Version No. 001 Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Act 2015 No. 51 of 2015 Version as at 23 December 2015 Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Regulations 2015 S.R. No. 169/2015 Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Bill 2015 Introduction Print EXPLANATORY MEMORANDUM Clause Notes The Parliament of Victoria enacts: 1 Purposes Part 1 Preliminary The purposes of this Act are to provide for (a) requirements that the operators of certain publicly funded health facilities staff certain wards with a minimum number of nurses or midwives; and (b) the reporting of compliance with and enforcement of those requirements. 2 Commencement (1) Subject to subsection (2), this Act comes into operation on a day or days to be proclaimed. (2) If a provision of this Act does not come into operation before 1 December 2017 it comes into operation on that day. 3 Definitions In this Act acute ward means a multi-day inpatient ward in which any of the following are cared for (a) patients who have an acute or chronic illness or an injury; (b) patients recovering from surgery; Clause 1 Part 1 Preliminary sets out the purposes of the Bill. The purpose of the Bill is to introduce a new Principal Act to provide for requirements that the operators of certain publicly funded health facilities staff certain wards with a minimum number of nurses or midwives. Furthermore, the Bill provides for the reporting of compliance and enforcement of those requirements. The intent is for the scope of the Bill to extend to only the public hospitals, health services, publicly operated denominational hospitals and multi purpose services that are currently covered by the Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement 2012 2016. Private and not-for-profit hospitals and residential aged care services that are not covered by the Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement 2012 2016 are not intended to be subject to this Bill. Clause 2 is the commencement provision. All clauses in the Bill will come into operation on a day or days to be proclaimed. However, if the Bill is not proclaimed before 1 December 2017 it will come into operation on that day. Clause 3 sets out the following definitions of the various words and expressions used in the Bill as follows acute ward is intended to include wards within a level 4 hospital that are used to care for patients who have an acute or chronic illness or an injury, or are recovering from surgery. It is intended that the definition only includes multi-day inpatient wards or beds where patients are admitted and hospitalised for a period greater than one day. The definition intends to exclude any wards or beds utilised for same-day patients where the patient is admitted and hospitalised for a period equal to or less than one day.
After Hours Coordinator means a registered nurse or a midwife who is responsible for overseeing the operations of the hospital when the Director of Nursing or Director of Midwifery is not on duty; aged high care residential ward means a ward at a location (a) the operator of which is an approved provider within the meaning of the Aged Care Act 1997 of the Commonwealth; and (b) that, as at 30 June 2014, had at least one place within the meaning of that Act that was high care allocated; bed includes cubicle, trolley, treatment chair, cot and delivery suite; below ratios distribution means a proposal under section 34(1); coronary care unit means a unit of specialised critical care beds dedicated to acute care, treatment and monitoring of patients with serious or unstable cardiac diseases; After Hours Coordinator is intended to mean a registered nurse or midwife who has been appointed by the hospital, whether temporarily or permanently, to oversee the operations of the hospital during the off duty periods of the Director of Nursing or Director of Midwifery. The off-duty periods of the Director of Nursing/Midwifery are usually the periods outside of office hours on Monday to Friday, and all shifts on the weekend. While the position is known as the "After Hours Coordinator" in the Bill, the title used for this person in a hospital may be a different title and still meet the definition of an "After Hours Coordinator" in the Bill. aged high care residential ward is intended to be read in the context of the definition of high care beds. It is intended that the definition includes only residential aged care services, operated by hospitals within the meaning of the Bill, that have been approved as a provider by the Commonwealth within the meaning of the Aged Care Act 1997 (Cth). The Bill is not intended to apply to any residential aged care services being operated by private or not-for-profit organisations that are not captured within the definition of hospital in the Bill. The nurse to patient ratios in the Bill are intended to apply only to high care allocated places within the meaning of the Aged Care Act 1997 (Cth) as at 30 June 2014, while specifically excluding any high care allocated places that are utilised for persons receiving aged persons mental health residential care as funded by the Department of Health and Human Services. Additionally, the nurse to patient ratios are not intended to apply to any low care allocated place within the meaning of the Aged Care Act 1997 (Cth) as at 30 June 2014. It is intended that the nurse to patient ratios for residential aged care facilities apply to an allocated place within the meaning of the Aged Care Act 1997 (Cth) and remain fixed, rather than apply to the actual level of care required by the resident, which can vary over time. Example: A residential aged care service that is operated by a hospital (as defined by the Bill) consists of 60 beds. Those beds include 30 high care allocated places, 20 high care allocated places where funding is provided by the Department of Health and Human Services for the provision of aged persons mental health residential care and 10 low care allocated places. The nurse to patient ratios contained in the Bill are intended to apply to only the 30 high care allocated places, irrespective of the care requirements of the residents utilising the beds at any given time. bed is intended to include cubicles, trolleys, treatment chairs, cots and delivery suites, so that all provisions of Division 1 of Part 2 of the Bill apply to all types of beds in relevant wards. This definition is not intended to include chairs within non-treatment areas, including emergency department waiting rooms or other waiting rooms. below ratios distribution has the meaning set out at clause 34(1) of the Bill. coronary care unit is intended to mean a unit within the hospital of specialised critical care beds that are dedicated to the acute care, treatment and monitoring of patients with serious or unstable cardiac diseases. Coronary care units may be stand-alone units or form part of a ward alongside other beds. It is not intended that this definition extends to other non-critical care cardiac, cardiology or cardiac surgery beds.
