Massachusetts Question 1 | |
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Election date November 6, 2018 | |
Topic Healthcare | |
Status Defeated | |
Type State statute | Origin Citizens |
Massachusetts Question 1, the Nurse-Patient Assignment Limits Initiative, was on the ballot in Massachusetts as an indirect initiated state statute on November 6, 2018. It was defeated.
A yes vote supported establishing patient assignment limits for registered nurses working in hospitals. |
A no vote opposed this initiative to establish patient assignment limits for registered nurses working in hospitals, thereby leaving the existing laws and rules in place. |
Massachusetts Question 1 |
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Result | Votes | Percentage | ||
Yes | 787,511 | 29.76% | ||
1,858,483 | 70.24% |
Question 1 was designed to establish patient assignment limits for registered nurses working in hospitals. Limits would have been determined by the type of medical unit or patient with whom a nurse is working, and the maximum numbers of patients assigned determined by the limits would have applied at all times except during a public health emergency as declared by the state or federal government. The measure would have required these patient limits to be met without reducing staff levels, such as service staff, maintenance staff, or clerical staff.
The measure would have required the Massachusetts Health Policy Commission to write regulations to implement and enforce the initiative. Under the measure, the commission could have conducted inspections of facilities to ensure their staffing ratios comply with the initiative. The commission would have been required report violations to the office of the attorney general. The commission could have reported violations to the state attorney general. The office of the attorney general could have filed suit in superior court to obtain an injunction for compliance with the initiative and civil penalties of up to $25,000 per violation.
Going into the election, the state of Massachusetts did not regulate the number of patients nurses can be assigned in private hospital emergency rooms, surgical units, maternity wards or psychiatric units, though the state did regulate the number of patients a nurse can be assigned in an intensive care unit. This requirement applies to all licensed intensive care units whether they are privately or publicly owned, or receive public funds.[1] In 2014, the Massachusetts legislature passed HB 4228, which stipulates that nurses in intensive care units can be assigned a maximum of two patients at one time.
Ballotpedia identified one ballot measure committee, the Committee to Ensure Safe Patient Care, registered in support of Question 1. The committee raised $12.04 million and spent the same. The committee was supported by the Massachusetts Nurses Association, which contributed $11.96 million (96.28 percent of the total contributions).
Ballotpedia identified one ballot measure committee, the Coalition to Protect Patient Safety, registered to oppose Question 1. The committee raised $26.48 million and spent $26.41 million. The committee was supported by the Massachusetts Health and Hospital Association, which contributed $25.18 million (93.53 percent of the total contributions).
According to state campaign finance officials The Coalition to Protect Patient Safety spent $24.7 million into efforts opposing Question 1, breaking a state record for ballot measure campaign spending. The Coalition to Protect Patient Safety beat the record $21.6 million spent by the Great Schools Massachusetts Committee, which supported an unsuccessful ballot question, Question 2 of 2016 to expand charter schools in Massachusetts.[2]
In 2014, the Massachusetts legislature passed HB 4228, which stipulates that nurses in intensive care units can be assigned a maximum of two patients at one time. The legislation was passed in response to two initiatives proposed that same year by the Massachusetts Nurses Association. One initiative would have placed more stringent caps on nurse-to-patient ratios in intensive care units. The other initiative would have regulated the annual operating margins, chief executive officer compensation, and financial asset disclosures of hospitals and certain other health-care facilities that accepted public funds. The CEO compensation initiative was supported by the Massachusetts Nurses Association and opposed by the Massachusetts Health and Hospital Association, mirroring the support and opposition campaigns of Question 1. Both 2014 initiatives were withdrawn in response to a compromise that resulted in the legislature passing HB 4228.[3][1]
Question 1 was designed to establish patient assignment limits for registered nurses working in hospitals. Limits would have been determined by the type of medical unit or patient with whom a nurse is working, and the maximum numbers of patients assigned determined by the limits would have applied at all times except during a public health emergency as declared by the state or federal government. The measure would have required these patient limits to be met without reducing staff levels, such as service staff, maintenance staff, or clerical staff.[4][4][5]
The patient assignment limits under the measure would have been as follows:[4]
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One patient per nurse |
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Two patients per nurse |
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Three patients per nurse |
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Four patients per nurse |
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Five patients per nurse |
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Six patients per nurse |
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The measure would have required the Massachusetts Health Policy Commission to write regulations to implement and enforce the initiative. As of 2018, the Health Policy Commission was an independent state agency established in 2012 with a mission to "provide data-driven policy recommendations regarding health care delivery and payment system reform and advance a more transparent, accountable, and innovative health care system through independent policy leadership and investment programs."
