On June 12, 2023, Governor Ned Lamont signed legislation that imposes significant burdens on Connecticut hospitals concerning nurse staffing plans, staffing committees, reporting requirements, civil penalties for non-conforming hospitals and the right of nurses to object to participating in certain hospital activities.  The law becomes effective October 1, 2023.

Under Public Act 23-204, hospitals must create a dedicated staffing committee to develop annual nurse staffing plans. The committee must include at least 50% direct care registered nurses (RNs) employed by the hospital as well as non-direct care RNs and a “broad base” of representatives “across hospital services.”

Although specific staffing ratios were proposed during the legislative session, the law does not expressly mandate such ratios.

The legislation affects both unionized and non-union hospitals. Key components include:

Establishment and Composition of Hospital Staffing Committees for Nurse Staffing Plans

Where RNs are unionized, the union will select direct care RNs to comprise at least 50% of the committee. The union will then provide the hospital with a list of other direct care RNs. Hospital management will choose an additional committee member from the list.  Thus, a majority of the committee will always consist of direct care RNs.

Where RNs are not represented by a union, the committee will be selected through a process in which the direct care RNs decide upon members of the committee. To determine the selection process, the existing hospital staffing committee must solicit feedback from all direct care RNs. Once feedback is gathered, the existing staffing committee shall select the best process via a majority vote. The remaining committee members (beyond 50% +1 RNs) shall be selected by hospital management.

In both unionized and non-unionized facilities, the hospital staffing committee shall have two co-chairpersons with direct patient care experience. One chair shall be elected by the committee’s direct care RNs. The other chair will be elected by committee members who are not direct care RNs.

Compensation for Committee Participation

Employees who serve on the staffing committee shall be compensated at their regular pay rate, including differentials, for their time spent serving on the committee. Hospitals are asked but not mandated to treat the time employees spend serving on the committee as part of their regularly scheduled work week to the extent possible. Hospitals will have an obligation to arrange sufficient coverage to allow direct care RNs to attend committee meetings.  

Responsibilities of the Hospital Staffing Committee

The RN staffing committee is tasked with:

1. Evaluating research about patient outcomes;
2. Sharing procedures for communicating concerns about the staffing plan and staffing assignments; and
3. Reviewing all reports communicated to the committee about these concerns or any RN’s objection or refusal to participate in a staffing assignment.

In order to conduct committee business, a majority of the committee members must be present. The committee must take minutes of each meeting. Upon request, the committee must make these minutes available to any hospital staff member. The committee is required to submit its minutes to the Connecticut State Department of Public Health (DPH) upon request.

Hospital Duties re Staffing Committees

Hospitals must inform nurses on their hire date, and annually thereafter, about the staffing committee. Such notices shall include the staffing committee’s purpose, the criteria and process for becoming a member, the hospital’s internal review process for the nurse staffing plan, and how input is obtained from direct care RNs and other members of patient care teams in developing the plan.

Hospitals must maintain for at least the previous three years records regarding the ratios of patients to direct care RNs per patient care unit per shift, and assistive personnel¹ providing patient care per patient care unit per shift.

Records must include the number of:

1. Patients in each unit during each shift;
2. Direct care RNs assigned to each patient in each unit on each shift; and
3. Assistive personnel providing patient care assigned to each patient in each unit on each shift.

Upon request these records must be made available to the DPH, hospital staff, patients, collective bargaining representatives, and the public.

Adoption and Submission of Nurse Staffing Plans to the State

Hospitals shall produce prospective nurse staffing plans semi-annually to the DPH, by January 1 and July 1. The plan must include a written certification that it is sufficient to provide adequate and appropriate patient health care services. Hospitals are required to post the plans on each patient care unit in a location that is accessible and visible to staff, patients, and the public.

Beginning January 1, 2024, the contents of each submitted plan must include:

1. Information on hospital staff objections or refusals to comply with the nurse staffing plan communicated to the hospital staffing committee;
2. Measurements and other evidence indicating the plan’s successful implementation;
3. Direct care registered nurse staff retention, turnover, and recruitment metrics, including (a) turnover rate per hospital unit during the prior 12 months and (b) average years of experience of permanent direct care RN staff per unit;
4. Each time since the last plan was submitted that the hospital was non-compliant with the plan, including nurse staffing ratios, a description of how and why the hospital was non-compliant, and the hospital’s plans to avoid future noncompliance; and
5. Certification that the hospital and its hospital staffing committee are meeting the law’s requirements, with a description of how each requirement is being met.

Hospital Compliance with Nurse Staffing Requirements, Further DPH Reporting, Civil Penalties

Hospitals must report twice a year to DPH regarding their compliance with nurse staffing assignments in the nurse staffing plans. This reporting obligation begins October 1, 2024. If the DPH receives complaints of noncompliance, it shall investigate and, if necessary, issue orders that require the hospital to implement corrective action plans and pay civil fines. The DPH may also audit nurse staffing assignments.

