I 
111TH CONGRESS 
1ST SESSION H. R. 2273 
To amend the Public Health Service Act to establish direct care registered 
nurse-to-patient staffing ratio requirements in hospitals, and for other 
purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 6, 2009 
Ms. SCHAKOWSKY (for herself, Ms. EDDIE BERNICE JOHNSON of Texas, Mr. 
STARK, Mr. RANGEL, Mr. CONYERS, Mr. YOUNG of Alaska, Mr. ABER-
CROMBIE, Mr. MCGOVERN, Mr. SHERMAN, Ms. DELAURO, Mr. ELLISON, 
and Ms. BALDWIN) introduced the following bill; which was referred to 
the Committee on Energy and Commerce, and in addition to the Com-
mittee on Ways and Means, for a period to be subsequently determined 
by the Speaker, in each case for consideration of such provisions as fall 
within the jurisdiction of the committee concerned 
A BILL 
To amend the Public Health Service Act to establish direct 
care registered nurse-to-patient staffing ratio require-
ments in hospitals, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; FINDINGS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Nurse Staffing Standards for Patient Safety and Quality 
Care Act of 2009’’. 
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(b) FINDINGS.—Congress finds the following: 
(1) The Federal Government has a substantial 
interest in promoting quality care and improving the 
delivery of health care services to patients in health 
care facilities in the United States. 
(2) Recent changes in health care delivery sys-
tems that have resulted in higher acuity levels 
among patients in health care facilities increase the 
need for improved quality measures in order to pro-
tect patient care and reduce the incidence of medical 
errors. 
(3) Inadequate and poorly monitored registered 
nurse staffing practices that result in too few reg-
istered nurses providing direct care jeopardize the 
delivery of quality health care services. 
(4) Numerous studies have shown that patient 
outcomes are directly correlated to direct care reg-
istered nurse staffing levels, including a 2002 Joint 
Commission on Accreditation of Healthcare Organi-
zations report that concluded that the lack of direct 
care registered nurses contributed to nearly a quar-
ter of the unanticipated problems that result in in-
jury or death to hospital patients. 
(5) Requirements for direct care registered 
nurse staffing ratios will help address the registered 
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nurse shortage in the United States by aiding in re-
cruitment of new registered nurses and improving 
retention of registered nurses who are considering 
leaving direct patient care because of demands cre-
ated by inadequate staffing. 
(6) Establishing adequate minimum direct care 
registered nurse-to-patient ratios that take into ac-
count patient acuity measures will improve the deliv-
ery of quality health care services and guarantee pa-
tient safety. 
(7) Establishing safe staffing standards for di-
rect care registered nurses is a critical component of 
assuring that there is adequate hospital staffing at 
all levels to improve the delivery of quality care and 
protect patient safety. 
SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 
STAFFING REQUIREMENT. 
(a) MINIMUM DIRECT CARE REGISTERED NURSE 
STAFFING REQUIREMENT.—The Public Health Service 
Act (42 U.S.C. 201 et seq.) is amended by adding at the 
end the following new title: 
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‘‘TITLE XXXI—MINIMUM DIRECT 
CARE 
REGISTERED 
NURSE 
STAFFING REQUIREMENT 
‘‘SEC. 3101. MINIMUM NURSE STAFFING REQUIREMENT. 
‘‘(a) STAFFING PLAN.— 
‘‘(1) IN GENERAL.—A hospital shall implement 
a staffing plan that— 
‘‘(A) provides adequate, appropriate, and 
quality delivery of health care services and pro-
tects patient safety; and 
‘‘(B) is consistent with the requirements of 
this title. 
‘‘(2) EFFECTIVE DATES.— 
‘‘(A) 
IMPLEMENTATION
OF
STAFFING 
PLAN.—Subject to subparagraph (B), the re-
quirements under paragraph (1) shall take ef-
fect not later than 1 year after the date of the 
enactment of this title. 
‘‘(B) APPLICATION
OF
MINIMUM
DIRECT 
CARE
REGISTERED
NURSE-TO-PATIENT
RA-
TIOS.—The requirements under subsection (b) 
shall take effect as soon as practicable, as de-
termined by the Secretary, but not later than 2 
years after the date of the enactment of this 
title, or in the case of a hospital in a rural area 
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(as defined in section 1886(d)(2)(D) of the So-
cial Security Act), not later than 4 years after 
the date of the enactment of this title. 
‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE- 
TO-PATIENT RATIOS.— 
‘‘(1) IN GENERAL.—A hospital’s staffing plan 
shall provide that, during each shift within a unit of 
the hospital, a direct care registered nurse may be 
assigned to not more than the following number of 
patients in that unit, subject to paragraph (3): 
‘‘(A) 1 patient in operating room units and 
trauma emergency units. 
