SF 2775 (Port)/HF 2289 (Johnson, P.)

The “Quality Patient Care Act” (QPCA) proposes mandated and burdensome nurse staffing ratios in hospitals. Key provisions include:

  • Staffing Ratio Requirements: Hospitals must maintain sufficient registered nursing staff based on specific patient-to-nurse ratios. These ratios vary by unit type, such as critical care, trauma, and psychiatric units. Ratios must also be set for Nursing Assistants and other direct care staff providing nursing services to patients.
  • Staffing Plans: Hospitals must develop staffing plans that detail the maximum number of patients assigned to each nurse, with limited processes to adjust staffing based on patient needs.
  • Safe Patient Assignment Committee: Each hospital must establish a new committee, composed of 60% direct-care nurses, to assess and oversee staffing conditions.
  • Prohibitions & Protections: The bill prohibits retaliation against nurses who unilaterally refuse patient care assignments, report unsafe staffing levels, and prevents the use of mandatory overtime and other staffing options to meet staffing needs.
  • Enforcement & Penalties: Hospitals failing to comply face multiple $25,000 civil penalties, with noncompliance publicly reported.

Section 1. “QUALITY PATIENT CARE ACT”

Section 1. Subd. 1. – Title. Titles bill as the “Quality Patient Care Act” or QPCA

Section 1. Subd. 2. – Definitions. The following terms have the meaning given:

  • “Assignment” means the provision of care to a patient for whom a direct-care registered nurse has responsibility within the nurse’s scope of practice.
  • “Charge nurse” means a nurse who:
    • oversees and supports nursing staff for each shift
    • serves as a unit resource and carries out duties that include assigning patients to nurses in the oncoming shift, coordinating patient flow, relieving staff for breaks, and operating as a safety valve in addressing emergency patient care issues and fluctuations in patient acuity and nursing intensity on the unit
    • has received special orientation and training to serve as a charge nurse for a unit or department in a hospital

“Direct-care registered nurse” means a registered nurse, as defined in section 148.171, subdivision 20, who is nonsupervisory and nonmanagerial and who directly provides nursing care to patients more than 60 percent of the time.

  • “Health care emergency” means a situation that creates an actual or imminent serious threat to the health and safety of people and that may require hospitals and other health care facilities to provide an exceptional level of emergency services or other health care services. A health care emergency may include a natural or man-made disaster, or an illness or health condition caused by bioterrorism or an infectious agent that causes a high probability of many deaths, serious or long-term disabilities, or substantial future harm.
  • “Nursing intensity” means a patient-specific, not diagnosis-specific, measurement of nursing care resources expended during a patient’s hospitalization. A measurement of nursing intensity includes the complexity of care required for a patient and the knowledge and skill needed by a nurse for the surveillance of patients to make continuous, appropriate clinical decisions in the care of patients.
  • “Patient acuity” means the measure of a patient’s severity of illness or medical condition, including but not limited to the stability of physiological and psychological parameters; the dependency needs of the patient and the patient’s family; and any other factors influencing the perceived health care needs of an individual patient as determined by a licensed provider, direct-care registered nurse, or other licensed health care professional whose primary job duties include providing care to patients more than 60 percent of the time. Higher patient acuity requires more intensive nursing time and advanced nursing skills for continuous surveillance. 
  • “Skill mix” means the composition of nursing staff by licensure, experience, and education, including but not limited to registered nurses, licensed practical nurses, and unlicensed personnel.
  • “Surveillance” means the continuous process of observing patients for early detection and intervention to prevent negative patient outcomes.
  • “Unit” means an area or location of a hospital where patients receive care based on similar patient acuity and nursing intensity.

Section 1. Subd. 3. Compliance. A hospital licensed in Minnesota must comply with QPCA

Section 1. Subd. 4. Staffing. Establishes the requirement for hospitals to always adhere to nationally accepted and evidence-based staffing ratios created in QPCA. Also puts sole charge of nursing care decisions at the discretion of the direct-care RN assigned to the patient.

Section 1. Subd. 5. Staffing Plans. Further qualifies staffing ratio requirements, including the requirement to set ratios for nursing assistants and any other direct-care staff providing nursing services directly to patients.

