The Citizens’ Statement 2018

Citizens’ Review Statement of Question 1: An Initiative Petition for a Law Relative to Patient Safety and Hospital Transparency (2018)

Key Findings

These findings were prioritized by citizen panelists, starting with the most important for voters to know.

• Currently, there is no statutory limit on the number of patients assigned to a nurse, except in Intensive Care Units. Each hospital determines staffing based on past usage, patient care, and budgeting considerations.

• Should this law go into effect on January 1, 2019, affected hospitals and health care facilities will be required to have a written plan in place. Actual implementation, including staffing increases, will occur after a deliberative, regulatory process.

• Fourteen states, including Massachusetts, regulate staffing levels in hospitals beyond federal standards, but Massachusetts would be one of two states to universally regulate nurse/patient ratios by law.

• The estimated costs of implementing this law vary between $46 million and $1.3 billion, which may impact the availability of hospital services. Consumers and businesses may face increased premiums, copays and deductibles.

• Unit specific ratios would legally apply to all Massachusetts hospitals, except during a state or nationally declared emergency. Time‐of‐day, hospital size or location, and the experience of nurses are not considered.

• After two decades of raising concerns, nurses collected 100,000 signatures to move Question 1 onto the ballot.

• Not all percentages reported by nursing associations reflect the actual number of nurses in support of or against Question 1.

• Unless other cost‐discretionary measures are adopted, according to the Massachusetts Association of Behavioral Health Systems, Question 1 would reduce patient volume of inpatient behavioral health facilities by 38%.

Statement in Support of the Measure

We find these to be the strongest reasons to vote for the measure.

• Finding: Studies show that when California set ratios as patient limits in 2004, hospitals had shorter Emergency Department wait times, lower health spending and insurance costs. No hospitals closed as a result. This is important because: The success of California's legislation of nurse/patient ratios provides data strongly suggesting that this can improve patient care in Massachusetts.

• Finding: The independent analysts assembled by the Citizens' Initiative Review who expressed an opinion are clear on this issue: higher nurse staffing levels correspond to increased nurse satisfaction and positive patient outcomes. This is important because: Independent experts agree that there are improvements in patient outcomes and a greater sense of professional satisfaction for nurses when patients are given more quality time.

• Finding: Having fewer patients per nurse could lead to better work environments and safer conditions for nurses.
This is important because: It would limit nurse burnout, reduce adverse patient outcomes, improve morale, and allow for better communication, as well as increase time for bedside care.

Nurses report that burdensome patient loads interfere with their ability to provide quality patient care. Question 1 will create safer work environments, enhance professional satisfaction and lead to better patient outcomes. Studies prove that balanced workloads will create improvements in the delivery of care.

Statement in Opposition of the Measure

We find these to be the strongest reasons to vote against the measure.

• Finding: Question 1 may dramatically increase emergency wait times, delay life‐saving treatments and prevent hospital admissions. Boston Medical Center estimates Question 1 would prevent the treatment of over 100 Emergency Department patients daily.

This is important because: The impact on emergency departments could put the most vulnerable patients at risk and could cause undue pressure on nurses and facilities.

• Finding: Rankings show Massachusetts has some of the best hospitals in the country. A rigid mandate may override the professional judgment of nurses and doctors who work in these hospitals. This is important because: Mandated ratios limit the ability of nurses and doctors to provide the best possible care to the greatest number of patients.

• Finding: There is no consensus that proposed ratios will result in better care. Additional factors that contribute to better care include work environment, nurse education, experience, resources, and technology. This is important because: Question 1 only addresses one of many factors that characterizes better healthcare. These ratios may not do enough to improve overall healthcare.

Question 1 imposes unnecessary constraints on some of the best hospitals in the country that rely on the clinical expertise of their nursing professionals. Question 1 threatens the health of community programs, increases costs for hospitals, other businesses, and consumers, while restricting hospitals’ ability to respond to emergencies.


Explanatory Note

This Citizens’ Statement on Question 1 was written by an independent panel of 20 Massachusetts voters through the 2018 Massachusetts Citizens’ Initiative Review. It includes information about Question 1 that the panel considered strong, reliable, and important for their fellow voters to know.

The Citizens' Initiative Review (CIR) system brings together a diverse group of voters to conduct an in-depth study of a ballot question and share their findings with their fellow voters. It originated in Oregon and has been used in that state's elections since 2011. The system is now being tested in Massachusetts to see if it will benefit voters in this state. It was first used in Massachusetts during 2016 when a CIR was convened to examine Question 4 on recreational marijuana legalization.

The 2018 Massachusetts CIR is being carried out through a partnership between the office of State Representative Jonathan Hecht, Tufts University’s Tisch College of Civic Life, and Healthy Democracy, the organization that pioneered CIR in Oregon.

The panel of 20 was formed from a pool of 15,000 randomly selected Massachusetts voters using a scientific method to ensure it is representative of the overall population (based on place of residence, party affiliation, age, gender, educational attainment, and race and ethnicity). Over four days in September 2018, the panel heard from the campaigns supporting and opposing Question 1 and relevant policy experts, deliberated among themselves with the help of professional facilitators, and produced this Citizens' Statement.

The views expressed in the Citizens' Statement are solely those of the Massachusetts CIR panel. They are not the opinions or positions of Representative Hecht, Tisch College, Healthy Democracy, the Commonwealth of Massachusetts, or any government agency.