Assessing the Impact of California’s Nurse C A L I FOR N I A Staffing Ratios on Hospitals and Patient Care H EALTH C ARE F OU NDATION Introduction address seismic building requirements had far In 2004, California became the first state to greater effects on finances. Hospital administrators establish minimum nurse-to-patient staffing found that it was challenge to meet the staffing requirements in acute-care hospitals. Little is requirements, particularly in ensuring that staff known about how these regulations affected were available at all times, including during breaks Issue Brief California’s hospitals, the market for nursing labor, and meals. Finally, many of the health care leaders or the quality of hospital care. While research and interviewed for the study expressed an expectation news reports do indicate that hospital staffing of that the minimum staffing ratios would increase licensed nurses increased between 2002 and 2004 the quality of care due to increased interaction and employment of unlicensed nursing assistants with patients; however, there was no evident dropped,1– 3 some hospitals did not meet the ratios change in patient length of stay or adverse patient in the first year of their implementation4 – 6 and no safety events. None of these findings were affected significant impact on the quality of patient care by hospital ownership, financial position, or has been measured.7– 9 patient mix. Prior studies have focused on average changes in Background staffing and patient outcomes across all California In 1999, the California State Assembly passed hospitals. This study, in contrast, examines how AB 394, mandating that the state establish the minimum staffing regulations affected different minimum nurse-to-patient staffing in acute-care types of hospitals, categorizing them according to hospitals. Between 1999 and 2002, the California ownership, financial position before the ratios were Department of Health Services developed enacted, and mix of patients. The research then registered and licensed vocational nurse-to-patient probes three issues: ratios.10,11 The law went into effect in January  What strategies did hospitals use to meet 2004 with specific ratios for different types of the staffing requirements? hospital units; for example, the minimum ratio in medical-surgical units was one nurse per six  Are the ratios associated with changes in patients. The ratios were to be adjusted in January hospital financial status? 2005 to require fewer patients per nurse in selected  Did the ratios improve the quality of units; for example, the ratio in medical-surgical hospital care? units would have dropped to one to five. This change was suspended in November 2004 by the The results show that the nurse staffing legislation Schwarzenegger administration, but the suspension resulted in higher use of registered nurses in was invalidated by the Sacramento County most California hospitals. Implementation of the Superior Court in March 2005. Court challenges staffing regulations could not be tied to changes by the California Hospital Association proved in hospital finances; rather, changes in Medicare unsuccessful, and the additional ratio regulations F ebruary and Medi-Cal payment rates and demands to went into full effect on April 7, 2005.12 2009 Licensed vocational nurses (LVNs) may make up half particularly difficult to recruit and retain nurses to meet of the licensed nurses in this ratio, but whether they the staffing regulations. Hospitals that were in weak can be employed to this extent in practice depends on financial positions prior to the enactment of the ratio the needs of patients in the hospital. The legal scope of legislation may not have had the financial resources to practice for LVNs, who must work under the direction pay for more nurses. Differences in hospitals’ ability to of physicians or registered nurses (RNs), does not respond to the regulations may in turn result in variation include administration of intravenous medications or the in the benefit to patients. assessment of patients; thus, in most hospitals LVNs can have full responsibility for only a small share of patients. For the research reported in this issue brief, the methods In addition, hospitals have tended to underuse LVNs by used by hospitals to meet the staffing requirements limiting their role to an even greater degree than the legal were explored: Did permanent employment increase? scope of practice requires.13 Did hiring and retention change? Were more temporary agency nurses used? Changes in