Under the measure, the commission would have been empowered to inspect of facilities to ensure their staffing ratios comply with the initiative. The commission would have been required to report violations to the office of the attorney general. The commission would have reported violations to the state attorney general. The office of the attorney general would have been authorized to file suit in superior court to obtain an injunction for compliance with the initiative and civil penalties of up to $25,000 per violation. Each day that a violation continued after a facility had been given notice of the violation would have been considered a separate and distinct violation subject to the same $25,000 penalty.[4]
Facilities covered by the initiative would have been required to post notices with language drafted by the commission with information about the patient limits. The notices would have been posted in all units, patient rooms, and patient areas. The commission would be required to set up a phone number and website for the submission of complaints about the violation of the initiative. A facility that refused to comply with the posting requirements would be subject to civil penalties of between $250 and $2,500 for each day of non-compliance.[4]
The enforcement of the initiative would have been suspended during a public health emergency as declared by the state or nationally.[4]
The ballot question was as follows:[6]
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Do you approve of a law summarized below, on which no vote was taken by the Senate or the House of Representatives on or before May 2, 2018?[7] |
” |
The ballot summary was as follows:[6]
This proposed law would limit how many patients could be assigned to each registered nurse in Massachusetts hospitals and certain other health care facilities. The maximum number of patients per registered nurse would vary by type of unit and level of care, as follows:
The proposed law would require a covered facility to comply with the patient assignment limits without reducing its level of nursing, service, maintenance, clerical, professional, and other staff. The proposed law would also require every covered facility to develop a written patient acuity tool for each unit to evaluate the condition of each patient. This tool would be used by nurses in deciding whether patient limits should be lower than the limits of the proposed law at any given time. The proposed law would not override any contract in effect on January 1, 2019, that set higher patient limits. The proposed law’s limits would take effect after any such contract expired. The state Health Policy Commission would be required to promulgate regulations to implement the proposed law. The Commission could conduct inspections to ensure compliance with the law. Any facility receiving written notice from the Commission of a complaint or a violation would be required to submit a written compliance plan to the Commission. The Commission could report violations to the state Attorney General, who could file suit to obtain a civil penalty of up to $25,000 per violation as well as up to $25,000 for each day a violation continued after the Commission notified the covered facility of the violation. The Health Policy Commission would be required to establish a toll-free telephone number for complaints and a website where complaints, compliance plans, and violations would appear. The proposed law would prohibit discipline or retaliation against any employee for complying with the patient assignment limits of the law. The proposed law would require every covered facility to post within each unit, patient room, and waiting area a notice explaining the patient limits and how to report violations. Each day of a facility’s non-compliance with the posting requirement would be punishable by a civil penalty between $250 and $2,500. The proposed law’s requirements would be suspended during a state or nationally declared public health emergency. The proposed law states that, if any of its parts were declared invalid, the other parts would stay in effect. The proposed law would take effect on January 1, 2019. A YES VOTE would limit the number of patients that could be assigned to one registered nurse in hospitals and certain other health care facilities. A NO VOTE would make no change in current laws relative to patient-to-nurse limits. |
The full text of the measure is as follows:[8]
SECTION 1. SECTIONS 2 through 4 below, along with section 231 of Chapter 111 of the General Laws, shall hereby be known as "The Patient Safety Act." SECTION 2. Chapter 111 of the General Laws is hereby amended by adding the following sections after section 231: Section 231 A. Definitions. As used in sections 231 through 231J the following words shall have the following meanings: "Patient assignment", a person admitted to a facility where a registered nurse accepts responsibility for the patient's direct nursing care. A patient must be assigned to a registered nurse at all times. "Complaint", any oral or written communication by a patient, medical professional, facility or any of its employees that a facility has violated any term or condition of this act. "Facility", a hospital licensed under section 51 of this chapter, the teaching hospital of the University of Massachusetts medical school, any licensed private or state-owned and state-operated general acute care hospital, an acute psychiatric hospital, an acute care specialty hospital, or any acute care unit within a state operated healthcare facility. This definition shall not include rehabilitation facilities or long-term care facilities. "Health Care Workforce", personnel employed by or contracted to work at a facility that have an effect upon the delivery of quality care to patients, including but not limited to registered nurses, licensed practical nurses, unlicensed assistive personnel, service, maintenance, clerical, professional