Section 1. Subd. 6. Assignment limits for direct care RNs. Staffing plans in Subd. 5 may not permit direct-care registered nurses to be assigned more patients than the following for any shift:

  • 1-to-1 ratios are required for the following units and/or patient care scenarios:
    • operating rooms
    • trauma units
    • patients who require immediate lifesaving interventions
    • hemodynamically unstable patients whose care needs include immediate response to life-threatening conditions
    • patients demonstrating compromised or otherwise unstable vital signs creating life-threatening conditions requiring immediate response
    • active delivery
    • post-anesthesia
    • conditions or health care needs that pose an immediate threat to life or limb
    • trauma patients requiring lifesaving interventions or patients with other conditions qualifying as a trauma code activation
    • unstable patients requiring transfer to another unit
  • 1-to-2 ratios are required for the following units and/or patient care scenarios:
    • Post- anesthesia care units
    • critical care units
    • intensive care units
    • any units treating intensive care unit patients within the emergency room
    • neonatal intensive care
    • labor and delivery
    • coronary care
    • acute respiratory care
    • burn units
  • 1-to-3 ratios are required for the following units and/or patient care scenarios:
    • intermediate care newborn nurseries
    • antepartum units
    • adult medical and surgical units
    • units providing both labor and delivery and postpartum services
    • postpartum couplets units providing services for infants and mothers
    • step-down units
    • telemetry units
    • pediatric units
    • emergency departments
  • 1-to-4 ratios are required for the following units and/or patient care scenarios:
    • acute psychiatric units
    • rehabilitation care units
    • chemical dependency units
    • immediate care nursery or Level II nursery
    • any other specialty care or patient care units organized to provide care for a specific medical condition, disease, diagnosis, or patient population for which specific assignment limits are not established in this paragraph
  • 1-to-5 ratios are required for the following units and/or patient care scenarios:
    • Skilled nursing units
  • Ratios cannot be set using averages of patients or the total number of licensed bargaining unit nurses on the unit during any one shift or over any period. Only licensed bargaining unit nurses providing direct patient care shall be included in the ratios. The ratios established shall be in place for all shifts throughout the calendar year.

Section 1. Subd. 7. Schedule for compliance. Hospitals must comply by August 1, 2027. Teaching hospitals must comply no later than August 1, 2029. The Commissioner of Health shall establish a compliance and enforcement schedule.

Section. 1. Subd. 8. Application of assignment limits to hospital nursing practice standards. Requires that ratios are set only using RNs that have validated competence to provide the patient care needed.

Section 1. Subd. 9. Nursing administrators and supervisors. In setting ratios and staffing plans, hospitals cannot include a nurse administrator, nurse supervisor, nurse manager, charge nurse, chief nursing officer, or any other nursing staff whose regular job duties do not include providing direct patient care during at least 60 percent of working hours.

Section 1. Subd. 10. Application of assignment limits. A hospital is prohibited from averaging the number of patients and the total number of direct-care registered nurses assigned to patients in a unit during any one shift or over any period to meet staffing ratios.

Section 1. Subd. 11. Assignments, assignment adjustments, and adding additional registered nurses.

  • For each patient population, a direct-care registered nurse – not a nursing administrator or supervisor – shall evaluate the following factors to assess and determine adequacy of staffing levels to meet patient care needs:
    • composition of skill mix and roles available
    • patient acuity
    • experience level of registered nurse staff
    • unit activity level, such as admissions, discharges, and transfer
    • variable staffing grids
    • availability of a registered nurse to accept an assignment
    • nursing intensity
  • Hospitals cannot do the following:
    • assign a patient to an RN that requires care not within the RN’s competence
    • assign a patient to an RN if the RN believes that taking the patient assignment violates the Minnesota Nurse Practice Act
    • assign a patient to a staffing agency nurse unless they have the necessary and demonstrate competence to take the assignment
    • Assign unlicensed personnel to provide any patient care services that RNs are responsible for.
  • If an RN determines staffing levels are inadequate on a unit, the manager or administrative supervisor shall consider the following:
    • current patient care assignments for potential redistribution
    • the ability to facilitate discharges, transfers, and admission
    • the availability of additional staffing resources
    • the hospital-wide census and staffing
  • If staffing inadequacies cannot be resolved, additional staff must be called in and until additional staff arrive the hospital must suspend nonemergency admissions and elective surgeries that are not life-threatening that often lead to inpatient stays.
  • Further, the charge nurse is authorized to close the unit to new patients if staffing levels cannot be kept after all good-faith efforts to bring in additional staffing to alleviate excessive boarding issues in the emergency department.

