident's
25           admission to be responsible for the direct nursing care
26           of the patient or resident;
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 1      (4)  Nursing service staffing standards;
 2      (5)  Professionally recognized standards of nursing
 3           practice; and
 4      (6)  Remedies for noncompliance with adopted rules.
 5      SECTION 4.  The commissioner shall convene a temporary
 6 patients' right to nursing care commission for the purposes of
 7 developing rules to implement the purpose and intent of this Act.
 8 The patients' right to nursing care commission shall be composed
 9 of:
10      (1)  Three health care consumer representatives including:
11           (A)  One health care consumer or a member of their
12                family who has received nursing care in an acute
13                care setting in the last six months;
14           (B)  One health care consumer who represents senior
15                citizens who have received nursing care in the
16                last six months; and
17           (C)  One health care consumer receiving nursing care in
18                a long-term/home care setting in the last six
19                months;
20      (2)  Two representatives from the Hawaii Nurses'
21           Association;
22      (3)  Two representatives from the Healthcare Association of
23           Hawaii;

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 1      (4)  One representative from the board of nursing;
 2      (5)  One representative from the Hawaii Long-Term Care
 3           Association;
 4      (6)  One representative from the Hawaii Association for Home
 5           Care; and
 6      (7)  One representative from the University of Hawaii,
 7           school of nursing.
 8      SECTION 5.  The commissioner shall report to the legislature
 9 not later than twenty days prior to the convening of the regular
10 session of 2001 on the progress being made in the development and
11 adoption of rules ensuring Hawaii's patients' rights to nursing
12 care.  The patients' rights to nursing care commission shall
13 terminate upon the adjournment sine die of the regular session of
14 2001.
15      SECTION 6.  There is appropriated out of the general
16 revenues of the State of Hawaii the sum of $           or so much
17 thereof as may be necessary for fiscal year 2000-2001 to
18 establish a commission whose purpose is to assist the insurance
19 commissioner to adopt rules that will ensure patient's rights to
20 nursing care.
21      The sum appropriated shall be expended by the insurance
22 commissioner for the purposes of this Act.
23      SECTION 7.  This Act shall take effect on July 1, 2000.
25                           INTRODUCED BY:  _______________________