and technical workers, and all other health care workers. "Nursing care", care which falls within the scope of practice as defined in Section SOB of Chapter 112 of the General Laws or is otherwise encompassed within recognized standards of nursing practice, including assessment, nursing diagnosis, planning, intervention, evaluation and patient advocacy. "Violation", any failure by a facility to abide by a term or condition of this act. "Written Implementation Plan", a written plan detailing both the maximum number of patients to be assigned at all times to a registered nurse in each of the units enumerated in section 231C as well as concurrently detailing the facility's plans to ensure that it will implement such limits without diminishing the staffing levels of its health care workforce. Section 23IB: Concurrently with establishing and enforcing the maximum patient assignment limits enumerated in Section 231C below, each facility shall submit a written implementation plan to the Massachusetts Health Policy Commission certifying that it will implement the patient assignment limits without diminishing the staffing levels of its health care workforce. Section 231C: It is the right of every patient in a facility to nursing care deemed safe by the registered nurse who has accepted responsibility for his or her care. It is the responsibility of each facility to provide the resources necessary to support the safe patient limits enumerated in this section. The maximum number of patients assigned at all times to a registered nurse in a facility shall not exceed the limits enumerated in this section. Nothing shall preclude a facility from assigning fewer patients to a registered nurse than the limits enumerated in this section; provided, however, that no such assignment shall result in a reduction in the staffing level of the health care workforce assigned to the facility's patients. The patient assignment limits shall be as follows: a. In all units with step-down/intermediate care patients, the maximum patient assignment of step-down/intermediate patients is three (3). Step-down/intermediate care patients are those patients that require an intermediate level of care between the intensive care unit and general medical surgical unit. b. In all units with post anesthesia care (PACU) patients, the maximum patient assignment of PACU patients under anesthesia is one (1). The maximum patient assignment of PACU patients post anesthesia is two (2). c. In all units with operating room (OR) patients, the maximum patient assignment of OR patients under anesthesia is one (1). The maximum patient assignment of OR patients post anesthesia is two (2). d. In the Emergency Services Department: (1) The maximum patient assignment of critical care or intensive care patients is one (1). A registered nurse may accept a second critical care or intensive care patient if that nurse assesses that each patient's condition is stable. (2) The maximum patient assignment of urgent non-stable patients is two (2). A patient is in an urgent non-stable condition when prompt care of the patient is necessary within fifteen to sixty minutes. (3) The maximum patient assignment of urgent stable patients is three (3). A patient is in an urgent stable condition when prompt care of the patient is necessary but can wait up to three hours if necessary. (4) The maximum patient assignment of non-urgent stable patients is five (5). A patient is in a non-urgent stable condition when the patient has a condition or conditions that need attention, but time is not a critical factor. e. In all units with maternal child care patients: (1) The maximum patient assignment of active labor patients, patients with intermittent auscultation for fetal assessment, and patients with medical or obstetrical complications is one (1) patient. (2) The maximum patient assignment during birth and for up to two (2) hours immediately postpartum is one (1) nurse responsible for the mother and, for each baby, one (1) nurse whose sole responsibility is the baby. When the condition of the mother and baby are determined to be stable and the critical elements are met, one (1) nurse may care for both the mother and the baby(ies). (3) The maximum patient assignment during the postpartum period for uncomplicated mothers or babies is six (6), which shall be comprised of either six (6) mothers or babies, three (3) couplets of mothers and babies, or, in the case of multiple babies, not more than a total of six (6) patients. As used in this subsection, couplet shall mean one (1) mother and one (1) baby. (4) The maximum patient assignment of intermediate care or continuing care babies is two (2) babies. (5) The maximum patient assignment of well-baby patients is six (6) babies. f In all units with pediatric patients, the maximum patient assignment of pediatric patients is four (4). g. In all units with psychiatric patients, the maximum patient assignment of psychiatric patients is five (5). h. In all units with medical, surgical and telemetry patients, the maximum patient assignment of medical, surgical and telemetry patients is four (4). i. In all units with observational/outpatient treatment patients, the maximum patient assignment of observational/outpatient treatment patients is four (4). j. In all units with rehabilitation patients, the maximum patient assignment of rehabilitation patients is five (5). k. in any unit not otherwise listed, the maximum patient assignment is four (4). Section 23 ID: Each facility shall implement the patient assignment limits established by Section 231C. However, implementation of these limits shall not result in a reduction in the staffing levels of the health care workforce. Section 23IE: The Massachusetts Health Policy Commission shall promulgate regulations governing and ensuring the implementation and operation of this act, including but not limited to regulations setting forth the