Get The Facts

This page contains the position of Brigham and Women's Hospital on timely and relevant issues that may be misrepresented by other sources. We want to ensure that our Brigham community, our patients and the general public have the facts. We will update this page on a regular basis.

Mandated Nurse Staffing Ratios

June 29, 2018

When voters go to the polls on Nov. 6, they will be asked whether government-mandated nurse staff ratios should be imposed on every hospital in the state.

While having more nurses may sound like a good idea on the surface, rigid staffing ratios will actually hurt health care by overriding the judgment and expertise of health care professionals, threatening quality and hospital services and increasing the cost of care throughout the state.

BWH, along with other hospitals and health care organizations, does not support mandated staffing ratios for the following reasons:

  • Rigid ratios: The ratios are identical for every hospital, regardless of the hospital’s size, location and whether it is a community hospital or an academic medical center.
  • Increasing the cost of care: At a time when many families are struggling to afford health care, this proposal would drive up costs even more. An independent study of mandated nurse staffing ratios found that implementing these ratios would cost the state’s health care system more than $1.3 billion in the first year and $900 million annually afterward. This would likely result in hospitals cutting programs and services to meet increased staffing costs. The Brigham would potentially need to reduce patient volume by 2 to 9 percent if it cannot meet these ratios.
  • No evidence: Research has not determined a conclusive nurse-to-patient ratio. Setting arbitrary, rigid ratios ignores the many variations in patient care, including differences in nurses’ education and experience, changing patient conditions, the make-up of the entire patient care team and the varying technologies and physical environments of different facilities.

The ballot question was proposed by the Massachusetts Nurses Association (MNA), a union that represents less than 25 percent of nurses in the state. The union has tried for more than 20 years to have nurse-staffing ratios mandated, with consistent rejection from the legislature.

Lessons Learned from Mandated Ratios

  • Massachusetts ICUs: In 2014, the MNA succeeded in gathering enough signatures to place a similar mandated ratio question on the statewide ballot. However, a legislative alternative was adopted, establishing a mandatory nurse-to-patient ratio of 1:1 or 1:2 for hospital intensive care units (ICUs) only. Since then, the mandate has adversely affected patient care in many ways. It has removed flexibility and nurse autonomy in care decisions, and it has caused back-ups in Emergency Departments and delayed the transfer of patients into and out of ICUs. In addition, the state has seen the closure of 11 percent of Neonatal ICU beds since the implementation of the law.
  • California: California is the only state that has implemented minimum nurse staffing ratios in acute care hospitals, though similar laws have been proposed – and rejected – in other states. The ratio in California, which is less restrictive than what the MNA is proposing, has increased hospital costs, provided little to no benefits to quality and safety and forced hospitals to cut non-nurse staff, programs and services.

How does care in California compare to Massachusetts?

Although California hospitals have operated under rigid and costly ratios for more than 13 years, the care California hospitals provide is no better – and sometimes worse – than the care patients receive in Massachusetts hospitals, which have among the best quality outcomes in the nation.

The latest evidenced-based, nursing-sensitive measures reported through the Centers for Medicare and Medicaid Services’ Hospital Compare website show that Massachusetts scores the same as or higher than California hospitals in quality and patient satisfaction.

Massachusetts scores are:

  • Equal to or better than California in all 11 Hospital Consumer Assessment of Healthcare Providers and Systems measure categories and receives scores equal to or better than the national average in 9 of 11 (82 percent) measure categories.
  • Equal to or better than California on all six mortality prevention measures and equal to or better than the national average on five of six mortality measures.
  • Comparable to both California and the national average on four of the eight hospital readmissions measures (50 percent).
  • Equal to or better than both California and the national average on 10 of the 11 patient safety indicators (91 percent).

Brigham and Women’s Hospital firmly believes that decisions about staffing and patient care must be made by our talented health care professionals at the bedside and in our clinics, not at the ballot box.

For more information, please visit the Coalition to Protect Patient Safety.

