§250.1130. Nurse Staffing by Patient Acuity

a)         As used in this Section, the following definitions apply:

 

"Acuity Model" – means assessment tool selected and implemented by a hospital, as recommended by a nursing care committee, that assesses the complexity of patient care needs requiring professional nursing care and skills and aligns patient care needs and nursing skills consistent with professional nursing standards.

 

"Direct Patient Care" – means care provided by a registered professional nurse with direct responsibility to oversee or carry out medical regimens or nursing care for one or more patients.

 

"Nursing-sensitive Care Performance Measure" – means data that examine nursing contributions to inpatient hospital care, including, but not limited to, the data collected and analyzed under the Hospital Report Card Act, the Illinois Adverse Health Care Events Reporting Law of 2005, and the National Database for Nursing Quality Indicators.  The National Database for Nursing Quality Indicators may be accessed at https://www.pressganey.com/products/clinical-excellence/national-database-nursing-quality-indicators.  Hospitals are not required to subscribe to the database.

 

"Nursing Care Committee" − means a hospital-wide committee or committees of nurses whose functions, in part or in whole, contribute to the development, recommendation, and review of the hospital's nurse staffing plan established pursuant to subsection (b). (Section 10.10(b) of the Act)

 

"Patient Acuity" − means the complexity of patient care needs requiring the skill and care of a nurse, which is addressed when aligning nursing resources and professional practice standards as part of the patient's treatment plan.

 

"Registered Professional Nurse" – means a person licensed as a Registered Nurse under the Nurse Practice Act.

 

"Written Staffing Plan for Nursing Care Services" – means a written plan for the assignment of patient care nursing staff based on multiple nurse and patient considerations that yield minimum staffing levels for inpatient care units and the adopted acuity model aligning patient care needs with nursing skills required for quality patient care consistent with professional nursing standards.  (Section 10.10(b) of the Act)

 

b)         Written Staffing Plan

 

1)         Every hospital shall implement a written hospital-wide staffing plan, prepared by a nursing care committee or committees, that provides for minimum direct care professional registered nurse-to-patient staffing needs for each inpatient care unit, including inpatient emergency departments.

 

2)         If the staffing plan prepared by the nursing care committee is not adopted by the hospital, or if substantial changes are proposed, the chief nursing officer shall either provide a written explanation to the committee of the reasons the plan was not adopted or provide a written explanation of any substantial changes made to the proposed plan prior to it being adopted by the hospital. 

 

3)         The written hospital-wide staffing plan shall include, but need not be limited to, the following considerations:

 

A)        The complexity of complete care, assessment on patient admission, volume of patient admissions, discharges and transfers, evaluation of the progress of a patient's problems, ongoing physical assessments, planning for a patient's discharge, assessment after a change in patient condition, and assessment of the need for patient referrals;

 

B)        The complexity of clinical professional nursing judgment needed to design and implement a patient's nursing care plan, the need for specialized equipment and technology, the skill mix of other personnel providing or supporting direct patient care, and involvement in quality improvement activities, professional preparation (credentials), and experience;

 

C)        Patient acuity and the number of patients for whom care is being provided;

 

D)        The ongoing assessments of a unit's patient acuity levels and nursing staff needed, routinely made by the unit nurse manager or his or her designee; and

 

E)        The identification of additional registered nurses available for direct patient care when patients' unexpected needs exceed the planned workload for direct care staff and the process to add additional staff.  (Section 10.10(c) of the Act)

 

F)         The process for submitting the nursing care committee's recommendations to hospital; and

 

G)        The process for providing feedback to the nursing care committee from the hospital administration regarding unresolved or ongoing issues.

 

4)         A written staffing plan shall consider the time required for nursing staff documentation of patient care.

 

5)         In order to provide staffing flexibility to meet patient needs, every hospital shall identify an acuity model for adjusting the staffing plan for each inpatient care unit.

 

6)         Each hospital shall implement the staffing plan and assign nursing personnel to each inpatient care unit, including inpatient emergency departments, in accordance with the staffing plan.

 

A)        A registered nurse may report to the nursing care committee any variations where the nurse personnel assignment in an inpatient care unit is not in accordance with the adopted staffing plan and may make a written report to the nursing care committee based on the variations.

 

B)        Shift-to-shift adjustments in staffing levels required by the staffing plan may be made by the appropriate hospital personnel overseeing inpatient care operations.  If a registered nurse in an inpatient care unit objects to a shift-to-shift adjustment, the registered nurse may submit a written report to the nursing care committee.

 

C)        The nursing care committee shall develop a process to examine and respond to written reports submitted under subsections (6)(A) and (6)(B), including the ability to determine if a specific written report is resolved or should be dismissed. (Section 10.10(c)(2.5) of the Act)

 

7)         The written staffing plan shall be posted, either by physical or electronic means, in a conspicuous and accessible location for both patients and direct care staff, as required under the Hospital Report Card Act.  A copy of the written staffing plan shall be provided to any member of the general public upon request. (Section 10.10(c)(3) of the Act)

 

8)         In addition to the hospital providing a copy of the written staffing plan per subsection (b)(6), the hospital shall allow members of the public to schedule an appointment with the Chief Nursing Officer or their designee to review the staffing plan and address any questions.

 

c)         Nursing Care Committee

 

1)         Every hospital shall have a nursing care committee that meets at least 6 times per year.  A hospital shall appoint members of a committee of which at least 55% of the members are registered professional nurses providing direct inpatient care, one of whom shall be selected annually by the direct inpatient care nurses to serve as co-chair of the committee.  (Section 10.10(d)(1) of the Act)

 

A)        The registered professional nurses on the nursing care committee shall be as broadly representative of the clinical service areas as practically reasonable; e.g., surgery, critical care, medical surgical, obstetrics, emergency department and pediatrics.

