Rules; Patients' Rights

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

THE SENATE                              S.B. NO.           867
TWENTIETH LEGISLATURE, 1999                                
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 was created to make recommendations to the
 4 President on how to address the compelling data that suggested
 5 the quality of health care nationally had declined radically with
 6 the onset of unregulated managed care.  On March 31, 1998, the
 7 Advisory Commission suggested that "The purpose of the health
 8 care system must be to continuously reduce the impact and burden
 9 of illness, injury and disability, and to improve the health and
10 functioning of the people of the United States".  The Commission
11 also suggested that an initial set of national aims should
12 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

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

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 1 outcomes.  Their report indicates that hospitals who employ fewer
 2 registered nurses or who "short staff" their units have longer
 3 lengths of stay than hospitals who employ registered nurses to
 4 provide all or most patient care or who have higher nurse to
 5 patient ratios.  These longer lengths of stay are associated with
 6 poor patient monitoring, omissions or delays in certain
 7 treatments, and an increase in medication errors and accidents.
 8 The report also indicates that mortality rates are indeed related
 9 to the quality of nursing care, as measured by the ratio of
10 registered nurses to all nursing staff.  This relationship
11 appears to stem from both the positive effect of a more qualified
12 nursing staff on direct patient care and the organizational
13 changes that often correspond to a larger proportion of
14 registered nurses.  While this does not imply a causal
15 relationship between mortality and nurse satisfaction, it does
16 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.
 3      "Nurse" means a person licensed under chapter 457.
 4      "Patient or resident" means an individual or family
 5 receiving nursing care within a health care facility.
 6      SECTION 3.  The commissioner shall adopt rules in accordance
 7 with chapter 91 to assure that every patient or resident of any
 8 health care facility in Hawaii during admission, and duration of
 9 stay for emergency, ambulatory, inpatient, or resident services,
10 shall be assured of sufficient nursing care to provide for the
11 patient's or resident's safety and to implement a plan of nursing
12 care based on applicable professionally recognized standards of
13 nursing practice.  The rules shall include:
14      (1)  A requirement that a registered nurse executive/leader
15           be designated by the facility to be involved in the
16           overall allocation of resources to assure that
17           patients' rights to nursing care is attained;
18      (2)  A registered nurse be designated by the health care
19           facility to be responsible for the overall quality
20           assurance for nursing care provided;
21      (3)  A registered nurse to be designated by the health care
22           facility at all times during a patient's or resident's
23           admission to be responsible for the direct nursing care

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 1           of the patient or resident;
 2      (4)  Nursing service staffing standards;
 3      (5)  Professionally recognized standards of nursing
 4           practice; and
 5      (6)  Remedies for non-compliance with adopted rules.
 6      SECTION 4.  The commissioner shall convene a temporary
 7 patients' right to nursing care commission for the purposes of
 8 developing rules to implement the purpose and intent of this Act.
 9 The patients' right to nursing care commission shall be composed
10 of:
11      (1)  Three health care consumer representatives including:
12           (A)  One health care consumer or a member of their
13                family who has received nursing care in an acute
14                care setting in the last six months;
15           (B)  One health care consumer who represents senior
16                citizens who have received nursing care in the
17                last six months; and
18           (C)  One health care consumer receiving nursing care in
19                a long-term/home care setting in the last six
20                months;
21      (2)  Two representatives from the Hawaii Nurses'
22           Association;
23      (3)  Two representatives from the Healthcare Association of

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 1           Hawaii;
 2      (4)  One representative from the board of nursing;
 3      (5)  One representative from the Hawaii Long-Term Care
 4           Association;
 5      (6)  One representative from the Hawaii Association for Home
 6           Care; and
 7      (7)  One representative from the University of Hawaii,
 8           School of Nursing.
 9      SECTION 5.  The commissioner shall report to the legislature
10 not later than twenty days prior to the convening of the regular
11 session of 2000 on the progress being made in the development and
12 adoption of rules ensuring Hawaii's patients' rights to nursing
13 care.  The patients' rights to nursing care commission shall
14 terminate upon the adjournment, sine die, of the regular session
15 of 2000.
16      SECTION 6.  There is appropriated out of the general
17 revenues of the State of Hawaii the sum of $          , or so
18 much thereof as may be necessary for fiscal year 1999-2000, for
19 the purposes of this Act.  The sum appropriated shall be expended
20 by the insurance commissioner.
21      SECTION 7.  This Act shall take effect on July 1, 1999.
23                           INTRODUCED BY:  _______________________