hospital Little is known about how the minimum staffing financial positions were also examined. Finally, patient regulations affected hospitals, nursing labor markets, safety measures were compared to learn whether the or the quality of hospital care in California. In fact few implementation of the staffing regulations was associated studies had been conducted from which the state could with improvements in patient safety. For each of develop the ratio requirements. A literature review these three topics, hospitals were categorized by their conducted for the California Department of Health ownership, financial position before the ratios were Services noted that only a handful of recent studies enacted, and mix of patients to learn whether the impact and reviews had demonstrated consistent relationships of minimum staffing ratios varied across hospitals. between staffing levels for licensed nurses and the quality of patient care, and none identified an ideal staffing ratio Methodology for hospitals.14,15 The few publications that examined the This study combined quantitative analysis of several data effect of California’s ratios reported that many hospitals sets with qualitative analysis of interviews conducted at did not appear to be meeting the standard in 2004 — the 12 hospitals. Quantitative analysis of the impact of the first year of the regulation.16 – 18 Recent research also found regulations on staffing, fiscal, and health care outcomes that licensed nursing staff increased notably between was conducted for 410 general acute-care hospitals from 2002 and 2004, while employment of unlicensed nursing 1999 through 2007. The main sources of data were three assistants dropped; however, no significant improvement datasets collected by the California Office of Statewide in the quality of patient care could be detected.19 – 21 Health Planning (OSHPD). With these data, changes in the hours worked by registered nurses, licensed vocational Because the papers published to date have focused nurses, aides and orderlies, and agency-employed nurses on average changes in staffing, patient outcomes, and were examined using the annual hospital disclosure hospital finances across all California hospitals, they may reports. The fiscal health of each hospital was determined not capture the full impact of the ratios, since minimum by comparing operating margins before and after ratios, staffing regulations may have had different effects on using the quarterly hospital financial data. A set of different types of hospitals. Previous studies have found nursing-sensitive metrics devised by the Agency for that some hospitals — such as those with a high share Healthcare Research and Quality (AHRQ) was calculated of publicly insured patients — are more likely to report for hospitals reporting thirty or more patients at risk for a shortage of nurses; these hospitals may have found it 2  |  California HealthCare Foundation an incident during one time period, using the patient Interviews were conducted with 23 chief nursing officers, discharge data. chief nurse executives, vice presidents of nursing, chief executive officers, emergency department directors, and Changes in employment also were studied using the base other managers and directors. Hospitals selected for the wage file of the California Employment Development case studies were chosen to represent a range of financial Department (EDD) from 1998 through 2007. These and recruiting positions from good to weak. Twenty data compile wage and employment information that hospitals were contacted for the study, with 12 agreeing to are primarily collected for unemployment insurance and participate. Seven of the 12 hospitals are nonprofits, four disability insurance programs. The base wage file does not are public hospitals, and one is for-profit. The researchers include occupation data, so it was not possible to identify also interviewed several people currently or recently registered nurses. Thus, all analyses of turnover were employed in the insurance industry to learn how the conducted for all hospital employees. Since RNs account ratio regulations were addressed in contract negotiations for about one-third of hospital employees, it is expected between hospitals and payers. that hospital-wide turnover rates will reflect proportional changes in nurse staffing. The final database included Findings 244 employers. Due to the confidentiality of wage and employer information, all analyses of these data were Staffing Changes and Challenges performed by the EDD. The