contents and implementation of: (a) certification plans each facility must prepare for implementing the patient assignment limits enumerated in Section 231C, including the facility obligation that implementation of limits shall not result in a reduction in the staffing level of the health care workforce assigned to such patients; and (b) written compliance plans that shall be required for each facility out of compliance with the patient assignment limits. Notwithstanding the terms of this or any other section of this act, the Massachusetts Health Policy Commission shall not promulgate any regulation that directly or indirectly permits any delay, temporary or permanent waiver, or modification of the requirements set forth in sections 231C and 23 ID above. Section 23 IF: Patient Acuity Tool. The patient acuity tool shall serve as an adjunct to the assessment of the registered nurse and shall be designed to promote and support the provision of safe nursing care for the patient(s); however, such tools are not to be utilized as a substitute for the assessment and clinical judgment of the registered nurse assigned to the patients. Each facility shall develop a patient acuity tool for each unit designated in Section 231C. The patient assessment and use of the patient acuity tool shall be performed by the nurse who has accepted the assignment for that patient(s). The patient acuity tool for each unit in a facility shall be developed by a committee, the majority of which is comprised of staff nurses assigned to the particular unit. The patient acuity tool shall be developed to determine if the maximum number of patients that may be assigned to a registered nurse(s) should be lower than the patient assignment limits specified in Section 231C, in which case that lower number will govern for those patients. The patient acuity tool shall be written so as to be readily used and understood by registered nurses, shall measure the acuity of patients not less frequently than each shift, upon admission of a patient, and upon significant change(s) in a patient's condition and shall consider criteria including but not limited to: (1) the need for specialized equipment and technology; (2) the intensity of nursing interventions required and the complexity of clinical nursing judgment needed to design, implement and evaluate each patient's nursing care plans consistent with professional standards of care; (3) the skill mix of members of the health care workforce necessary for the delivery of quality care for each patient; and (4) the proximity of patients to one another who are assigned to the same nurse, the proximity and availability of other healthcare resources, and facility design. A facility's patient acuity tool shall, prior to implementation, be certified by the Massachusetts Health Policy Commission as meeting the above criteria, and the Commission may issue regulations governing such tools, including their content and implementation. Such patient acuity tool and information contained and documented therein shall be part of the patient medical record. Section 231G: This act shall not be construed to impair any collective bargaining agreement or any other contract in effect as of the effective date of this act, but shall have full force and effect upon the earliest expiration date of any such collective bargaining agreement or other contract. Nothing in this act shall prevent the validity or enforcement of terms in a collective bargaining agreement or other contract that provides for a lower number of patients assigned to a nurse than the number mandated by the patient assignment limits set forth in this act. Section 231H: Enforcement. The Massachusetts Health Policy Commission may conduct inspections of facilities to ensure compliance with the terms of this act. A facility's failure to adhere to the patient assignment limits set forth in Section 231C, as adjusted per the requirements set forth in Sections 23 ID and 23IF, shall be reported by the Massachusetts Health Policy Commission to the Attorney General for enforcement. The Attorney General may bring a Superior Court action seeking injunctive relief and civil penalties in the amount of up to twenty-five thousand dollars per violation. A separate and distinct violation, for which the facility shall be subject to a civil penalty of up to twenty-five thousand dollars, shall be deemed to have been committed on each day during which a violation continues following notice to the facility. Upon written notice by the Health Policy Commission that a complaint has been made or a violation has occurred, a facility receiving such notice shall submit a written compliance plan to the Commission that demonstrates the manner in which the facility will ensure future compliance with all of the provisions of this act within the time frame required by the Commission. No employee shall be disciplined or retaliated against in any manner for complying with the patient limits set forth in section 231C above, and any such employee so disciplined or retaliated against shall be entitled to the remedies provided in section 185(d) of chapter 149 regardless of whether the employee satisfies any other terms or conditions set forth in section 185 of chapter 149. The requirements of this act, and its enforcement, shall be suspended during a state or nationally declared public health emergency. Section 231I: Every facility shall post in a conspicuous place or places on its premises, including within each unit, patient room, and waiting areas, a notice to be prepared or approved by the Massachusetts Health Policy Commission that is easily readable in lay terms in English and in other languages determined by the commission setting forth excerpts of this act, including all of the patient assignment limits set forth in Section 231C, along with the manner in which to report violations and such other relevant information which the commission