 

B)        When committee or nurse staff volume is not practically reasonable to include representatives from each clinical service area at any one time, the hospital may schedule for rotating representation of the hospital's clinical service areas over a defined timeframe to achieve input from all clinical service areas every three years.

 

C)        Minutes for the nursing care committee meetings, summarizing key issues, discussions and recommendations, shall be recorded and maintained for five years.

 

2)         A nursing care committee shall prepare and recommend to hospital administration the hospital's written hospital-wide staffing plan.  If the staffing plan is not adopted by the hospital, the chief nursing officer shall provide a written statement to the committee prior to a staffing plan being adopted by the hospital that:

 

A)        Explains the reasons the committee's proposed staffing plan was not adopted; and

 

B)        Describes the changes to the committee's proposed staffing or any alternative to the committee's proposed staffing plan. (Section 10.10(d)(2.5) of the Act)

 

3)         A nursing care committee's or committees' written staffing plan for the hospital shall be based on the principles from the staffing components set forth in subsection (b).  In particular, a committee or committees shall provide input and feedback on the following:

 

A)        Selection, implementation, and evaluation of minimum staffing levels for inpatient care units.

 

B)        Selection, implementation, and evaluation of an acuity model to provide staffing flexibility that aligns changing patient acuity with nursing skills required.

 

C)        Selection, implementation, and evaluation of a written staffing plan incorporating the items described in subsections (b)(1) through (b)(5).  (Section 10.10(d)(3) of the Act)

 

i)          The process for review and evaluation of the written staffing plan shall take into consideration nursing-sensitive care performance measures.

 

ii)         The process for review and evaluation of the written staffing plan shall consider the National Quality Forum's Safe Practices for Better Healthcare.

 

4)         The committee or committees shall review the nurse staffing plans for all inpatient areas and current acuity tools and measures in use.  The nursing care committee's review shall consider:

 

A)        Patient outcomes;

 

B)        Complaints regarding staffing, including complaints about a delay in direct care nursing or an absence of direct care nursing;

 

C)        The number of hours of nursing care provided through an inpatient hospital unit compared with the number of inpatients served by the hospital unit during a 24-hour period;

 

D)        The aggregate hours of overtime worked by the nursing staff;

 

E)        The extent to which actual nurse staffing for each hospital inpatient unit differs from the staffing specified by the staffing plan; and

 

F)         Any other matter or change to the staffing plan determined by the committee to ensure that the hospital is staffed to meet the health care needs of patients. (Section 10.10(d)(3)(D) of the Act)

 

5)         System-related or clinical service area nurse staffing or patient issues identified between meetings shall be shared, reviewed and addressed at the next nurse care committee meeting.

 

6)         A nursing care committee must issue a written report addressing the items described in subsections (c)(3) and (c)(4) semi-annually. A written copy of this report shall be made available to direct inpatient care nurses by making available a paper copy of the report, distributing it electronically, or posting it on the hospital's website.  (Section 10.10(d)(4) of the Act)

 

7)         A nursing care committee must issue a written report at least annually to the hospital governing board that addresses items including, but not limited to:

 

A)        The items described in subsections (b)(1) through (b)(5);

 

B)        Changes made based on committee recommendations and the impact of these changes;

 

C)        Recommendations for future changes related to nurse staffing (Section 10.10(d)(5) of the Act);

 

D)        The composition of the nursing units represented by members of the nursing care committee;

 

E)        Goals and accomplishments of the nursing care committee;

 

F)         Outline of the current acuity tools in each inpatient and emergency department;

 

G)        Personnel data including annual registered nurse turnover rate, current registered nurse vacancy rate, current and posted full-time or full-time equivalent registered nurse positions, and annual certified nurse aid/tech turnover and vacancy rate;

 

H)        Number of registered nurse injuries related to patient lifting and handling as per Section 250.1030(d)(7); and

 

I)         Number of hospital inpatient acquired pressure injuries.

 

d)         Nothing in this Section shall be construed to limit, alter, or modify any of the terms, conditions, or provisions of a collective bargaining agreement entered into by the hospital.  (Section 10.10(e) of the Act)

 

e)         No hospital may discipline, discharge, or take any other adverse employment action against an employee solely because the employee expresses a concern or complaint regarding an alleged violation of this Section or concerns related to nurse staffing. (Section 10.10(f) of the Act)

 

f)         Any employee of a hospital may file a complaint with the Department regarding an alleged violation of this Section.  The Department will forward notification of the alleged violation to the hospital in question within 10 business days after the complaint is filed. Upon receiving a complaint of a violation of this Section, the Department may take any action authorized under Section 7 or 9 of the Act. (Section 10.10(g) of the Act)

 

g)         If a hospital demonstrates a pattern or practice of failing to substantially comply with the requirements of Section 10.10 of the Act or the hospital's written staffing plan, the hospital shall provide a plan of correction to the Department within 60 days after receiving notice of noncompliance.  The Department may impose fine as follows:

 

1)         If a hospital fails to implement a written staffing plan for nursing services, a fine not to exceed $500 per occurrence may be imposed;

 

2)         If a hospital demonstrates a pattern or practice of failing to substantially comply with a plan of correction within 60 days after the plan takes effect, a fine not to exceed $500 per occurrence may be imposed; and

 

3)         If a hospital demonstrates for a second or subsequent time a pattern or practice of failing to substantially comply with a plan of correction with 60 days after the plan takes effect, a fine not to exceed $1,000 per occurrence may be imposed. (Section 7(a-5) of the Act)

 

(Source:  Amended at 46 Ill. Reg. 15597, effective September 1, 2022)