nurse staffing legislation resulted in higher employment of licensed nurses in most California All quantitative data were first analyzed for all hospitals hospitals. Figure 1 presents changes in hours worked combined. The analyses were then repeated for three by RNs, LVNs, and aides/orderlies between 1999 and categorizations of hospitals: profit status (public, 2006. The hours worked by regular RN employees and for-profit, and nonprofit), fiscal strength (fiscally agency RNs also are indicated. RN hours per patient day strongest, fiscally weakest, and average fiscal position), increased throughout this period, with more rapid growth and patient demographics (i.e., those serving higher- after 2002. Agency RN hours rose notably between 2000 income populations with few recent immigrants; those and 2002. After 2002, RN hours per patient day for whose patient mix includes a disproportionate share of non-agency RNs increased. The levels of LVN and aide lower-income, non-resident, or homeless patients; and hours were fairly stable throughout the entire period. average patient mix). Table 1 presents the number of each category of hospital included in this study. Figure 2 compares RN hours per patient day before and after 2004, for all hospitals and by type of hospital. Table 1: Number of Hospitals in the Study, by Type Prior to the enactment of the ratios, nonprofit hospitals Nonprofit 223 had the highest number of RN hours per patient day, For-profit 125 while district, for-profit, and fiscally weak hospitals had District 41 fewer RN hours per patient day. After the ratios were Public 30 implemented, average RN hours per patient day increased Fiscally Strong (average operating margin: 10.9 percent) 42 for hospitals overall, as well as for each type of hospital. Fiscally Weak (average operating margin: – 15.8 percent) 31 This growth varied by type of hospital. One might expect Lower-income Patients 71 (average share of patients in public programs: 64.7 percent) that staffing would have increased more among hospitals Higher-income Patients 39 that had lower initial staffing; however, this is not the case (average share of patients in public programs: 51.7 percent) Total 410 for the groups presented in Figure 2. Less growth in RN Assessing the Impact of California’s Nurse Staffing Ratios on Hospitals and Patient Care  |  3 Figure 1: Changes in Nursing Hours per Patient Day, 1999 – 2006 MNS legislation passed MNS Phase I MNS Phase II 8 All RNs 7 Non-registry RNs 6 Registry RNs LVNs 5 Aides and Orderlies 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 Source: Office of Statewide Planning and Development, Hospital Annual Financial Data, Fiscal Years 24 through 32, October 2008. hours per patient day was observed for district hospitals, Figure 3 examines hospital hiring of new employees from for-profit hospitals, and hospitals with lower-income 1999 through 2007, as calculated from the EDD’s base patients — all of which had initial staffing below the wage file. Hiring peaked in 2002 for all hospitals, with statewide average. an average of 29 percent of employees being new to their Figure 2: Changes in Average Nursing Hours per Patient Day, by Hospital Type, Before and After 2004 R N H O U R S P E R PAT IENT DAY Additional After Ratios Before Ratios 8 16.5% 16.2% 7 18.9% 16.5% 15.9% 1.0 19.2% 14.6% 14.3% 1.0 0.9 6 1.1 0.9 0.8 0.8 14.5% 1.0 6.2 5.9 0.7 5.8 5 5.6 5.7 5.7 5.5 5.4 4 4.9 3 2 1 0 All Nonprofit For-profit District Public Fiscally Fiscally Higher-income Lower-income Hospitals Strong Weak Patients Patients Source: Office of Statewide Planning and Development, Hospital Annual Financial Data, Fiscal Years 24 through 32, October 2008. 4  |  California HealthCare Foundation Figure 3: Percent of Employees New to Hospitals Each Year, by Hospital Type 35% All Hospitals 30% Nonprofit For-profit 25% Public and District 20% 15% 10% 5% 0% 1999 2000 2001 2002 2003 2004 2005 2006 2007 Source: California Employment Development Department, Hospital Employee Wage File, 1999 through 2007, October 2008. hospitals that year. For-profit hospitals increased their ratios in 2004, most hospitals had completed financial hiring earlier, in 2001. This is not surprising because and staffing assessments. A few interviewees reported staffing levels at for-profit hospitals were below the that staffing ratios at their hospitals or units were already statewide average before the ratios were implemented, at or above the mandated levels, but most reported that which meant they had a greater need to hire to meet they needed