‘‘(B) 2 patients in critical care units, in-
cluding emergency critical care and intensive 
care units, labor and delivery units, and 
postanesthesia units. 
‘‘(C) 3 patients in antepartum units, emer-
gency room units, pediatrics units, stepdown 
units, and telemetry units. 
‘‘(D) 4 patients in intermediate care nurs-
ery units, medical/surgical units, and acute care 
psychiatric units. 
‘‘(E) 5 patients in rehabilitation units. 
‘‘(F) 6 patients in postpartum (3 couplets) 
units and well-baby nursery units. 
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‘‘(2) 
SIMILAR
UNITS
WITH
DIFFERENT 
NAMES.—The Secretary may apply minimum direct 
care registered nurse-to-patient ratios established in 
paragraph (1) to a type of hospital unit not referred 
to in such paragraph if such other unit performs a 
function similar to the function performed by the 
unit referred to in such paragraph. 
‘‘(3) ADJUSTMENT OF RATIOS.— 
‘‘(A) IN GENERAL.—If necessary to protect 
patient safety, the Secretary may prescribe reg-
ulations that— 
‘‘(i) increase minimum direct care reg-
istered nurse-to-patient ratios under this 
subsection to further limit the number of 
patients that may be assigned to each di-
rect care nurse; or 
‘‘(ii) add minimum direct care reg-
istered nurse-to-patient ratios for units not 
referred to in paragraphs (1) and (2). 
‘‘(B) CONSULTATION.—Such regulations 
shall be prescribed after consultation with af-
fected hospitals and registered nurses. 
‘‘(4) RELATIONSHIP
TO
STATE-IMPOSED
RA-
TIOS.— 
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‘‘(A) NO PREEMPTION OF CERTAIN STATE- 
IMPOSED RATIOS.—Nothing in this title shall 
preempt State standards that the Secretary de-
termines to be at least equivalent to Federal re-
quirements for a staffing plan established under 
this title. Minimum direct care registered nurse- 
to-patient ratios established under this sub-
section shall not preempt State requirements 
that the Secretary determines are at least 
equivalent to Federal requirements for a staff-
ing plan established under this title. 
‘‘(B) SATISFACTION OF CERTAIN FEDERAL 
REQUIREMENTS WITH CERTAIN STATE-IMPOSED 
NURSE-TO-PATIENT
RATIOS.—States that, at 
least 2 years prior to the date of the enactment 
of this title, have enacted minimum direct care 
nurse-to-patient ratios that allow the use of li-
censed practical nurses to meet State-imposed 
minimum direct care nurse-to-patient ratios 
may continue to make such allowance, and such 
allowance shall be considered to satisfy require-
ments imposed under this subsection, so long as 
the particular licensed practical nurse is em-
ployed in the same or a comparable position. 
‘‘(5) EXEMPTION IN EMERGENCIES.— 
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‘‘(A) IN GENERAL.—The requirements es-
tablished under this subsection shall not apply 
during a declared state of emergency if a hos-
pital is requested or expected to provide an ex-
ceptional level of emergency or other medical 
services. 
‘‘(B) EMERGENCY
DEFINED.—For pur-
poses of subparagraph (A), the term ‘declared 
state of emergency’ means a state of emergency 
that has been declared by the Federal Govern-
ment or the head of the appropriate State or 
local governmental agency having authority to 
declare that the State, county, municipality, or 
locality is in a state of emergency, but such 
term does not include a state of emergency that 
results from a labor dispute in the health care 
industry or consistent understaffing. 
‘‘(c) DEVELOPMENT AND REEVALUATION OF STAFF-
ING PLAN.— 
‘‘(1) CONSIDERATIONS
IN
DEVELOPMENT
OF 
PLAN.—In developing the staffing plan, a hospital 
shall provide for direct care registered nurse-to-pa-
tient ratios above the minimum direct care reg-
istered nurse-to-patient ratios required under sub-
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section (b) if appropriate based upon consideration 
of the following factors: 
‘‘(A) The number of patients and acuity 
level of patients as determined by the applica-
tion of an acuity system (as defined in section 
3106(1)), on a shift-by-shift basis. 
‘‘(B) The anticipated admissions, dis-
charges, and transfers of patients during each 
shift that impacts direct patient care. 
‘‘(C) Specialized experience required of di-
rect care registered nurses on a particular unit. 
‘‘(D) Staffing levels and services provided 
by other health care personnel in meeting direct 
patient care needs not required by a direct care 
registered nurse. 
‘‘(E) The level of technology available that 
affects the delivery of direct patient care. 
‘‘(F) The level of familiarity with hospital 
practices, policies, and procedures by temporary 
agency direct care registered nurses used dur-
ing a shift. 
‘‘(G) Obstacles to efficiency in the delivery 
of patient care presented by physical layout. 
