Some Hospitals Met Nurse Ratios

Times Staff Writer

Though the hospital industry has insisted it was all but financially impossible to meet the state’s strict nurse-to-patient ratios, a number of hospitals have been able to do it without breaking their budgets.

About 36% of the hospitals inspected by the state’s Department of Health Services passed their surveys, according to a Times review of state data from the first 10 months of last year.

That’s more than the 15% compliance rate that the California Healthcare Assn. has estimated based on its survey of 300 institutions.

The findings come as the Schwarzenegger administration and major hospitals are trying to scale back the ratios in California, which was the first state in the nation to limit the number of patients a nurse can treat.


Though most of the hospitals inspected by the state did not meet the ratio standards, those that did offer a lesson in balancing the financial burden of hiring more nurses with the benefits of complying with the law.

The hospitals that have been able to meet the ratios vary in size and location, from a 70-bed public facility in Banning to a 540-bed medical center run by UC San Diego.

But they tend to have several things in common:

* Many have been able to make up the costs of more nurses by renegotiating rates with private insurance companies or persuading insurers to send more patients their way.


* Most are in relatively good fiscal health, with a median net income of about $10 million for 2003. Only two facilities reported losses for 2003.

* Officials at some hospitals say they have less trouble recruiting than other medical centers because their facilities have nationally known specialties and they work hard to keep their nurses happy. Their rates for turnover and job vacancy are lower than state averages, which both hover around 15%.

The hospitals also tend to have low rates of using temporary nurses. Many have the added perk of being in attractive locations: pretty seaside towns, for instance, or areas with affordable housing.

The numbers of patients that nurses are allowed to handle are based on the severity of patients’ illnesses. In an operating room, for example, each patient is required to have a nurse. In a medical-surgical ward, one nurse can care for six patients.


The nurse-patient ratio law took effect in January 2004. But Gov. Arnold Schwarzenegger’s administration has moved to scale it back, citing complaints from hospitals. Schwarzenegger wants to give hospitals more flexibility in emergency rooms during unexpected surges of patients. He also wants to delay implementation of a second phase of the law that would further reduce nurse-to-patient ratios.

The department inspects hospitals only when it receives a complaint, and it had completed reports on nurse staffing at just 28 hospitals by October. A Times review of those reports showed that 10 hospitals complied with the law.

One of those hospitals was UC San Diego Medical Center, which was accused of assigning nurses too many patients in the orthopedics department in January. When a state inspector reviewed records in February, she found nothing wrong.

Mary Middleton, the hospital’s chief nursing officer, said she manages the situation by having her office count heads at the units every four to six hours.


She also constantly tries to predict influxes of patients by the time of day, day of the week and weather. For instance, she said, clusters of patients often show up after 5 p.m. because clinics close at that time.

People often arrive Monday because they wait for doctors’ offices to open on the first work day of the week and then find out they need care at the medical center. When it rains, she added, there usually are more car accidents, so she beefs up intensive care units.

If a unit needs a nurse, Middleton said, she tries not to use temporary nurses -- who cost on average about $65 an hour, compared to $40 an hour for a staff nurse.

If staffing officials determine that a unit needs more nurses, they begin by calling part-time nurses who work only on certain days and full-time staffers who might want to earn overtime pay.


Robert Hogan, the hospital’s chief financial officer, said it has cost an extra $10 million to meet the ratios. Administrators found the money by renegotiating contracts with private insurance companies to reimburse at 6% to 10% more than they did before. Hogan said the hospital also expected to make up some of the money by economizing on supplies.

But even facilities that have done well in meeting the ratios insist that they struggle to do so, and say they may not always have the numbers right every hour of every day.

Passing an inspection can be “luck of the draw,” said Jennifer Jacoby, who oversees nursing at Sharp Mary Birch Hospital for Women in San Diego, which also passed a state inspection.

“If they come in and say, ‘Show me staffing schedules for April 5 and 10,’ it can be great on the 5th and 10th and not on the 11th,” she said.


Indeed, two other hospitals she oversees at the same campus, Sharp Memorial Hospital and Sharp Mesa Vista Hospital, did not pass the state review. Jacoby said she set down the same nursing rules for all three sites.

One policy that has helped Mary Birch is shifting some scheduled nurses to “on-call” status when there are not as many patients as expected. If, for instance, four nurses were scheduled to work, but managers found that three could handle the load, the fourth could leave and return when new patients came to the unit. This nurse would receive a lower rate of pay when she was off-campus, but would receive full salary if she had to come back.

Jacoby said Mary Birch had several strategies for paying the $2.3 million in added costs for nurses to meet the ratios. As an example, she said, the hospital was able to persuade insurers to send more women to give birth at Mary Birch because the free-standing women’s hospital handles a high volume of births and has specialized staff and equipment to handle difficult deliveries.

A state inspection of Glendale Memorial Hospital for staffing has not been completed, but the nursing union and the Hospital Assn. of Southern California say the hospital has become a model for complying with the ratios.


The facility has added about $1 million to the budget -- including creating two positions just to monitor the ratios -- to pay for the new staffing law, said Patrick Lash, chief financial officer. The hospital will make less money this year than the $6 million in profit last year, but will remain on the plus side, he said.

Like UC San Diego, Glendale Memorial has been able to stanch most of the loss by negotiating higher reimbursement rates from private insurance companies. Lash said the hospital, which is part of Catholic Healthcare West, also plans to reduce some costs by buying supplies in bulk with other network hospitals and paying less for services such as legal consultations.

Glendale’s low usage of traveling and local registry nurses helps keep the costs of the ratios in check, officials said.

Fewer than 1% of the nurses at work on a given day come from temporary agencies, said Rhoda Vincent, who oversees nursing for the hospital. Vincent said the facility has been able to hire 340 full-time nurses and has to cover for only 36 vacancies.


“We have to make sure our nurses are happy,” Vincent said. “We have a low turnover rate -- 0.2% for this past year -- so I think we are.”

Though the 36% compliance rate for meeting the ratios is more than the hospital association found, it is far less than the 80% estimated by the nurse union that pushed for the law.

Though both sides stand behind their statistics, they acknowledge that the state’s inspections are a useful snapshot of hospital compliance.

Jan Emerson, spokeswoman for the California Healthcare Assn., said state reports don’t tell the whole story.


Inspectors pulled only selected records during their visits and looked at just a fraction of the 450 hospitals licensed in the state, she said.

Jill Furillo, who is Southern California director for the California Nurses Assn. and lobbied for the ratio law, said nurses monitoring 175 hospitals have told her that far more facilities were in compliance than the state found.

“What the data is showing and what our information is showing is, where there is a will, there is a way to meet the ratios,” she said.




Hospital staffing

A Times review of state data from the first 10 months of 2004 revealed that 10 of 28 hospitals inspected for nurse staffing were complying with the law:

Desert Regional Medical Center in Palm Springs


Petaluma Valley Hospital in Petaluma

Riverside Community Hospital in Riverside

San Gorgonio Memorial Hospital in Banning

Scripps Memorial Hospital in Chula Vista


Sharp Grossmont Hospital in La Mesa

Sharp Mary Birch Hospital for Women in San Diego

Sutter Solano Medical Center in Vallejo

Ukiah Valley Medical Center in Ukiah


UC San Diego Medical Center

Source: California Department of Health Services