deems necessary to explain the requirements of this act. Any facility subject to this act which refuses to comply with the provisions of this section shall be punished by a civil penalty of not less than two hundred and fifty dollars and not more than two thousand five hundred dollars for each day the facility is not in compliance. The provisions of this section shall be enforced by the Attorney General. Section 231 J: The Massachusetts Health Policy Commission shall establish a toll-free telephone number where complaints against facilities can be reported, and a public website where complaints, certification and compliance plans, and violations shall appear and be updated at least quarterly for each facility. The toll-free telephone number and website location shall be included in all notices prepared and posted pursuant to Section 231I above. SECTION 2: Severability. The provisions of this act are severable, such that, if any clause, sentence, paragraph or section, or an application thereof, shall be adjudged by any court of competent jurisdiction to be invalid, such adjudication shall not affect, impair, or invalidate the remainder of any clause, sentence, paragraph or section thereof and shall be confined in its operation to such clause, sentence, paragraph, section or application adjudged invalid; provided further, that any such clause, sentence, paragraph, section or application deemed invalid shall be reformed and construed such that it would be valid to the maximum extent permitted. SECTION 3: This act shall take effect on January 1, 2019. |
Using the Flesch-Kincaid Grade Level (FKGL) and Flesch Reading Ease (FRE) formulas, Ballotpedia scored the readability of the ballot title and summary for this measure. Readability scores are designed to indicate the reading difficulty of text. The Flesch-Kincaid formulas account for the number of words, syllables, and sentences in a text; they do not account for the difficulty of the ideas in the text. The secretary of the commonwealth[9] wrote the ballot language for this measure.
In 2018, for the 167 statewide measures on the ballot, the average ballot title or question was written at a level appropriate for those with between 19 and 20 years of U.S. formal education (graduate school-level of education), according to the FKGL formula. Read Ballotpedia's entire 2018 ballot language readability report here. |
The Committee to Ensure Safe Patient Care led the campaign in support of Question 1.[10]
The following officials and organizations endorsed the Committee to Ensure Safe Patient Care or otherwise endorsed Question 1:[11]
Officials
Health care organizations
Nurses associations
Labor groups
Democratic groups
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The following official argument was submitted by RN Donna Kelly-Williams, representing the Massachusetts Nurses Association, in favor of Question 1:[6]
“ |
I have worked as a bedside nurse for 40 years. I joined nurses from across Massachusetts to write this law and place safe patient limits on the ballot to improve the quality of patient care in Massachusetts hospitals. Independent scientific studies have consistently found that quality of care decreases dramatically when nurses are forced to care for too many patients at once, putting patients at increased risk for complications like pneumonia, medication errors, and more. This initiative establishes a safe maximum limit for the number of patients assigned to nurses in all hospital areas to ensure our patients receive the care and attention they need. It provides maximum flexibility, requiring hospitals to adjust Registered Nurse staffing levels based on the needs of patients and does so without reducing other members of the health care workforce. A recent survey found that 86% of Registered Nurses in Massachusetts favor this question.[7] |
” |
The following videos were released by the Committee to Ensure Safe Patient Care:[21][22]
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The Coalition to Protect Patient Safety led the campaign in opposition to the initiative.[23][16]
The following organizations and chambers of commerce have endorsed the Coalition to Protect Patient Safety or have otherwise indicated their opposition to Question 1:[24]
Elected officials
Health and nursing organizations
Chambers of commerce
Massachusetts hospitals
Individuals |
The following official argument was submitted by RN Amanda S. Oberlies, representing the Coalition to Protect Patient Safety, in opposition to Question 1:[6]
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Nurses are asking you to Vote No on Question 1. Massachusetts hospitals rank among the best in the nation, but Question 1 will put that patient care quality and safety at risk. It forces rigid, government-imposed nurse staffing ratios at every hospital, overriding the professional judgment of nurses and doctors. Question 1 would create a massive unfunded government mandate costing more than one billion dollars in higher healthcare costs annually, causing community hospitals to close and forcing others to reduce emergency, addiction and behavioral health services. Question 1 has been called “the most irresponsible approach to healthcare”. There is no scientific evidence that these rigid ratios improve patient care. Question 1: higher costs, rigid mandates, and one-size-fits-all healthcare. Nurses and over one hundred healthcare organizations, including American Nurses Association Massachusetts, Massachusetts Medical Society, Massachusetts College of Emergency Physicians, and every Massachusetts hospital urge: Vote NO on Question 1.[7] |
” |
The following videos were released by the Coalition to Protect Patient Safety:[31]
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Ballotpedia did not identify any media editorials in support of Question 1. If you are aware of one, please send an email with a link to editor@ballotpedia.org.
