Patient-to-Nurse Ballot Measure Could Have a Big Impact on Massachusetts Providers

As election season comes to a head, Massachusetts Health Care Providers should be learning all they can about ballot measure Question 1, the “Initiative Petition for A Law Relative to Patient Safety and Hospital Transparency” (the “Initiative”).  The Initiative sets maximum patient-to-nurse assignment limits, creates new patient assessment requirements, and conveys enforcement authority for regulating the great majority of hospitals and acute care facilities in the Commonwealth. The measure applies to hospitals licensed under M.G.L. c. 111 § 51, “the teaching hospitals of the University of Massachusetts medical school, any licensed private or state owned and state-operated general acute care hospital, acute psychiatric hospitals, and any acute care unit within a state operated health care facility.” Rehabilitation and long-term care facilities fall outside the scope of the measure.


If adopted, the Initiative would set the following patient-to-nurse assignment limits:

  • Step-Down Intermediate Care—Patients requiring intermediate level of care between the intensive care unit and general medical surgical unit—three (3) patients per nurse.
  • Post Anesthesia Care (PACU) — One (1) patient under anesthesia per nurse; Two (2) patients post-anesthesia per nurse.
  • Operating Room (OR) Units—One (1) patient under anesthesia per nurse; Two (2) patients post-anesthesia per nurse.
  • Emergency Services Departments:
    • One (1) critical or intensive care patient per nurse. (RNs may accept a second patient if initial patient is assessed as “stable”.)
    • Three (3) urgent stable patients per nurse.
    • Five (5) non-urgent stable patients per nurse.
  • Maternal Child Care Patients:
    • One (1) patient in active labor, with intermittent auscultation, or obstetrical complication per nurse.
    • During Birth and Two Hours Post Partum: One (1) Mother per nurse whose sole responsibility is the mother AND (1) baby per nurse whose sole responsibility is the baby.
    • After mother and child are stable and critical elements are met, one nurse may be assigned to mother and baby.
    • Uncomplicated Postpartum Mother/Baby: Six (6) total individual patients / three (3) couplets.
    • Intermediate or Continuing Care Babies: Two (2) babies per nurse.
    • Well-baby patients: Six (6) per nurse.
  • Pediatric Patients—Four (4) pediatric patients per nurse.
  • Psychiatric Patients—Five (5) psychiatric patients per nurse.
  • Medical, Surgical, Telemetry Patients—Four (4) patients per nurse.
  • Observational/Outpatient Treatments—Four (4) patients per nurse.
  • Rehabilitation Patients—Five (5) patients per nurse.
  • Other Unspecified Units—Four (4) patients per nurse.

In addition to staffing requirements, the Initiative requires facilities to develop a compliant “Patient Acuity Tool” designed to improve care quality in conjunction with a RN’s assessment and clinical judgment. This tool must be developed by a committee with a majority membership of staff nurses.  The tool will be utilized by nurses to determine whether a lower nurse-to-patient ratio should be applied to a particular patient. The Patient Acuity Tool must be certified by the Massachusetts Health Policy Commission (“HPC”) based on a proscribed criteria and providers should expect the HPC to promulgate regulations governing the tool’s content and implementation. The Initiative also compels the HPC to develop a notice regarding these requirements that must be placed on display in each unit, patient room, or waiting area.

The Initiative empowers the HPC to enforce the foregoing through facility inspections and the imposition of fines up to $25,000 for each initial violation and up to $25,000 per day following notification. Failure to properly post notice may result in a civil penalty between $250 and $2,500.

Proponents of the Initiative argue that patient-to-nurse limits improve nursing outcomes by preventing burnout and increasing job satisfaction. This is believed to translate to systemic improvements in patient outcomes and safety.  However, the Initiative specifically states that the new staffing requirements must be implemented without reducing other health care workforce staffing levels. That means that providers will either need to limit services to preserve profitability or grow their workforce to maintain current levels of operation, and those strategic decisions come at a cost.


According to a detailed presentation before the Market Oversight and Transparency Committee on October 3, 2018, the HPC estimates that the Initiative will require an infusion of between 2,286 and 3,101 additional RNs into the workforce, which will drive up demand for qualified nurses resulting in increased RN earnings over time. The HPC’s research also indicates that once these standards are fully implemented, maintaining staffing ratios and the new compliance infrastructure may result in annual increased costs between $676 and $949 million. The HPC cautions that its projections are “conservative” because they do not take certain known costs into account such as implementation into emergency departments, observation units, outpatient departments, or one-time costs. For example, the HPC estimates that acute care hospitals will incur a collective one-time cost as high as $57.9 million just to develop the Patient Acuity Tool. The HPC advises that the measure could result in reductions in hospital margins or assets, reduced capital investments, closure of unprofitable service lines, and reductions in non-health care staffing. The Massachusetts Nurses Association has vehemently challenged the HPC’s cost projections as inflated and misleading.

The Initiative will come to a vote on November 6, 2018. In the intervening period, the HPC will hold Health Care Cost Trends Hearings on October 16 and October 17. Providers with questions about the details of the Initiative and/or plans for future compliance should reach out to a qualified legal professional.