I 
108TH CONGRESS 
2D SESSION 
H. R. 4374
To require Medicare providers to disclose publicly staffing and performance 
in order to promote improved consumer information and choice. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 17, 2004
Mr. HINCHEY introduced the following bill; which was referred to the Com-
mittee on Ways and Means, and in addition to the Committee on Energy 
and Commerce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction of the committee concerned 
A BILL 
To require Medicare providers to disclose publicly staffing 
and performance in order to promote improved consumer 
information and choice.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Patient Safety Act of 
2004’’. 
SEC. 2. FINDINGS. 
The Congress finds as follows:
(1) The past decade has been a turbulent time 
for health care facilities and nurses. 
(2) Recent research published in the Journal of 
the American Medical Association has shown that 
registered nurse staffing levels have a significant im-
pact on preventable deaths in hospitals, and that the 
odds of patient mortality increase 7 percent for 
every additional patient added to the average reg-
istered nurse’s workload. 
(3) Recent research supported by the Agency 
for Health Care Research and Quality, the Centers 
for Medicare & Medicaid Services, and the National 
Institute for Nursing Research shows that inad-
equate registered nurse staffing is directly related to 
serious complications such as pneumonia, upper gas-
trointestinal bleeding, and urinary tract infections, 
as well as failure to stop deaths caused by shock, 
cardiac arrest, sepsis, and deep vein thrombosis in 
hospitalized patients. 
(4) The Joint Commission on the Accreditation 
of Healthcare Organizations recently reported that 
inadequate nurse staffing contributes to nearly a 
quarter of all unexpected incidents that kill or injure 
hospitalized patients.
(5) The Institute of Medicine has reported that 
both nursing-to-resident staffing levels and the ratio 
of professional nurses to other nursing personnel are 
important indicators of high quality of care, and 
that the participation of registered nurses in direct 
care giving and in the provision of hands-on guid-
ance to nurse assistants is positively associated with 
quality of care in nursing facilities. 
(6) Recent research conducted by the Centers 
for Medicare & Medicaid Services found strong, ob-
jective proof that nurse staffing in nursing homes is 
directly related to quality measures such as sepsis, 
urinary tract infections, incidence of pressure sores, 
resisting care improvement, and weight loss. 
(7) As a payer for inpatient and outpatient hos-
pital services for individuals entitled to benefits 
under the medicare and medicaid programs estab-
lished under titles XVIII and XIX of the Social Se-
curity Act, the Federal Government has a compelling 
interest in promoting the safety of such individuals 
by requiring providers participating in such pro-
grams to provide these individuals with information 
regarding nurse staffing levels.
SEC. 3. PUBLIC DISCLOSURE OF STAFFING AND OUTCOMES 
DATA. 
(a) DISCLOSURE OF STAFFING AND OUTCOMES.—
Any provider under the medicare program shall, as a con-
dition of continued participation in such program, make 
publicly available information regarding nurse staffing 
and patient outcomes as specified by the Secretary. Such 
information shall include at least the following: 
(1) The number of registered nurses providing 
direct patient care. This information shall be ex-
pressed both in raw numbers, in terms of total hours 
of nursing care per patient (including adjustment for 
case mix and acuity), and as a percentage of nursing 
staff, and shall be broken down in terms of the total 
nursing staff, each unit, and each shift. 
(2) The number of licensed practical nurses or 
licensed vocational nurses providing direct care. This 
information shall be expressed both in raw numbers, 
in terms of total hours of nursing care per patient 
(including adjustment for case mix and acuity), and 
as a percentage of nursing staff, and shall be broken 
down in terms of the total nursing staff, each unit, 
and each shift. 
(3) Numbers of unlicensed personnel utilized to 
provide direct patient care. This information shall be 
expressed both in raw numbers and as a percentage
of nursing staff and shall be broken down in terms 
of the total nursing staff, each unit, and each shift. 
(4) The average number of patients per reg-
istered nurse, licensed practical nurse, or unlicensed 
personnel providing direct patient care. This infor-
mation shall be broken down in terms of the total 
nursing staff, each unit, and each shift. 
(5) Risk-adjusted patient mortality rate (in raw 
numbers and by diagnosis or diagnostic-related 
group). 
(6) Incidence of adverse patient care incidents, 
including as such incidents at least medication er-
rors, patient injury, pressure ulcers, nosocomial in-
fections, and nosocomial urinary tract infections. 
(7) Methods used for determining and adjusting 
staffing levels and patient care needs and the pro-
vider’s compliance with these methods. 
(b) DISCLOSURE OF COMPLAINTS.—Data regarding 
complaints filed with the State agency, the Centers for 
Medicare & Medicaid Services, or an accrediting agency, 
compliance with the standards of which have been deemed 
to demonstrate compliance with conditions of participation 
under the medicare program, and data regarding inves-
tigations and findings as a result of those complaints and
whether a provider is eligible for continued partici-
pation in the medicare program. 