The following editorial boards have also endorsed a no vote on Question 1:
Total campaign contributions: | |
Support: | $12,044,919.81 |
Opposition: | $24,808,566.78 |
Ballotpedia identified one ballot measure committee, the Committee to Ensure Safe Patient Care, registered in support of Question 1. The committee raised $12.04 million and spent the same. The committee was supported by the Massachusetts Nurses Association, which contributed $11.96 million (96.28 percent of the total contributions).[45][46]
Ballotpedia identified one ballot measure committee, the Coalition to Protect Patient Safety, registered to oppose Question 1. The committee raised $26.48 million and spent $26.41 million. The committee was supported by the Massachusetts Health and Hospital Association, which contributed $25.18 million (93.53 percent of the total contributions).[46][47]
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According to the most current reports available, the donors who had given $50,000 or more to the committee were as follows:[45]
Donor | Cash | In-kind | Total |
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Massachusetts Nurses Association | $11,600,278.46 | $357,020.26 | $11,957,298.72 |
California Nurses Association | $150,000.00 | $0.00 | $150,000.00 |
American Federation of Teachers | $50,000.00 | $1,000.00 | $51,000.00 |
Massachusetts Teachers Association | $50,000.00 | $0.00 | $50,000.00 |
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According to the most current reports available, the top five donors in opposition to this initiative were as follows:[47]
Donor | Cash | In-kind | Total |
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Massachusetts Health & Hospital Association | $24,573,500.00 | $606,698.84 | $25,180,198.84 |
Organization of Nurse Leaders, Inc. | $1,000.00 | $43,059.28 | $44,059.28 |
Spaulding Rehabilitation Hospital | $0.00 | $104,253.34 | $104,253.34 |
Boston Medical Center | $0.00 | $84,961.15 | $84,961.15 |
Steward Healthcare System LLC | $225,000.00 | $0.00 | $225,000.00 |
To read Ballotpedia's methodology for covering ballot measure campaign finance information, click here.
Shown below are poll results for Massachusetts Question 1. Also displayed are who conducted the poll, the dates the poll took place, the number of respondents, and the margin of error.