to hire more RNs to meet the requirements, the regulations. Hiring by nonprofit hospitals was particularly to cover meals and breaks. California’s labor comparatively stable over time, though it decreased code regulates how many meal breaks employees must somewhat after 2001. Hiring by public hospitals, which receive based upon shift length, and the interaction of this in Figure 3 includes district hospitals, also was fairly stable regulation with the minimum staffing requirement posed between 1999 and 2007. Hospitals that served a greater a particular challenge. proportion of higher-income patients engaged in more hiring throughout this time period, with hiring rising The majority of the individuals interviewed for this study, notably in 2003, dropping in 2004, and then rising again both at high-performing and under-performing hospitals, through 2007. Hospitals that served more lower-income/ discussed the problems associated with meeting the “at all non-resident patients increased hiring somewhat in 2001 times” requirement of the ratios law in conjunction with and 2002, but decreased hiring after 2004. Fiscally strong meal breaks for staff. This challenge was addressed with hospitals did more hiring than fiscally weak hospitals, but a wide variety of solutions. Many created “float pools” to the difference was not large. (In the interest of clarity, the have a supply of staff to cover meal breaks. Charge nurses data tracking patient demographics and financial strength and nurses from registries are also used to cover meal were not included in Figure 3.) breaks. One hospital created a position whereby a nurse works a truncated shift for the sole purpose of providing The hospital leaders interviewed for this study reported meal breaks. Several interviewees noted that the need to that they faced many challenges as the staffing regulations cross-train staff increased, particularly in specialty areas, were put in place. Prior to the implementation of the in order to increase float coverage. Some interviewees Assessing the Impact of California’s Nurse Staffing Ratios on Hospitals and Patient Care  |  5 thought the implementation of the ratios increased in sick. Another recommendation focused on using tension between management and staff, and associated acuity-based ratios, so as to avoid situations where the this with rules regarding meal breaks. The combination minimum staffing regulations dictate a lower ratio than of meal break and staffing regulations was perceived as was generally thought of as necessary, or vice versa. The reducing the ability of staff nurses to use their professional night shift and patients waiting to be discharged were judgment in determining the best time to take a break, both cited as examples of situations requiring fewer nurses and interviewees believed that nurses found this loss of than the ratios prescribe. On the other hand, caring for autonomy frustrating. patients with complex conditions, such as multiple and chronic illnesses, was cited as an example of an area where Nine of the 12 hospitals that participated in the the staffing ratios fell short of meeting the patient’s needs. interviews reported that 90 percent or more of their nursing staff were RNs, and six hospitals said they employ Fiscal Stability and Change traveling or agency nurses to meet staffing requirements. Over the eight years examined in this study, California’s Many hospital leaders reported difficulty finding specialty hospitals experienced decreasing operating margins; nurses or experienced nurses holding bachelor’s or master’s however, these changes could not be tied directly to the degrees, noting that new graduates are not appropriate for nurse staffing legislation. A variety of financial policies some positions. Interviewees also noted that they could had a substantial effect on hospitals from 1999 to 2007. not readily use LVNs to meet the staffing regulations due to their limited scope of practice. Because only RNs can Medicare margins severely declined as the Balanced assess patients and administer intravenous medications Budget Act of 1997 constricted government payment those few hospitals that used LVNs had to partner them rates and Medicare significantly changed its billing with RNs; some of the nursing managers reported that procedures and payment streams.22,23 After a series of their RN staff thought this arrangement increased their emergency state funding bills, California had fewer workload, since they had to provide care to both their hospitals reporting operating deficits