Compliance Requirements

The periodic reports on compliance require hospitals to inform the DPH whether they have complied in the past six months with at least 80% of nurse staffing assignments as outlined in the submitted nurse staffing plan.

DPH Actions for Noncompliance

The DPH Commissioner may issue an order that requires a hospital to submit and implement a corrective action plan. DPH may disapprove the plan within 20 business days of submission. It may impose a civil penalty of $3,500 for the first violation and $5,000 for subsequent violations if a hospital fails to:

1. Establish or maintain a hospital staffing committee;
2. Submit required compliance reports to the DPH;
3. Post the staffing plan; or
4. Comply with the plan at least 80% of the time during the reporting period.

Hearings

To oppose a DPH order, a hospital must request a hearing in writing within five business days of receiving the order. The decision is deemed final and takes effect five business days after the hospital receives the order if a written hearing request is not submitted to DPH in a timely manner. Where DPH receives a timely hearing request, it will conduct the hearing as a contested case under the Uniform Administrative Procedure Act (UAPA).

Civil Penalty Payment

DPH Penalties must be paid within 15 days after the final deadline for appealing the DPH order to the Superior Court under the UAPA, or if the hospital does appeal, within 15 days of the final court judgment.

DPH Audits

DPH may audit a hospital’s nursing staffing assignments for each unit as outlined in its nurse staffing plan. Audits may include assessment of the hospital’s compliance with the staffing plan, the accuracy of reports submitted to the DPH, and staffing committee membership.

When deciding to conduct an audit, DPH will consider (1) whether the hospital has been consistently noncompliant with nurse staffing plans, (2) potential false reporting from the hospital, and (3) other healthcare quality safety concerns. The hospital must pay for such an audit. DPH should conduct the audit so as not to interfere with the work of any medical review committee conducting a peer review of hospital activity.

RN Objections to Participation in Certain Hospital Activities

Hospitals are prohibited from requiring RNs to perform patient tasks that are beyond the scope of their license, education, training, or experience. RNs may object to such assignments, activities, policies, or practices assigned by the hospital, unless the refusal occurs:

1. During an ongoing surgical procedure, as the RNs must wait until it is completed;
2. In critical care units, labor and delivery, or emergency departments, as the RNs must wait until they are relieved by another nurse;
3. Public health or institutional emergencies; and
4. Where the RN’s inaction or abandonment would jeopardize patient safety.

Notably, a hospital, the DPH, or the State Board of Examiners for Nursing can require a nurse to complete additional training or education consistent with the nurse’s job description and assigned roles.

RN Refusal/Objection to Participation

A hospital is prohibited from taking adverse actions against an RN for objecting or refusing to perform patient tasks outside their expertise as outlined above, for participating in a hospital staffing committee or for raising concerns about unsafe staffing or workplace violence, racism, or bullying.

Where an RN intends to refuse or object to participation in any activity, policy, practice or task the hospital assigns, the RN must immediately contact a supervisor to obtain assistance or allow the hospital to find a suitable replacement. Within 12 hours, the objecting/refusing RN must submit a written report on a form developed by the hospital and approved by DPH. This form shall include:

1. Detailed statement that outlines the reasoning for refusal or objection;
2. A description of how the RN claims the activity, policy, practice, or task would compromise patient safety; and
3. How the RN claims the activity, policy, practice, or task was inconsistent with the nurse’s education, training, experience, or job description.

Hospital Review of Refusal/Objection Forms

Hospitals must review and analyze the reports made on these forms and implement necessary adjustments to nurse staffing assignments to improve patient safety where necessary. Hospitals must provide the DPH with confidential access to the forms upon request.

Complaints

An RN may file a complaint with the nurse staffing committee if the RN believes their participation in an activity, practice, or task violates a provision of the nurse staffing plan or a policy of the nurse staffing committee. The hospital and its nurse staffing committee shall review all RN complaints when received and provide the DPH with an analysis of actions the hospital and the nursing staffing committee took in response to the complaints.

Takeaways

While the new legislation stops short of prescribing specific staffing ratios, it mandates specific nurse staffing committee requirements that RN unions and advocates can be expected to use to accomplish staffing ratios indirectly.  

Union and non-union hospitals face mandatory and burdensome compliance obligations concerning the new staffing committee and reporting requirements. Hospitals will learn only once the arduous new obligations are in place exactly how they will affect existing labor-management relationships. The new law itself will become effective October 1, 2023. The first staffing plans required under it must be submitted by January 1, 2024. Hospitals should begin their compliance planning immediately, inasmuch as it appears that the new nurse staffing committees and staffing plans will take considerable study to formulate and time to create.