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‘‘(2) DOCUMENTATION OF STAFFING.—A hos-
pital shall specify the system used to document ac-
tual staffing in each unit for each shift. 
‘‘(3) ANNUAL
REEVALUATION
OF
PLAN
AND 
ACUITY SYSTEM.— 
‘‘(A) IN GENERAL.—A hospital shall annu-
ally evaluate— 
‘‘(i) its staffing plan in each unit in 
relation to actual patient care require-
ments; and 
‘‘(ii) the accuracy of its acuity system. 
‘‘(B) UPDATE.—A hospital shall update its 
staffing plan and acuity system to the extent 
appropriate based on such evaluation. 
‘‘(4) REGISTERED
NURSE
PARTICIPATION.—A 
staffing plan of a hospital shall be developed and 
subsequent reevaluations shall be conducted under 
this subsection on the basis of input from direct care 
registered nurses at the hospital or, where such 
nurses are represented through collective bargaining, 
from the applicable recognized or certified collective 
bargaining representative of such nurses. Nothing in 
this title shall be construed to permit conduct pro-
hibited under the National Labor Relations Act or 
under the Federal Labor Relations Act. 
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‘‘(d) SUBMISSION OF PLAN TO SECRETARY.—A hos-
pital shall submit to the Secretary its staffing plan and 
any annual updates under subsection (c)(3)(B). A feder-
ally operated hospital may submit its staffing plan 
through the department or agency operating the hospital. 
‘‘SEC. 3102. POSTING, RECORDS, AND AUDITS. 
‘‘(a) POSTING REQUIREMENTS.—In each unit, a hos-
pital shall post a uniform notice in a form specified by 
the Secretary in regulation that— 
‘‘(1) explains requirements imposed under sec-
tion 3101; 
‘‘(2) includes actual direct care registered 
nurse-to-patient ratios during each shift; and 
‘‘(3) is visible, conspicuous, and accessible to 
staff, patients, and the public. 
‘‘(b) RECORDS.— 
‘‘(1) MAINTENANCE OF RECORDS.—Each hos-
pital shall maintain accurate records of actual direct 
care registered nurse-to-patient ratios in each unit 
for each shift for no less than 3 years. Such records 
shall include— 
‘‘(A) the number of patients in each unit; 
‘‘(B) the identity and duty hours of each 
direct care registered nurse assigned to each 
patient in each unit in each shift; and 
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‘‘(C) a copy of each notice posted under 
subsection (a). 
‘‘(2) AVAILABILITY
OF
RECORDS.—Each hos-
pital shall make its records maintained under para-
graph (1) available to— 
‘‘(A) the Secretary; 
‘‘(B) registered nurses and their collective 
bargaining representatives (if any); and 
‘‘(C) the public under regulations estab-
lished by the Secretary, or in the case of a fed-
erally operated hospital, under section 552 of 
title 5, United States Code (commonly known 
as the ‘Freedom of Information Act’). 
‘‘(c) AUDITS.—The Secretary shall conduct periodic 
audits to ensure— 
‘‘(1) implementation of the staffing plan in ac-
cordance with this title; and 
‘‘(2) accuracy in records maintained under this 
section. 
‘‘SEC. 3103. MINIMUM DIRECT CARE LICENSED PRACTICAL 
NURSE STAFFING REQUIREMENTS. 
‘‘(a) ESTABLISHMENT.—A hospital’s staffing plan 
shall comply with minimum direct care licensed practical 
nurse staffing requirements that the Secretary establishes 
for units in hospitals. Such staffing requirements shall be 
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the date of the enactment of this title, or in the case of 
a hospital in a rural area (as defined in section 
1886(d)(2)(D) of the Social Security Act), not later than 
4 years after the date of the enactment of this title. 
‘‘SEC. 3104. ADJUSTMENT IN REIMBURSEMENT. 
‘‘(a) MEDICARE REIMBURSEMENT.—The Secretary 
shall adjust payments made to hospitals (other than feder-
ally operated hospitals) under title XVIII of the Social Se-
curity Act in an amount equal to the net amount of addi-
tional costs incurred in providing services to medicare 
beneficiaries that are attributable to compliance with re-
quirements imposed under sections 3101 through 3103. 
The amount of such payment adjustments shall take into 
account recommendations contained in the report sub-
mitted by the Medicare Payment Advisory Commission 
under subsection (c). 
‘‘(b) AUTHORIZATION OF APPROPRIATION FOR FED-
ERALLY OPERATED HOSPITALS.—There are authorized to 
be appropriated such additional sums as are required for 
federally operated hospitals to comply with the additional 
requirements established under sections 3101 through 
3103. 
‘‘(c) MEDPAC REPORT.—Not later than 2 years after 
the date of the enactment of this title, the Medicare Pay-
ment Advisory Commission (established under section 
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