in 2005 than in own and the LVN’s patients while supervising the LVN. A 1999. However, in late 2005, the state began enacting a reduction of ancillary staff support was reported at several series of changes in Medicaid funding that, along with of the hospitals. These reductions resulted in additional new changes in Medicare funding, sought to decrease primary care duties for the RNs, such as giving baths to government transfers to safety-net hospitals. patients. Managers reported hearing from their RN staff that they were unhappy with these additional job tasks As a result of these policies and trends, by 1999, the and the shift in their role in patient care. These issues first year examined in this study, California hospitals were of equal importance among both high-performing had experienced significant declines in operating and under-performing hospitals. margins. Hospitals started to recover from these fiscal woes in 2001, but by 2004 margins had declined again. Overwhelmingly, interviewees said they want some These declines occurred primarily in district hospitals, flexibility in applying the ratios. particularly the removal for-profit hospitals, hospitals serving higher-income or of the “at all times” language. The lack of flexibility was lower-income patients, and hospitals that prior to 2002 singled out as the reason hospitals have trouble remaining were fiscally strongest (Figure 4). Public, nonprofit, in compliance, since it is expensive and challenging and the fiscally weakest hospitals experienced increases to maintain the mandated ratios at all times and in all in operating margins over the same period, while contingencies, such as days when too many nurses call public hospital margins declined after 2004. Due to 6  |  California HealthCare Foundation Figure 4: Operating Margins Prior to Ratios for Selected Types of California Hospitals MNS legislation passed MNS Phase I MNS Phase II 20% All Hospitals 15% Fiscally Strongest Mostly Higher-income Patients 10% Mostly Lower-income Patients For-profit Hospitals 5% District Hospitals 0% –5% –10% 1999 2000 2001 2002 2003 2004 2005 2006 Source: California Office of Statewide Planning and Development, Hospital Quarterly Financial Data, 1999 through 2006, October 2008. these pre-ratio trends, most hospital types experienced one reason for rising costs, and that these costs are likely statistically significant variation in operating margin after passed on to the consumer. ratios. (The two exceptions were district hospitals and those serving mostly higher-income patients.) While the Quality of Care ratio regulations may have influenced the amount of The desired outcome of minimum nurse staffing change experienced by each hospital type, this analysis legislation was the improvement of patient outcomes; cannot isolate any such effect. In fact, it is likely that the however, most of the quality measures analyzed for staffing requirements had at most a marginal impact on this study do not appear to have been directly affected hospital financial stability. by the increase in RN staffing. For example, one of the metrics sensitive to nursing care, average length of Several of the nursing executives and managers reported patient stay, showed very low rates of change during that the staffing legislation made it easier to secure the study period. Average length of stay did not change additional funding or avoid budget cuts within their own for nonprofit hospitals, increased significantly in public hospitals, particularly for hiring nursing staff. However, hospitals, and decreased significantly among for-profit CEOs at both high- and under-performing hospitals hospitals. As a result, the overall level of average length said that it was difficult to absorb costs related to the of stay in California has stayed the same since the ratios ratios. They noted that they needed to find funds from were imposed. Other nursing-sensitive measures such other budget areas, which in some cases involved the as decubitus (pressure) ulcers, failure to rescue after reduction of some services. A small number reported a post-surgical complication, deep vein thrombosis/ that their hospitals successfully obtained higher insurance pulmonary embolism (DVT), pneumonia mortality, reimbursement rates from insurers to defray some of the and postoperative sepsis show similar results. Figure 5 increased costs. The insurers interviewed for this study shows the average ratio of observed patient incidents over indicated that hospitals have cited the minimum ratios as expected patient