Massachusetts Question 1 | |||||||||||||||||||
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Poll | Support | Oppose | Undecided | Margin of error | Sample size | ||||||||||||||
WBUR News/MassInc Polling Group poll 10/25/18 - 10/28/18 | 31.0% | 58.0% | 10.0% | +/-4.4 | 500 | ||||||||||||||
Suffolk University/Boston Globe poll 10/24/18 - 10/27/18 | 32.0% | 59.0% | 9.0% | +/-4.4 | 500 | ||||||||||||||
Boston Globe/UMass Lowell poll 10/1/18 - 10/7/18 | 46.0% | 48.0% | 7.0% | +/-4.4 | 791 | ||||||||||||||
WBUR News/MassInc Polling Group poll 9/17/18 - 9/21/18 | 44.0% | 44.0% | 12.0% | +/-4.4 | 506 | ||||||||||||||
Suffolk University/Boston Globe poll 9/13/18 - 9/17/18 | 52.0% | 33.0% | 15.0% | +/-4.4 | 500 | ||||||||||||||
AVERAGES | 41% | 48.4% | 10.6% | +/-4.4 | 559.4 | ||||||||||||||
Note: The polls above may not reflect all polls that have been conducted in this race. Those displayed are a random sampling chosen by Ballotpedia staff. If you would like to nominate another poll for inclusion in the table, send an email to editor@ballotpedia.org. |
Further explanations of the poll results can be expanded here | |||||
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As of 2018, the state of Massachusetts did not regulate the number of patients nurses can be assigned in private hospital emergency rooms, surgical units, maternity wards or psychiatric units. As of 2018, the state did regulate the number of patients a nurse can be assigned in an intensive care unit. This requirement applies to all licensed intensive care units whether they are privately or publicly owned, or receive public funds.[1]
In 2014, the Massachusetts legislature passed HB 4228, which stipulates that nurses in intensive care units can be assigned a maximum of two patients at one time. The legislation was passed in response to two initiatives that were proposed that same year. One initiative would have placed more stringent caps on nurse-to-patient ratios in intensive care units. The other initiative would have regulated the annual operating margins, chief executive officer compensation and financial asset disclosures of hospitals and certain other health-care facilities that accepted public funds. The initiative was supported by the Massachusetts Nurses Association and opposed by the Massachusetts Health and Hospital Association, mirroring the support and opposition campaigns of Question 1. Both 2014 initiatives were withdrawn in response to a compromise that resulted in the legislature passing HB 4228.[49][1]
As of December 2015, 14 states had enacted legislation or adopted regulations addressing nurse staffing. Of those states, seven states (CT, IL, NV, OH, OR, TX, WA) required hospitals to have committees responsible for staffing policy and five states (IL, NJ, NY, RI, VT) required disclosure or public reporting of staffing. Massachusetts enacted legislation for nurse-to-patient ratios specifically for ICU nurses in 2014, and California enacted limits on nurse assignments in 1999.[50]
California became the first state to establish patient assignment limits for nurses hospitals in 1999. Hospitals were required to meet the staffing ratios by January 1, 2004. In California, the required ratio of nurses to patients (as of 2018) was as follows:[51]
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One patient per nurse |
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Two patients per nurse |
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Three patients per nurse |
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Four patients per nurse |
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Five patients per nurse |
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Six patients per nurse |
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Research Presentation: Analysis of Potential Cost Impact of Mandated Nurse-to-Patient Staffing Ratios in Massachusetts
On October 3, 2018, the Massachusetts Health Policy Commission (HPC) released a report analyzing the potential cost impact of implementing Question 1. The report was led by David Auerbach, Ph.D., health economist and director of research and cost trends at the HPC, and Joanne Spetz, Ph.D., a professor at the Institute for Health Policy Studies at the University of California. The report concluded that, once fully implemented, the provisions created by Question 1 would cost $676 to $949 million annually.[52]
Key findings of the report can be expanded here |
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A spokesman for the Coalition to Protect Patient Safety (opponents of Question 1) said, "The Health Policy Commission's analysis confirms that the negative consequences are too great and the costs are too high for rigid, government-mandated nurse staffing ratios in the Commonwealth."[53]
The executive director of the Massachusetts Nurses Association (supporters of Question 1) said, "This guess on costs by the HPC is irresponsible and inconsistent and resembles nothing that the HPC has ever done before. This estimates a cost of $300,000 per nurse (full-time equivalent), per year, and — like the inflated numbers distributed by hospital executives — there is no independent data source or transparency in these cost estimates."[53][54]
The full report can be read here.
Estimated Massachusetts Hospital Costs
Judith Shindul-Rothschild, an associate professor at the William F. Connell School of Nursing at Boston College, released a report on the estimated costs of implementing Question 1. Supporters of the measure, the Committee to Ensure Safe Patient Care wrote, "The study shows a total cost for Massachusetts acute care hospitals to implement the law of under $47 million, which is a fraction of than the $1.3 billion figure posited by the opponents of Question 1."[55]
The executive summary of the report can be expanded here | |||
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The full report can be read here.
Implications of Mandated Nurse Staffing Ratios
In August 2018, opponents of the measure, the Massachusetts Behavior Health System, released a report titled "Implications of Mandated Nurse Staffing Ratios." The report concluded that mandated nurse staffing ratios would result in a decreased capacity to care for patients, decreased access to behavioral health services, increased costs for patients, and increased costs for hospitals to comply with staffing regulations.