(g) DEFINITIONS.—For purposes of this section: 
(1) LICENSED PRACTICAL NURSE OR LICENSED 
VOCATIONAL NURSE.—The term ‘‘licensed practical 
nurse or licensed vocational nurse’’ means an indi-
vidual who is entitled under State law or regulation 
to practice as a licensed practical nurse or a licensed 
vocational nurse. 
(2) PUBLICLY AVAILABLE.—The term ‘‘publicly 
available’’ means, with respect to information of a 
provider, information that is—
(A) provided to the Secretary and to any 
State agency responsible for licensing or accred-
iting the provider; 
(B) provided to any State agency which 
approves or oversees health care services deliv-
ered by the provider directly or through an in-
suring entity or corporation; and 
(C) provided to any member of the public 
which requests such information directly from 
the provider. 
(3) MEDICARE PROGRAM.—The term ‘‘medicare 
program’’ means the programs under title XVIII of 
the Social Security Act.
(4) PROVIDER.—The term ‘‘provider’’ means an 
entity that is—
(A) a psychiatric hospital described in sec-
tion 1861(f) of the Social Security Act (42 
U.S.C. 1395x(f)); 
(B) a provider of services described in sec-
tion 1861(u) of such Act (42 U.S.C. 1395x(u)), 
other than a skilled nursing facility, as defined 
in section 1819(a) of such Act (42 U.S.C. 
1395i–3(a)); 
(C) a rural health clinic described in sec-
tion 1861(aa)(2) of such Act (42 U.S.C. 
1395x(aa)(2)); 
(D) an ambulatory surgical center de-
scribed in section 1832(a)(2)(F)(i) of such Act 
(42 U.S.C. 1395k(a)(2)(F)(i)); or 
(E) a renal dialysis facility described in 
section 1881(b)(1)(A) of such Act (42 U.S.C. 
1395rr(b)(1)(A)). 
(5) REGISTERED
NURSE.—The term ‘‘reg-
istered nurse’’ means an individual who is entitled 
under State law or regulation to practice as a reg-
istered nurse. 
(6) SECRETARY.—The term ‘‘Secretary’’ means 
the Secretary of Health and Human Services.
SEC. 4. PUBLIC DISCLOSURE OF ACCURATE DATA ON 
NURSING FACILITY STAFFING. 
(a) MEDICARE.—Section 1819(b)(8) of the Social Se-
curity Act (42 U.S.C. 1395i–3(b)) is amended—
(1) in subparagraph (A), by adding at the end 
the following new sentence: ‘‘The information posted 
under this subparagraph shall include information 
regarding nurse staffing with respect to beds made 
available by reason of an agreement under section 
1883.’’; and 
(2) by adding at the end the following new sub-
paragraphs: 
‘‘(C) 
SUBMISSION
AND
POSTING
OF 
DATA.—
‘‘(i) IN GENERAL.—Beginning on Jan-
uary 1, 2005, a skilled nursing facility 
shall submit to the Secretary in a uniform 
manner (as prescribed by the Secretary) 
the nursing staff data described in section 
3(a) of the Patient Safety Act of 2004 
through electronic means not less fre-
quently than quarterly and the Secretary 
shall make such data publicly available (as 
defined in section 3(g)(2) of such Act), in-
cluding by posting such data on an Inter-
net website.
‘‘(ii) 
INFORMATION
ON
NURSE 
AIDES.—In addition to the nursing staff 
data described in clause (i), a skilled nurs-
ing facility shall submit to the Secretary 
the numbers of nurse aides (as defined in 
paragraph (5))(F)) utilized to provide di-
rect patient care. This information shall be 
expressed both in raw numbers and as a 
percentage of nursing staff and shall be 
broken down in terms of the total nursing 
staff, each unit, and each shift. 
‘‘(D) AUDIT OF DATA.—As part of each 
standard survey conducted under subsection 
(g)(2)(A), there shall be an audit of the nursing 
staff data reported under subparagraph (C) to 
ensure that such data are accurate.’’. 
(b) MEDICAID.—Section 1919(b)(8) of the Social Se-
curity Act (42 U.S.C. 1395r(b)(8)) is amended—
(1) in subparagraph (A), by adding at the end 
the following new sentence: ‘‘The information posted 
under this subparagraph shall include information 
regarding nurse staffing with respect to beds made 
available by reason of an agreement under section 
1883.’’; and
(2) by adding at the end the following new sub-
paragraphs: 
‘‘(C) 
SUBMISSION
AND
POSTING
OF 
DATA.—
‘‘(i) IN GENERAL.—Beginning on Jan-
uary 1, 2005, a nursing facility shall sub-
mit to the Secretary in a uniform manner 
(as prescribed by the Secretary) the nurs-
ing staff data described in section 3(a) of 
the Patient Safety Act of 2004 through 
electronic means not less frequently than 
quarterly and the Secretary shall make 
such data publicly available (as defined in 
section 3(g)(2) of such Act), including by 
posting such data on an Internet website. 
