DESCRIPCIÓN DE LA ACTIVIDAD UND CANT

As previously noted in Section 3.2, although the law’s stated intent was to improve quality of care and ensure a minimum standard for it, the law was not structured to directly achieve this. This includes both the manner in which it targeted facilities (i.e., it’s uncertain whether its targeted facilities were low quality) and its method for quality improvement. This is in contrast to other quality improvement initiatives that have made quality outcomes their direct focus and benchmark for achievement. Some of these initiatives like the Centers for Medicare and Medicaid Services’ Hospital Readmissions Reduction Program have received criticism regarding their structure and may

be vulnerable to gaming attempts, but their design more directly reflects an attempt to incentivize higher quality.11 _{Programs structured along these lines additionally allow for greater efficiency in} achieving their quality outcomes, because hospitals are not constrained with respect to their inputs and approach to quality improvement.

The structure of AB 394 suggests an alternative motivation for the law different from quality improvement—namely, that of rent-seeking by nurses. Rent-seeking describes behavior designed to appropriate wealth from another party without value creation. In many ways, rent-seeking by nurses could be argued in light of the circumstances leading up to the law along with its structure and aftermath. As noted in Chapter 2, the run-up to the law’s passage involved extensive lobbying by California’s nurse unions and political action. Additionally, the law’s main focus and effect was to force hospitals to increase their nurse-staffing levels, not necessarily improve quality. This had two main consequences that clearly benefited nurses. The first was a potential lightening of nurses’ workloads at the hospitals at which staffing increases occurred. The second and arguably more significant consequence was a dramatic increase in nurse wages (shown in Chapter 5) as the short- run supply of nurses proved inelastic to the growing demand for them across the state. For RNs, this amounted to an inflation-adjusted wage increase of 35% from the law’s pre-passage period to 2006, two years after the law’s implementation deadline. As described in Chapter 4, it’s unclear if any quality of care improvements occurred. Unsurprisingly, nurse satisfaction was documented to have increased. Viewed through this lens, nurses won rents through political means and lobbying, but it’s unclear if patients were better off. In fact, patients may have faced higher prices and reduced choice of care facilities for services.

11_{Hospitals operating under programs of this sort face objective functions along the lines of the following where}

Sminis the regulator’s minimum acceptable quality level.

max

Chapter 4

The Literature on AB 394 and

Quality of Care

Although nurses are generally regarded as an important component in quality of care,12 it’s unclear whether mandating hospitals to maintain minimum nurse-to-patient ratios would improve quality. Since 2005, a number of studies have been published aimed at addressing this in the context of AB 394. These studies have examined a varied set of quality-related measures. They’ve also implemented a diverse set of analytic approaches with different degrees of rigor in terms of identifying causal effects. Although the findings across these studies have been somewhat mixed, they generally don’t point to clear quality effects. These results, however, may be regarded with some caution as limitations exist. These include issues around study design, data sources (e.g., convenience samples and reporting changes in administrative claims datasets), and a limited set of outcomes in the more rigorous studies. The following sections provide an overview of the quality studies performed to date.

4.1

Quality measures and analytic approaches

As previously noted, the studies on AB 394 and quality have examined a range of measures. The most frequently analyzed have consisted of patient safety indicators (PSIs) that represent nurse- sensitive preventable events, as designated by the National Quality Forum or the Agency for Health Care Research and Quality (AHRQ). Chief among these have been “failure to rescue” (FTR) and

12_{One of the chief mechanisms attributed to nurses’ influence on quality is their monitoring and surveillance of}

patients, which constitutes a primary responsibility [Fagin and Fund, 2001]. During this process, nurses are expected to recognize impending or current problems and coordinate actions to mitigate them. Examples of this include identifying the signs of postoperative infections and ensuring that appropriate treatment is administered and taking action to prevent patient falls and pressure ulcers. These actions can be essential for preventing patient harm and in some cases even saving lives.

hospital-acquired pressure ulcers. (FTR describes patient death from complications that could have been prevented under normal circumstances.) Other safety events that have been examined to a lesser extent include infections due to medical care, falls, pneumonia mortality, and postoperative events such as deep vein thrombosis (DVT)/pulmonary embolism (PE), sepsis, pneumonia, and respiratory failure. In addition to these clinical measures, more general risk-adjusted mortality and risk-adjusted complications have been assessed.

Non-clinical and process-oriented measures have also been examined in some studies. These include emergency department (ED) wait times for patients, use of restraints, time to first antibiotics for pneumonia patients, percentage of acute cardiac syndrome (ACS) patients receiving aspirin, and length of stay. Two studies have also examined general patient satisfaction (and complaints) and impressions of quality of care as reported by hospital leaders and staff.

The analytic approaches have been quite diverse across studies examining AB 394 and quality. They have included case studies, descriptive comparisons pre- and post-AB 394’s implementation using convenience samples, cross-sectional correlation analyses, and interviews with hospital leaders and staff among others. A minority have sought to use more rigorous techniques to identify causal effects. A summary is presented in the following sections organized by general type of analysis.