incidents for all California hospitals. Assessing the Impact of California’s Nurse Staffing Ratios on Hospitals and Patient Care  |  7 Figure 5: Trends in Patient Safety Measures for California Hospitals, 1998 – 2006 M E A N PAT IE N T OU TCOM ES POOR 2.0 MNS legislation passed MNS Phase I MNS Phase II Failure to Rescue Post Operative Sepsis 1.6 Pneumonia Mortality Deep Vein Thrombosis 1.2 Decubitus Ulcer 0.8 0.4 GOOD 0.0 1999 2000 2001 2002 2003 2004 2005 2006 Source: California Office of Statewide Planning and Development, Patient Discharge Data, 1999 through 2006, October 2008. Adverse event rates calculated using AHRQ patient safety indicators and inpatient quality indicators software, v3.1a, June 2007. Ratios greater than one indicate poorer quality, whereas staffing, or, in rare cases, the emergency departments rates less than one indicate better quality. California were put on diversion so patients had to be transported performed better than expected through the entire period to other hospitals. Very few hospitals had conducted any for rates of DVT and decubitus ulcer. All California analysis of data related to the ratios. While many hospitals hospitals performed worse than expected for rates of conduct regular patient satisfaction surveys, most of the pneumonia mortality and failure to rescue, but these leaders we interviewed said they did not believe there had rates improved throughout the study period and were been a significant change in patient satisfaction as a result improving well before the minimum staffing requirements of the nurse staffing regulations. were implemented. Conclusion Many of the healthcare leaders we interviewed expressed Staffing changes have created challenges and adjustments an expectation that the minimum staffing ratios would for some hospitals, particularly with regard to the raise the quality of care due to increased interaction logistics of meal break compliance and the roles of RNs. with patients. However, only a few interviewees felt that The leaders we interviewed did not notice significant the ratios had resulted in such an improvement. Some changes to the quality of patient care, though emergency expressed concern about the break in the continuity of departments became bottlenecks at some hospitals. care resulting from maintaining compliance between both Leaders reported difficulties in absorbing the costs of the the ratios and the meal break rules. Some interviewees ratios, and many had to reduce budgets, reduce services, reported that the ratios affected patients in their or employ other cost-saving measures. The interviews emergency departments. In those hospitals, emergency did not reveal any important differences in the effects of department waiting times increased, patients occasionally the ratios upon high-performing and under-performing had to be held in the emergency department due to lack hospitals. 8  |  California HealthCare Foundation The minimum nurse staffing regulations did achieve one Endnotes goal of the legislation: skill mix increased in California 1. Donaldson, N., Bolton, L.B., Aydin, C., Brown, D., hospitals. The hours worked per patient by RNs and Elashoff, J., Sandhu M. 2005. “Impact of California’s registry RNs significantly increased. These improvements Licensed Nurse-Patient Ratios on Unit-Level Nurse in skill mix did not have a clear impact on hospital Staffing and Patient Outcomes.” Policy, Politics and Nursing finances. While overall margins declined between 1999 Practice 6(3): 1–12. and 2007, there was no clear relationship between those 2. Conway, P.H., Konetzka T., Zhu, J., Volpp, K.G., declines and the start of staffing ratios. This is likely Sochalski, J. 2008. “Nurse Staffing Ratios: Trends and due to other fiscal challenges facing California hospitals. Policy Implications for Hospitalists and the Safety Net.” Ratios did not appear to affect most nursing-sensitive Journal of Hospital Medicine 3(3): 193–199. outcomes. While the average length of stay changed 3. Donaldson, N., Bolton, L.B., Aydin, C., Brown, D., after 2004, trends in rates of decubitus ulcer, failure to Elashoff, J., Sandhu, M. 2005. “Impact of California’s rescue, and deep vein thrombosis, were not changed. Licensed Nurse-Patient Ratios on Unit-Level Nurse More detailed analysis of this and other nursing-sensitive Staffing and Patient Outcomes.” Policy, Politics and Nursing outcomes is needed to fully explore the effect of nurse Practice 6(3): 1–12. staffing ratios on the quality of patient care. 4. Chong, J.