‘‘(ii) 
INFORMATION
ON
NURSE 
AIDES.—In addition to the nursing staff 
data described in clause (i), a skilled nurs-
ing facility shall submit to the Secretary 
the numbers of nurse aides (as defined in 
paragraph (5))(F)) utilized to provide di-
rect patient care. This information shall be 
expressed both in raw numbers and as a 
percentage of nursing staff and shall be
broken down in terms of the total nursing 
staff, each unit, and each shift. 
‘‘(D) AUDIT OF DATA.—As part of each 
standard survey conducted under subsection 
(g)(2)(A), there shall be an audit of the nursing 
staff data reported under subparagraph (C) to 
ensure that such data are accurate.’’. 
SEC. 5. CREATING A STAFFING QUALITY MEASURE FOR 
CONSUMERS TO COMPARE NURSING FACILI-
TIES. 
(a) IN GENERAL.—Beginning no later than 90 days 
after the date of the enactment of this Act, and for as 
long as the Secretary of Health and Human Services pub-
lishes quality measures to help the public compare the 
quality of care that nursing facilities provide, these quality 
measures shall include a quality measure for nursing staff 
that—
(1) reflects the average daily total nursing 
hours worked for the quarterly reporting period for 
which 
data 
are 
submitted 
under 
sections 
1819(b)(8)(C) and 1919(b)(8)(C) of the Social Secu-
rity Act (as added by subsections (a)(2) and (b)(2), 
respectively, of section 4), as well as, in the case of 
a skilled nursing facility, other information required 
to be reported under section 3(a);
(2) is sensitive to case mix and quality out-
comes; 
(3) indicates the percentile in which each nurs-
ing facility falls compared with other nursing facili-
ties in the State; 
(4) indicates the rate of retention of registered 
nurses, licensed practical nurses, and certified nurse 
assistants; and 
(5) includes such other measures as the Sec-
retary determines to be appropriate. 
The Secretary shall not be required to comply with the 
requirements of paragraph (2) to the extent that the devel-
opment of a methodology to comply with such requirement 
would delay the implementation of this section. 
(b) FORM AND MANNER.—The nursing facility com-
parative staffing measure described in subsection (a) shall 
be displayed in the same form and manner as information 
that the Secretary displays to help the public compare the 
quality of care that nursing facilities provide. 
SEC. 6. PROTECTION OF CERTAIN ACTIVITIES BY EMPLOY-
EES OF MEDICARE PROVIDERS. 
(a) IN GENERAL.—Subject to subsection (c), no pro-
vider under the medicare program shall terminate or take 
other adverse employment action (including the failure to 
promote an individual or provide any employment-related
benefit, an adverse evaluation or decision made in relation 
to accreditation, certification, credentialing or licensing of 
an individual, or other adverse personnel action) against 
any employee or group of employees for actions taken for 
the purpose of—
(1) notifying the provider of conditions which 
the employee or group of employees identifies, in 
communications with the provider, as dangerous or 
potentially dangerous or injurious to—
(A) patients who currently receive services 
from the provider; 
(B) individuals who are likely to receive 
services from the provider; or 
(C) employees of the provider; 
(2) notifying a Federal or State agency or an 
accreditation agency, compliance with the standards 
of which have been deemed to demonstrate compli-
ance with conditions of participation under the medi-
care program, of such conditions as are identified in 
paragraph (1); 
(3) notifying other individuals of conditions 
which the employee or group of employees reason-
ably believe to be such as are described in paragraph 
(1);
(4) discussing such conditions as are identified 
in paragraph (1) with other employees for the pur-
poses of initiating action described in paragraph (1), 
(2), or (3); or 
(5) other related activities as specified in regu-
lations promulgated by the Secretary of Health and 
Human Services. 
(b) SANCTION.—A provider that takes an action in 
violation of subsection (a) is subject to a civil money pen-
alty of not more than $20,000 for each such action. The 
provisions of section 1128A of the Social Security Act 
(other than subsections (a) and (b)) shall apply to civil 
money penalties under this subsection in the same manner 
as they apply to a penalty or proceeding under section 
1128A(a) of such Act. 
(c) EXCEPTION.—The provisions of subsection (a) 
shall not apply to the knowing or reckless provision of sub-
stantially false information by an employee or group of 
employees. 
SEC. 7. REPORT. 
Not later than 90 days after the date of the enact-
ment of this Act, the Secretary of Health and Human 
Services shall submit to Congress a report on—
(1) the manner in which the Secretary intends 
to implement reporting of additional nurse staffing
variables such as unit worked, day of week (weekday 
and weekend), and type of care (direct or adminis-
trative) provided; and 
(2) the most effective mechanisms for auditing 
nurse staffing data under sections 1819(b)(8)(D) 
and 1919(b)(8)(D) of the Social Security Act (as 
added by subsections (a)(2) and (b)(2), respectively, 
of section 4) and for auditing nurse staffing date 
under section 3(f)(2).
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