Merging of the PACU, Day Surgery Unit and Pre-op Areas and Professional Development Model

January 31, 2018

  • We met with the MNA on Nov. 17 to discuss the merging of these three perioperative patient care areas. Unfortunately, the MNA rejected our proposal to facilitate a smooth transition, but we have heard from several nurses who are interested in being trained to work in the new model, and some who would prefer to pursue other opportunities.  We are pleased to be able to make both options available to the 25 nurses impacted by this merger.   
  • To ensure that all involved feel comfortable that we can continue to provide the highest possible care to our patients and their families, the merging of the units will occur over time as nurses complete orientation and begin work in the new model. 
  • Having nurses in these areas care for patients in pre-op, the Day Surgery Unit and the PACU is a standard of practice across the country, and we have the utmost confidence that our highly skilled BWH nurses can work in this model. This model will provide more timely access for patients to the recovery unit and enable staff to flow throughout these areas to promptly respond to patients’ needs and manage changes in patient volume.

Employee Flu Vaccination Policy and MNA Lawsuit

December 11, 2017

The Massachusetts Nurses Association’s injunction to prevent the implementation of the Brigham’s mandatory flu vaccination policy was denied in late November by a Massachusetts State Superior Court judge. Following are facts about the Brigham’s flu vaccination policy and the hospital’s position:

  • The hospital updated its flu vaccination policy to require that all personnel receive a flu shot. Those with a documented medical contraindication or sincerely held religious beliefs may qualify for an exemption.
  • The MNA lawsuit claimed that BWH’s policy violated the Department of Public Health regulations by not allowing employees to decline to be vaccinated for reasons other than medical issues or religious beliefs.
  • The hospital’s position continues to be that the DPH regulations set the minimum requirements for what health care facilities must do in regards to employee vaccination, and hospitals are permitted to have more stringent requirements.
  • Ninety-four percent of nurses at the Brigham received the vaccine last flu season (2016/2017).
  • The deadline for BWH employees to receive flu vaccinations (or approval for a valid exemption) was Friday, Dec. 1. Employees vaccinated for flu represent the hospital’s first line of defense against cases of hospital-acquired flu.

Although our employee flu vaccination rates were high last year, BWH still sees cases of hospital-acquired flu each year. We want to better protect our patients – especially those with compromised immune systems – against the spread of flu.

Massachusetts Nurses Association Informational Picket Nov. 15

November 15, 2017

While it’s disappointing that the union is conducting an informational picket, it is their right to do so. Brigham and Women’s Hospital values our nurses and their incredible contributions to patient care, educating the next generation of nurses and other health care professionals, research and community outreach. Our perspective on the issues raised by the union is available below.

Nurse Staffing (Updated April 10, 2017)

  • BWH continues to explore ways to proactively identify potential staffing concerns as well as respond in a timely way when issues surface to ensure the right care is provided to the right patients. These include improvements in our staffing concerns form process. Specifically, we are educating staff about the best use of the staffing concerns form, and enhancing both proactive and follow up communication.  A daily handoff for nurse directors and nurse administrators has been implemented in an effort to ensure any concerns are addressed quickly, and a new review process as well as a new database to track any concerns has been developed.
  • The safety of our patients is among our highest priorities at the Brigham, and we take concerns about staffing very seriously. There have not been unsafe patient care situations related to staffing.
  • We determine the number of nurses needed to care for each patient based on acuity, meaning the severity of their illness.
  • In our intensive care units, we have a nurse-to-patient ratio of one nurse for each patient, or one nurse for two patients, depending on acuity. In our intermediate care units, we average one nurse for three patients. Detailed information about staffing ratios and how we compare to other hospitals in Massachusetts is publicly available on the Patient Care Link website. As the site shows, our staffing levels are very good. When we have challenges, we address them as quickly as possible.

Staffing “Cutbacks”

  • We have not reduced the number of nursing positions at the Brigham; rather, we have added positions. This year, BWH has hired 350 nurses to backfill vacancies created by the 230 nurses who accepted the hospital’s Voluntary Retirement Offering, as well as new, full-time positions that were added to accommodate recent increases in patient volume and acuity throughout the Brigham.

