Oregon HCLC Nurse Staffing Audit Report

In keeping with the provisions of House Bill 2800, a 2001 law setting forth requirements for hospital nursing services staffing, HCLC staff developed a standardized audit process intended to evaluate a hospital's compliance with all of the rules related to nurse staffing.

• Introduction
  
• Rule_making Process
  
• Audit Process
  
• Conclusion

• 2005 Nursing Staffing Report - data table only  (60K)
  
• 2005 Nursing Staffing Report - full report   (88K)
  

Introduction

In 2001 the Oregon Legislature enacted into law the provisions of House Bill (HB) 2800. The law can be found in the Oregon Revised Statutes (ORS) 441.160 through 441.192. The law sets forth requirements for hospital nursing services staffing. These include:

• Specific requirements and limitations with respect to hospital nursing services staffing;
• A requirement that hospitals post a notice of the ORS affecting nurses;
• A mandate to the Oregon Department of Human Services to conduct a random audit of not less than seven percent of all hospitals in the state solely to verify compliance with the requirements of ORS 441.162, written staffing plan for nursing services; ORS 441.166, need for replacement of staff; and ORS 441.192, notice of employment outside of hospital;
• A mandate to the Oregon Department of Human Services to prepare an annual report summarizing the audit findings;
• Provisions for assessment of civil penalties, when applicable; and
• Whistle-blower protection.

The Health Care Licensure and Certification (HCLC) section of the Department of Human Services is the agency responsible for the licensure of hospitals in the State of Oregon. HCLC was charged with drafting the Oregon Administrative Rules (OARs) for Hospitals that were required to implement the statutes.

As part of the rule-making process, HCLC convened a work group with broad representation of all interested parties to draft rule language. The work group met a number of times and rules were drafted. Two public hearings were held on the proposed rule language, and the rules were filed on December 10, 2002.

Rule-making Process

The rule-making process resulted in the adoption of two new sections and significant revisions to the OARs for Hospitals for nurse staffing. The rules can be found in the OARs for Hospitals at the following sites:

• 333-500-0056 Annual Random Audits;

• 333-500-0057 Civil Penalties and Table 1-Civil Penalty Assessments;

• 333-505-0005(5) Governing Body Responsibility; and

• 333-510-0045 Nursing Services Staffing

HCLC staff developed a standardized audit process intended to evaluate a hospital's compliance with all of the rules related to nurse staffing. Hospitals were randomly selected from the list of hospitals licensed in the State of Oregon. The audits were unannounced - the surveyors did not notify the hospital of the audit prior to their arrival at the hospital. The same two-surveyor team conducted all audits with the intent of bringing consistency to the process.

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Audit Process

The audit process included the following tasks:

• A tour was conducted of one or more hospital units. Clinical staff on the unit was interviewed with respect to the nursing process and staffing.
• Documentation was reviewed and included, but was not limited to, the hospital's written staffing plan for nursing services; individual unit staffing plans; staffing guidelines or matrices for each unit; the daily staffing or payroll reports for each unit to verify actual staff who worked and the number of hours staff worked; nurse staffing policies; nurse staffing committee meeting minutes; quality assurance data; reports of inadequate staffing filed by clinical staff; nurse sensitive outcome data related to infection control, decubitus ulcers, medication errors, and patient satisfaction surveys; job descriptions; and personnel files for evaluation of current licensure/certification, qualifications, in-service training, and performance evaluations.
• Interviews were conducted with nursing administrative, management, and clinical staff.
• The hospital environment was observed for posting of the required notice.

The findings were reviewed against the requirements set forth in the OARs for Hospitals. A narrative report was documented for each hospital audit. A copy of the report was sent to the hospital along with a standard form entitled a Statement of Deficiencies. A copy of both is retained in the hospital's permanent facility file in the HCLC office.

HCLC staff met with members of the work group on April 22, 2003 following the completion of two hospital audits. The purpose of the meeting was to describe the audit process and seek comments and recommendations from the group. As a result of the meeting, the audit process was modified to include recommendations of the group. The remaining three audits were completed and an annual report was drafted.

HCLC met with the work group again on November 5, 2003. The purpose was to review the nursing services staffing audit process, review the draft annual report, and seek comments and recommendations from the work group with respect to format, content, and distribution of the annual report. The group discussed problems identified during the audits and again made recommendations with respect to the audit process and the annual report.

Conclusion

As a result of this meeting the following changes were made to the audit process and annual report format: surveyors are now able to provide cell phone contact to arrange for confidential interviews with clinical nursing staff during the on site audit; the audit sampling time was increased from one week to two weeks, one week from two separate hospital quarters; and the format of the annual report was changed to include the language of each of the Oregon Administrative Rules for Hospitals for Nurse Staffing.

A copy of the final annual report is on file in the office of Health Care Licensure and Certification located in the Portland State Office Building, 800 NE Oregon Street, Portland, OR 97232. The telephone number is 971-673-0540.

The four audits for fiscal year 2005 were conducted between 02/01/05 and 03/28/05. The licensed bed capacity for the four audited hospitals ranged from 25 beds to 176 beds. The number and type of services provided by the hospitals varied. The staffing plan for nursing services at each hospital corresponded to the level of services provided by the hospital. The number and qualifications of nursing staff members varied accordingly. The complexity of the organization and operation of nursing services corresponded to the size of the hospital organization.

This information provided by the Health Care Licensure and Certification section of the Office of Community Health and Health Planning.

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