-R. 2004. “Hospitals Fail Nurse Head Count.” Los Angeles Times, December 31, 2004 Authors 5. Chong, J.-R. 2005. Some hospitals met nurse ratios. Joanne Spetz, Ph.D. Los Angeles Times, February 6, 2005. Susan Chapman, Ph.D., R.N. Carolina Herrera, M.A. 6. Spetz, J. 2006. “California Nursing Staff Ratios.” Policy Jennifer Kaiser, B.A. and Politics in Nursing and Health Care, 5 th edition, Mason, Jean Ann Seago, Ph.D., R.N. D., ed. (Philadelphia PA: W.B. Saunders Company, 2006): Catherine Dower, J.D. 518 – 527. Center for California Health Workforce Studies, University of 7. Donaldson, N., Bolton, L.B., Aydin, C., Brown, D., California, San Francisco Elashoff, J., Sandhu M. 2005. “Impact of California’s Licensed Nurse-Patient Ratios on Unit-Level Nurse Staffing and Patient Outcomes.” Policy, Politics and Nursing About the F o u n d at i o n Practice 6(3): 1–12. The California HealthCare Foundation is an independent 8. Greenberg, P.B. 2006. “Nurse-to-Patient Ratios: What Do philanthropy committed to improving the way health care We Know?” Policy, Politics and Nursing Practice 7(1): 14 –16. is delivered and financed in California. By promoting innovations in care and broader access to information, our 9. Bolton, L.B., Aydin, C.E., Donaldson, N., Brown, goal is to ensure that all Californians can get the care they D.S., Sandhu, M., Fridman, M., Aronow, H.U. 2007. need, when they need it, at a price they can afford. For more “Mandated Nurse Staffing Ratios in California: A information, visit www.chcf.org. Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Post-Regulation.” Policy, Politics and Nursing Practice 8(4): 238 – 250. Assessing the Impact of California’s Nurse Staffing Ratios on Hospitals and Patient Care  |  9 10. Donaldson, N., Bolton, L.B., Aydin, C., Brown, D., 19. Donaldson, N., Bolton, L.B., Aydin, C., Brown, D., Elashoff, J., Sandhu, M. 2005. “Impact of California’s Elashoff, J., Sandhu M. 2005. “Impact of California’s Licensed Nurse-Patient Ratios on Unit-Level Nurse Licensed Nurse-Patient Ratios on Unit-Level Nurse Staffing and Patient Outcomes.” Policy, Politics and Nursing Staffing and Patient Outcomes.” Policy, Politics and Nursing Practice 6(3): 1-12. Practice 6(3): 1–12. 11. Bolton, L.B., Aydin, C.E., Donaldson, N., Brown, 20. Greenberg, P.B. 2006. “Nurse-to-Patient Ratios: What Do D.S., Sandhu, M., Fridman, M., Aronow, H.U. 2007. We Know?” Policy, Politics and Nursing Practice 7(1): 14 –16. “Mandated Nurse Staffing Ratios in California: A 21. Bolton, L.B., Aydin, C.E., Donaldson, N., Brown, Comparison of Staffing and Nursing-Sensitive Outcomes D.S., Sandhu, M., Fridman, M., Aronow, H.U. 2007. Pre- and Post-Regulation.” Policy, Politics and Nursing Practice “Mandated Nurse Staffing Ratios in California: A 8(4): 238 – 250. Comparison of Staffing and Nursing-Sensitive Outcomes 12. Dauner, C.D. 2005. “California Hospitals Express Pre- and Post-Regulation.” Policy, Politics and Nursing Practice Disappointment Over Denial of Stay in Nurse Ratio 8(4): 238 – 250. Case.” Sacramento, CA: California Hospital Association, 22. Gold, M., Achman, L. 2002. “Average Out-of-Pocket Media Statement, April 7, 2005. Accessed November 18, Health Care Costs for Medicare+Choice Enrollees Increase 2008 at www.calhealth.org/public/press/Article/107/ Substantially in 2002. Issue Brief, Commonwealth Fund, CHA%20Media%20Statement%20-%20Denial%20of%20 575: 1– 8. Stay%20in%20Nurse%20Ratio%20Case%204-7-05.pdf. 23. Harrison, M.G., Montalvo, C.C. 2002. “The Financial 13. Seago, J.A., Spetz, J., Chapman, S.A., Dyer, W.T. 2004. Health of California Hospitals: A Looming Crisis.” “Supply, Demand, and Use of Licensed Practical Nurses.” Health Affairs 21(1): 15 – 23. Washington, DC: Bureau of the Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services. 14. Kravitz, R., Sauve, M.J., Hodge, M., Romano, P.S., Maher, M., Samuels, S., et al. 2002. “Hospital Nursing Staff Ratios and Quality of Care. Davis, CA: University of California, Davis. 15. Spetz, J., Seago, J.A., Coffman, J., Rosenoff, E., O’Neil, E. 2000. “Minimum Nurse Staffing Ratios in California Acute Care Hospitals. San Francisco: California HealthCare Foundation. 16. Chong, J.-R. 2004. “Hospitals Fail Nurse Head Count.” Los Angeles Times, December 31, 2004 17. Chong, J.-R. 2005. “Some Hospitals Met Nurse Ratios.” Los Angeles Times, February 6, 2005. 18. Spetz, J. 2006. “California Nursing Staff Ratios.” Policy and Politics in Nursing and Health Care, 5 th edition, Mason, D., ed. (Philadelphia PA: W.B. Saunders Company, 2006): 518 – 527. 10  |  California HealthCare Foundation