The executive summary of the report can be expanded here | |||
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The full report can be read here.
Protecting the Best Patient Care in the Country: Local Choices v. Statewide Mandates in Massachusetts
On April 30, 2018, BW Research Partnership and Mass Insight Global Partnerships released a study commissioned by the Massachusetts Health and Hospital Association (MHA) titled "Protecting the Best Patient Care in the Country: Local Choices v. Statewide Mandates in Massachusetts," an analysis of the proposed measure which would mandate a certain nurse to patient ratio. The report concluded that the approval of this initiative could cost the healthcare system $1.31 billion in the first year and $900 million annually thereafter due to nurse salaries, wage inflation, and technology. The study also concluded that implementation of the initiative would "reduce quality of care and increase inequality in care provision."[56]
The executive summary described by the report as its key findings can be expanded here | |||
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The full study can be read here.
The State of Patient Care in Massachusetts
A survey of nurses conducted by Anderson Robbins Research and commissioned by the Massachusetts Nurses Association (MNA) was released in May 2018. The survey questions were asked between April 9 and April 25, 2018. The survey polled nurses, many of whom were members of the MNA. Among the nurses surveyed, the following results were reported:[57]
The survey results can be expanded here | ||
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When asked about the challenges faced by bedside nurses, the following responses were given:[57]
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To read a full summary of the nurse survey, click here.
In Massachusetts, the number of signatures required to place an indirect initiated state statute on the ballot is equal to 3.5 percent of votes cast for governor in the most recent gubernatorial election. The first 3 percent is collected in order to refer the indirect initiative to the Massachusetts General Court. If members of the General Court pass and the governor signs the initiative, then the initiative becomes law. If the legislature declines to act on an initiative or the governor vetoes it, sponsors of the initiative need to collect additional signatures equal to 0.5 percent of the votes cast for governor.
To make the 2018 ballot, sponsors of an initiative needed to collect the first round of 64,750 signatures between September 20, 2017, and November 22, 2017. If the General Court failed to act on the initiative by May 2, 2018, then an additional 10,792 signatures were required by July 4, 2018.
Cost of signature collection:
Sponsors of the measure hired JEF Associates to collect signatures for the petition to qualify this measure for the ballot. A total of $570,518.17 was spent to collect the 75,542 valid signatures required to put this measure before voters, resulting in a total cost per required signature (CPRS) of $7.55.
Lawsuit overview | |
Issue: Single-subject rule; whether the provision requiring certain patient assignment limits and the provision prohibiting reduced staffing are unrelated. | |
Court: Massachusetts Supreme Judicial Court | |
Ruling: Ruled in favor of defendants, the initiative may appear on November ballot | |
Plaintiff(s): Four Massachusetts voters backed by the Steward Health Care System LLC | Defendant(s): Attorney General Maura Healey |
Plaintiff argument: The initiative's provision concerning nurse-patient assignment limits and the provision prohibiting reduced staffing are unrelated and violate the constitutional requirement that initiatives concern only one subject. | Defendant argument: The initiative was designed to establish a system of related regulations and meets the constitutional requirement. |
A lawsuit was filed by four Massachusetts voters against Attorney General Maura Healey in the Massachusetts Supreme Judicial Court seeking to block the initiative from the ballot. The lawsuit was backed by the Steward Health Care System LLC which argued that Healey should not have certified the initiative for circulation because it violated the state's single-subject rule. The supreme court heard arguments in the case on April 3, 2018.[64]
Thaddeus A. Heuer, an attorney for the Steward Health Care System LLC, said, “This appeal is about upholding the ability of Massachusetts voters to make clear, uniform public policy choices through the initiative petition process." Attorney Elissa Flynn-Poppey said, “Voters who might favor mandatory nurse-patient ratios cannot register their preference without also supporting the enactment of a costly, unfunded and overbroad workforce retention mandate."[64]
Healey’s office said it would defend the initiative and that it contained an “integrated regulatory scheme” that meets the constitutional requirements. The Committee to Ensure Safe Patient Care stated, “we are pleased that the Attorney General approved the language we put forth for the Patient Safety Act and we believe that decision will stand up to any challenge.”[64]
On June 18, 2018, the Supreme Court ruled that the measure's provisions were related and therefore that the measure could appear on the November 2018 ballot.[65]
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State of Massachusetts Boston (capital) | |
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