| (D) The CNO shall report directly to the individual
who has authority to represent the hospital and who is responsible
for the operation of the hospital according to the policies and procedures
of the hospital's governing board.
(E) The CNO shall participate with leadership from
the governing body, medical staff, and clinical areas, in planning,
promoting and conducting performance improvement activities.
(2) Staffing and delivery of care.
(A) The nursing services shall adopt, implement and
enforce a procedure to verify that hospital nursing personnel for
whom licensure is required have valid and current licensure.
(B) There shall be adequate numbers of RNs, licensed
vocational nurses (LVNs), and other personnel to provide nursing care
to all patients as needed.
(C) There shall be supervisory and staff personnel
for each department or nursing unit to provide, when needed, the immediate
availability of an RN to provide care for any patient.
(D) An RN shall be on duty in each building of a licensed
hospital that contains at least one nursing unit where patients are
present. The RN shall supervise and evaluate the nursing care for
each patient and assign the nursing care to other nursing personnel
in accordance with the patient's needs and the specialized qualifications
and competence of the nursing staff available.
(E) The nursing staff shall develop and keep current
a nursing plan of care for each patient which addresses the patient's
needs.
(F) The hospital shall establish a nurse staffing committee
as a standing committee of the hospital. The committee shall be established
in accordance with Health and Safety Code (HSC), §§161.031
- 161.033, to be responsible for soliciting and receiving input from
nurses on the development, ongoing monitoring, and evaluation of the
staffing plan. As provided by HSC, §161.032, the hospital's records
and review relating to evaluation of these outcomes and indicators
are confidential and not subject to disclosure under Government Code,
Chapter 552 and not subject to disclosure, discovery, subpoena or
other means of legal compulsion for their release. As used in this
subsection, "committee" or "staffing committee" means a nurse staffing
committee established under this subparagraph.
(i) The committee shall be composed of:
(I) at least 60% registered nurses who are involved
in direct patient care at least 50% of their work time and selected
by their peers who provide direct care during at least 50% of their
work time;
(II) at least one representative from either infection
control, quality assessment and performance improvement or risk management;
(III) members who are representative of the types
of nursing services provided at the hospital; and
(IV) the chief nursing officer of the hospital who
is a voting member.
(ii) Participation on the committee by a hospital employee
as a committee member shall be part of the employee's work time and
the hospital shall compensate that member for that time accordingly.
The hospital shall relieve the committee member of other work duties
during committee meetings.
(iii) The committee shall meet at least quarterly.
(iv) The responsibilities of the committee shall be
to:
(I) develop and recommend to the hospital's governing
body a nurse staffing plan that meets the requirements of subparagraph
(G) of this paragraph;
(II) review, assess and respond to staffing concerns
expressed to the committee;
(III) identify the nurse-sensitive outcome measures
the committee will use to evaluate the effectiveness of the official
nurse services staffing plan;
(IV) evaluate, at least semiannually, the effectiveness
of the official nurse services staffing plan and variations between
the plan and the actual staffing; and
(V) submit to the hospital's governing body, at least
semiannually, a report on nurse staffing and patient care outcomes,
including the committee's evaluation of the effectiveness of the official
nurse services staffing plan and aggregate variations between the
staffing plan and actual staffing.
(G) The hospital shall adopt, implement and enforce
a written official nurse services staffing plan. As used in this subsection,
"patient care unit" means a unit or area of a hospital in which registered
nurses provide patient care.
(i) The official nurse services staffing plan and policies
shall:
(I) require significant consideration to be given to
the nurse staffing plan recommended by the hospital's nurse staffing
committee and the committee's evaluation of any existing plan;
(II) be based on the needs of each patient care unit
and shift and on evidence relating to patient care needs;
(III) require use of the official nurse services staffing
plan as a component in setting the nurse staffing budget;
(IV) encourage nurses to provide input to the nurse
staffing committee relating to nurse staffing concerns;
(V) protect from retaliation nurses who provide input
to the nurse staffing committee; and
(VI) comply with subsection (o) of this section.
(ii) The plan shall:
(I) set minimum staffing levels for patient care units
that are:
(-a-) based on multiple nurse and patient considerations
including:
(-1-) patient characteristics and number of patients
for whom care is being provided, including number of admissions,
discharges and transfers on a unit;
(-2-) intensity of patient care being provided and
variability of patient care across a nursing unit;
(-3-) scope of services provided;
(-4-) context within which care is provided, including
architecture and geography of the environment, and the availability
of technology; and
(-5-) nursing staff characteristics, including staff
consistency and tenure, preparation and experience, and the number
and competencies of clinical and non-clinical support staff the nurse
must collaborate with or supervise.
(-b-) determined by the nursing assessment and in accordance
with evidence-based safe nursing standards; and
(-c-) recalculated at least annually, or as necessary;
(II) include a method for adjusting the staffing plan
shift to shift for each patient care unit based on factors, such as,
the intensity of patient care to provide staffing flexibility to meet
patient needs;
(III) include a contingency plan when patient care
needs unexpectedly exceed direct patient care staff resources;
(IV) include how on-call time will be used;
(V) reflect current standards established by private
accreditation organizations, governmental entities, national nursing
professional associations, and other health professional organizations
and should be developed based upon a review of the codes of ethics
developed by the nursing profession through national nursing organizations;
(VI) include a mechanism for evaluating the effectiveness
of the official nurse services staffing plan based on patient needs,
nursing sensitive quality indicators, nurse satisfaction measures
collected by the hospital and evidence based nurse staffing standards.
At least one from each of the following three types of outcomes shall
be correlated to the adequacy of staffing:
(-a-) nurse-sensitive patient outcomes selected by
the nurse staffing committee, such as, patient falls, adverse drug
events, injuries to patients, skin breakdown, pneumonia, infection
rates, upper gastrointestinal bleeding, shock, cardiac arrest, length
of stay, or patient readmissions;
(-b-) operational outcomes, such as, work-related injury
or illness, vacancy and turnover rates, nursing care hours per patient
day, on-call use, or overtime rates; and
(-c-) substantiated patient complaints related to staffing
levels;
(VII) incorporate a process that facilitates the timely
and effective identification of concerns about the adequacy of the
staffing plan by the nurse staffing committee established pursuant
to subparagraph (F) of this paragraph. This process shall include:
(-a-) a prohibition on retaliation for reporting concerns;
(-b-) a requirement that nurses report concerns timely
through appropriate channels within the hospital;
(-c-) orientation of nurses on how to report concerns
and to whom;
(-d-) encouraging nurses to provide input to the committee
relating to nurse staffing concerns;
(-e-) review, assessment, and response by the committee
to staffing concerns expressed to the committee;
Cont'd... |