Section 1. Subd. 12. Prohibited Actions. Hospitals are prohibited from taking any of the following actions to meet staffing ratios:

  • Use mandatory overtime
  • Assign or transfer a RN to a unit they are not competent or trained for
  • Assing an RN to a unit to relieve another RN during breaks, meals, or other absences from a unit
  • Impose layoffs
  • Make patient assignments that violate the MN Nurse Practice Act
  • Discharge, discipline, penalize, interfere with, threaten, restrain, coerce, or otherwise retaliate or discriminate against a nurse who communicates their objection to a patient assignment based on the requirements of the Nurse Practice Act.

Section 1. Subd. 13. Exemption for emergency situations. Staffing ratios do not apply during a health care emergency. Hospitals must take all steps to always maintain staffing ratios.

Section 1. Subd. 14. Charge nurse inclusion in the staffing grid. A charge nurse shall not be included in the unit’s staffing grid that is regularly reviewed and determines the unit’s staffing budget. This subdivision does not limit the ability of a charge nurse to take a patient assignment in the event of an emergency.

Section 2. PATIENT CARE AND USE OF TECHNOLOGY. 

Section 2. Subd. 1. Patient-acuity adjustable units prohibited. Requires that patients must be cared for in units or patient care areas where ratios are met.

Section 2. Subd. 2. Use of technology. Hospitals shall not use any form of video monitoring as a substitute for direct observation done. Video monitoring shall not be included in ratios and technology that limits RNs from performing their duties and using their professional judgement is prohibited.

Section 3. SAFE PATIENT ASSIGNMENT COMMITTEE.

Section 3. Subd. 1. Committee Required. Hospitals must establish a Committee by October 1, 2026

Section 3. Subd. 3. Membership; compensation. Membership is comprised of at least 60% nonsupervisory and nonmanagerial RNs who provide direct patient care, including RNs appointed by a CBA to proportionately represent the bargaining unit. RNs serving on the Committee must be compensated for their time.

Section 3. Subd. 3. Committee Duties. The Committee’s duties are as follows:

  • complete a staffing for patient safety assessment by March 31, 2026, and annually thereafter
  • implement and evaluate ratios
  • convert ratios into RN hours of care per patient
  • recommend a mechanism for tracking and analyzing staffing trends within the hospital
  • develop a procedure for making shift-to-shift adjustments in staffing levels when adjustments are required by patient acuity and nursing intensity
  • identify any incidents when the hospital has failed to meet the ratios

Section 4. RETALIATION PROHIBITED.

  • Allows RNs to unilaterally refuse patient assignments.
  • Hospitals cannot retaliate against an RN for patient assignment refusal, reporting concerns for safe staffing, or objecting to a specific or additional patient assignment on grounds that it would violate the MN Nurse Practice Act.

Section 5. ENFORCEMENT.

  • Requires the Commissioner of Health to impose a civil penalty of not less than $25,000 for each incident of a hospital failing to comply with Sections 1-4. 
  • The Commissioner must publicly report all instances of noncompliance on a quarterly basis beginning September 1, 2026.

Section 6. MODIFYING EXISTING STAFFING PLAN REPORTS. 

Section 6. Subd. 2. Hospital staffing report. Modifies criteria in existing hospital RN staffing reports to include:

  • the number of beds available and average number of patients per day in each unit
  • FTE for each unit broken down by 8-hour shifts and type of staff assigned to the unit, including but not limited to RNs, LPNs, CNAs, and other care team members.
  • RNs must certify that the report is correct before submitting it to MHA on a quarterly basis

Section 6. Subd. 3. Standard electronic reporting developed. Modifies MHA’s duties to report the staffing plans on a quarterly basis.

Section 6. Subd. 4. Enforcement. The Commissioner shall impose a civil penalty of not less than $25,000 for each hospital that fails to comply. Each day of the violation shall constitute a separate violation, and the penalties prescribed shall be applicable to each separate violation.

Section 6. Subd. 5. Staffing grid; compliance; enforcement. Hospitals must submit their staffing grid to the Commissioner on a quarterly basis. Additionally, the Commissioner shall accept staffing complaints from persons employed by a hospital. Lastly, the Commissioner shall impose a civil penalty of not less than $25,000 for the following: 

  • failing to submit the grid
  • when ratios are determined to have not been met
  • when it is determined that understaffing has led to increase adverse health events.

Section 7. “WHISTLEBLOWER” PROTECTIONS.

  • States that any RN that reports unsafe staffing or a hospital’s violation of staffing ratios, or violation of any QPCA mandates, is protected from civil liability or criminal appropriations.
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