You have probably begun to see television advertisements and heard the debate surrounding the upcoming Ballot Question 1 that proposes to regulate nurse staffing ratios at all Massachusetts hospitals. This Ballot Question will be decided on Election Day, Nov. 6^th.

We all want good nurse staffing and, quite frankly, good staffing for all our departments, but we do not need the government telling us what to do. We want that autonomy and flexibility to make these decisions on our own, not a one-size-fits-all mandate that would devastate health care in Massachusetts, especially our tiny hospital.   I want you to know why Nantucket Cottage Hospital (NCH) has joined more than 95 other hospitals and over 200 professional organizations, businesses, and chambers of commerce around the state in opposing this ballot initiative (see listing at end).

Specifically:

• Ballot Question 1 would impose rigid staffing ratios at all times, in all units, in all hospitals, with no flexibility, regardless of circumstances, regardless of patient acuity or volume. At all times means these ratios must be adhered to even for meal breaks (see table below).
• This would override the local decision-making of our nurse managers, nurses and physicians about how to best care for our patients as we would be forced to adopt a one-size-fits all approach that doesn’t differentiate us from the large Boston teaching hospitals.  This approach removes the flexibility nurses need to make the best decisions for patients. Nurse staffing is not something that can be determined by some remote government agency.
• If Question 1 passes, hospitals will face fines of $25,000 per day, per violation if they don’t meet the prescribed staffing ratios. The ballot Question also requires implementation of an expensive patient acuity system throughout the hospital with no benefit
• As an unfunded government mandate, there is no money allocated in this proposal to invest in nursing education programs. The demand for nurses is increasing every year due to the aging baby boomer generation but the supply cannot keep up due to a lack of faculty.
• Hospitals, like NCH, that cannot afford to hire more nurses or can’t find and recruit additional qualified nurses will be forced to close beds, entire units and important programs. Some hospitals may be forced to close altogether.  Either of these scenarios would result reduced ability for hospitals to care for patients.
• The cost of ballot Question 1 to NCH is estimated to be $2.6 million annually. Obviously, this is an unsustainable amount and will result in program cuts. Moreover, it would wipe out the funds we receive from the generous island community through fundraisers like the Boston Pops concert and our Annual Fund.
• In early October, the Massachusetts Health Policy Commission, which is our state’s health care watchdog agency, announced that its independent analysis of Question 1 concluded that the proposal would cost Massachusetts more than $900 million a year, and severely impact community hospitals like NCH.
• In early October, the Massachusetts Health Policy Commission, which is our state’s health care watchdog agency, announced that its independent analysis of Question 1 concluded that the proposal would cost Massachusetts more than $900 million a year, and severely impact community hospitals like NCH.
• Question 1 will reduce access to critically needed psychiatric beds statewide.  It is estimated that 1,000 behavioral health beds across the state would need to close.   Psychiatric hospitals use a different staffing model, relying on a skill mix of clinicians such counselors, LISCWs, psychologists, etc. and less so on nurses. This proposal would require them to comply to almost the same nurse ratios as Med-Surg units. This is unnecessary and unaffordable. Access, to these off-island facilities to provide care to the patients that NCH cannot, will be further hindered.
• Question 1 will result in patient access delays and increase wait times for emergency department patients.  In California, the only state with mandated nurse-to-patient ratios, EMS personnel regularly hold patients in their ambulances waiting to get them into emergency departments. They have a term called, “Holding the Wall,” for ambulance patient offload delay.
• Ratios in California have had no beneficial effect on all quality measures (see Chart below). Massachusetts, without mandated ratios, consistently ranks among the best states in the U.S. on hospital quality and patient outcome measures and has earned national acclaim from several top tier ranking systems including the Commonwealth Fund’s State Health System Performance, that placed Massachusetts 2nd overall in the nation, versus California’s 14th place finish. NCH has recently received four-star recognition from Medicare and 43% of all Massachusetts’ hospitals were either four or five stars.  In California, only 30% of hospitals receive this recognition years after implementing staffing ratios that were marketed to have a direct impact on nursing care, patient outcomes and overall quality.

Our NCH staffing model developed over years to address NCH’s unique circumstances, seasonal volume, and housing challenges, allows us to be flexible and provide excellent, quality care despite our remote geography. If ballot Question 1 passes, this model would be outlawed – literally.

I appreciate that this is a lot of information and a hot topic.  While the ballot Question may be well-intentioned, the negative impacts will raise costs and do harm across the Massachusetts healthcare system. This is extremely worrisome for small community hospitals like NCH.

Nantucket community members are of course free to vote their conscience on this ballot initiative, but I encourage you to digest the information above and further research this on your own before Election Day. The future of your hospital and others is a stake.  Let’s keep staffing decisions in the hands of nurses.

Thank you,

Greg Bird, RN, MS

COO/CNO, VP for Patient Care Services