Inter-Departmental Correspondence

San Mateo Medical Center



March 8, 2004


March 23, 2004



Honorable Board of Supervisors


Nancy J. Steiger, Chief Executive Officer, San Mateo Medical Center



Nursing Ratio Requirements



Adopt an Amendment to the Master Salary Ordinance adding 25 additional licensed nursing positions for San Mateo Medical Center due to the enactment of the Nursing Ratio legislation January 1, 2004.



San Mateo County is responsible for meeting the legislative and regulatory requirements for the Nursing Ratio in January of 2004.



The Nurse Staff Ratio bill (AB 394) was passed in 1999 and was the first comprehensive legislation in the U.S. to establish minimum staffing levels for Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs) working in hospitals. The legislation directs the California Department of Health Services to establish "minimum, specific, and numerical licensed staff-to-patient-ratios by licensed nurse classification and hospital unit." In the Critical Care and Postanesthesia units, the ratio is 1:2 or fewer patients, in the Emergency Departments, the ratio is 1:4 patients, in the Medical/Surgical Unit and Psychiatric units, the ratio is 1:6 patients at this time.

Nurse administrators, supervisors, managers, charge nurses and triage nurses cannot be counted in the ratios. LVNs and Licensed Psychiatric Technicians can be used, but may only constitute up to 50% of the licensed nurses assigned on any unit. Ratios are the same on all shifts and all breaks and lunch/dinner times must be covered by another licensed nurse to maintain the same ratio. It is required that all hospitals have a written staffing plan and documentation that supports that ratios are met on a shift by shift basis. The hospital must also have a plan for routine fluctuations in census.

In order to meet the required ratios, San Mateo Medical Center will need to add 25.0 positions in all inpatient units, the majority on the evening and night shifts.

Without these positions, San Mateo Medical Center will experience additional Emergency Department diversion, longer wait times for patients in the Emergency Department, cancellation of scheduled surgeries and the inability to admit patients to inpatient medical/surgical, psychiatric, and Intensive Care Unit (ICU) beds. We will also be out of compliance with the regulatory requirements.


Vision Alignment

This agreement keeps the commitment to Ensure Basic Health and Safety for All and goal number 5: Provide patients access to healthcare and preventive care. This is a regulatory and legislative requirement.


Fiscal Impact

The fiscal input of this unfunded mandate will be in the range of 1.7-2.9 million dollars dependent on the number and mix of staff we are able to recruit and hire. We will not be able to hire all 25 positions within the next four months of the fiscal year but will have positions available for qualified applicants and will continue to use registry until we can fill positions. Nursing staff will continue to fluctuate with number of patients and acuity.

To finance these positions, $1 million dollars has been allocated from current fiscal year savings in other areas of the Medical Center and by not filling 6.0 vacant MSA II positions.

Because the requested positions will not all be hired before the end of this fiscal year, these positions will be brought forward to next years budget. The proposed changes in the Nursing Ration regulations include a 1:5 nursing ratio in the Medical Surgical Unit instead of the 1:6 ratio that we have currently. This change is scheduled to begin in January of 2005 and will also be included in next years budget.