Code Amber

  • Code Amber is not called due to lack of staff, but rather due to a number of causes, including high patient volume. This can lead to over-crowding in the ED and bottlenecks in the OR and Post Anesthesia Care Unit (PACU). Since January, the hospital has called a Code Amber three times due to high patient volume.
  • During the Nov. 8 Code Amber, three nurses (one in the OR and two in Peri-anesthesia) were asked to stay beyond their shift while leadership assessed patient needs across the organization. The hospital has reported this to the Department of Public Health, as it must do when staff are required to stay past their shift.

Nurse Education

  • The Department of Nursing is not eliminating nursing education; rather, we have created a new model that enhances education for all nurses. Ensuring that staff have the right education and training to care for patients and to develop new skills is critically important to quality and safety, as well as staff satisfaction. A new professional development manager role has been created to coordinate and oversee clinical education programs and professional development opportunities, as well as lead quality and safety efforts. The new model of nurse education offers many improvements, including:
    • 24/7 coverage, filling a current gap in education resources for nursing staff who work the evening and night shifts.
    • Consistency in evidence-based practice across divisions and service lines to better serve nursing staff, as well as patients and families. The previous model was focused on individual patient care units.
    • Greater flexibility and bandwidth in sharing clinical expertise and educational resources across the hospital.
    • More dedicated and protected time for nurses to pursue educational opportunities.

Safety in the Newborn Intensive Care Unit (NICU)

  • There have been some interpersonal challenges among the staff working in the NICU. We have contracted with an outside expert, who is a nurse, to help us address communication and teamwork within the multi-disciplinary team. The NICU continues to provide high-quality patient care, and there have not been adverse patient outcomes related to these interpersonal issues.

Safety in the Operating Rooms (OR)

  • In the OR, we have not reduced the number of nurses. We have hired 38 nurses since January to fill vacancies left by nurses who are retiring and to fill 20 new, full-time staff nurse positions that have been added to the OR budget. We provide robust education and extensive training during the orientation period for new nurses.
  • Overall, our surgical site infection outcomes are comparable to other hospitals and, for some types of surgery, are better than average.
  • There have been four cases reported this past year where specimens were not received by pathology, and a corrective plan has been put in place to address this.

Partners HealthCare Second Quarter Financial Results and Salary of Hospital CEOs

  • Partners HealthCare reported an overall gain of $406 million in the 2017 quarter. This includes a non-operating gain of $382 million, of which $323 million (80% of the overall gain) represents the net impact of adding Wentworth Douglass Health System, in Dover, New Hampshire, to the Partners system on Jan. 1, 2017. Accounting rules require the fair value of acquired net assets to be recognized as non-operating gains.
  • The salary of Brigham Health President Betsy Nabel, MD, along with the salaries of other hospital presidents in the Partners system, is set by the Partners Board of Directors. According to a recent statement from Partners HealthCare Board Chair Edward P. Lawrence, Esq.: “The market for senior health care executives, particularly physicians, is a national one and we must provide competitive wages and benefits in order to attract and retain the best individuals at a time when health care is undergoing sweeping change. The competition for excellent managers and leaders is especially strong at this time. …These leaders have helped ensure that Partners HealthCare and its hospitals remain at the forefront of medical science and continue to be a major economic engine for Massachusetts and the region.”

Magnet Designation

September 8, 2017

BWH is pursuing Magnet designation, which is considered the highest standard for nursing and clinical excellence. Currently, eight percent of hospitals in the U.S. have received Magnet designation from the American Nurses Credentialing Center (a division of the American Nurses Association). We already embody the rigorous standards of Magnet hospitals, which consistently deliver the highest level of care and patient experience. We are proud of our nurses and every member of the care team and would like to be recognized among our peers for the work we do every day.

Although we had hoped to partner with the Massachusetts Nurses Association, which represents about 3,300 nurses at the Brigham, we do not have the union's support. The MNA chooses to oppose Magnet rather than share our goal of recognizing Brigham nurses with the gold-standard designation that Magnet represents. This devalues the work of not only our nurses, but all staff at the institution, as Magnet is an institutional recognition.

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