Department means the Department of Health and Human Services; enrolled nurse means a person registered in Division 2 of the Register of Nurses kept by the Nursing and Midwifery Board of Australia under the Health Practitioner Regulation National Law, other than as a student; general medical or surgical ward means (a) a multi-day inpatient ward in which either of the following are cared for (i) patients with an acute or chronic illness or an injury; (ii) patients recovering from surgery; or (b) an area of a hospital into which patients admitted to the emergency department are transferred for the provision of short-term treatment, observation, assessment or reassessment when they no longer require emergency care; high care beds do not include (a) aged person mental health beds for which supplementary funding is provided by the Department in accordance with the Victorian health policy and funding guidelines published by the Department from time to time; or (b) low care allocated places as at 30 June 2014; Department is intended to mean the Department of Health and Human Services. enrolled nurse means an enrolled nurse registered under the Health Practitioner Regulation National Law. general medical or surgical ward is intended to include wards within level 1, level 2 and level 3 hospitals that care for patients who have an acute or chronic illness or an injury, or are recovering from surgery. It is intended that the acute ward definition only includes multi-day inpatient wards or beds where patients are admitted and hospitalised for a period greater than one day. The definition intends to exclude any wards or beds utilised for same-day patients where the patient is admitted and hospitalised for a period equal to or less than one day. Same-day wards that are excluded include day surgery wards, day procedure wards, chemotherapy wards, dialysis wards and admission centres. Additionally, the general medical or surgical ward definition is intended to include Short Stay Observation areas, which are areas of a hospital often adjacent or near to an emergency department into which patients are transferred from the emergency department when they no longer require emergency care for short-term treatment, observation, assessment or reassessment. Typically Short Stay Observation areas are utilised as an interim step for patients who no longer require emergency department level care, but require short-term ongoing observation to determine whether admission to an inpatient multi-day ward is clinically necessary. Short Stay Observation areas can be stand-alone wards or can be an area of an emergency department. It is not intended that this definition applies to the emergency department waiting room or other waiting rooms, as nurse to patient ratios have not applied to these areas. high care beds is intended to inform the aged high care residential ward definition, and is intended to specifically exclude any high care allocated place being utilised for aged persons receiving mental health residential care and any low care allocated place within the meaning of the Aged Care Act 1997 (Cth) as at 30 June 2014. In relation to the aged persons mental health beds, each financial year the Department of Health and Human Services releases the Department of Health and Human Services Policy and Funding Guidelines (or equivalent). This document specifies a bed day funding rate that is applicable to clinical bed-based services for that financial year, including supplementary funding for all aged persons nursing home beds. The operator of the hospital receives supplementary funding from the Department of Health and Human Services on top of any funding provided by the Commonwealth for aged persons mental health high care residential beds for "aged clients who cannot be managed in the general residential system due to their level of persistent cognitive, emotional or behavioural disturbances". The number of aged persons mental health high care residential funded beds is nominated in the same document each financial year. hospital means (a) a level 1 hospital, a level 2 hospital, a level 3 hospital or a level 4 hospital; or hospital is intended to include, when read in conjunction with the level 1, level 2, level 3 and level 4 hospital definitions, all Victorian public hospitals, public health services, publicly operated denominational hospitals and multi purpose services as defined by the Health Services Act 1988, with the addition of four independently operated residential aged care services, specifically Darlingford Upper Goulburn
(b) the following (i) Darlingford Upper Goulburn Nursing Home Inc.; (ii) Indigo North Health Inc.; (iii) Lyndoch Living Inc.; (iv) Red Cliffs and Community Aged Care Services Inc.; level 1 hospital means a hospital specified in Part 1 of Schedule 1; Part 1 Level 1 hospitals Alfred Hospital Austin Hospital Box Hill Hospital Dandenong Hospital Footscray Hospital Frankston Hospital Heidelberg Repatriation Hospital Monash Medical Centre (Clayton) Northern Hospital Peter MacCallum Cancer Centre St Vincent's Hospital The Royal Children's Hospital The Royal Melbourne Hospital University Hospital Geelong Nursing Home Inc., Indigo North Health Inc., Lyndoch Living Inc. and Red Cliffs and Community Aged Care Services Inc. (currently trading as Jacaranda Village). It is not intended that the Bill cover private or not-for-profit hospitals, private or notfor-profit day procedure centres, private or not-for-profit day surgery centres or private or not-for-profit residential aged care facilities. level 1 hospital means the hospitals set out in Part 1 of Schedule 1 to the Bill. level 2 hospital means a hospital specified in Part 2 of Schedule 1; level 2 hospital means the hospitals set out in Part 2 of Schedule 1 to the Bill. Part 2 Level 2 hospitals Ballarat Base Hospital Bendigo Hospital Goulburn Valley Health Latrobe Regional Hospital Maroondah Hospital Mercy Hospital for Women
New Mildura Base Hospital Northeast Health Wangaratta Sunshine Hospital The Royal Women's Hospital Werribee Mercy Hospital level 3 hospital means a hospital specified in Part 3 of Schedule 1; level 3 hospital means the hospitals set out in Part 3 of Schedule 1 to the Bill. Part 3 Level 3 hospitals Albury Wodonga Health (Wodonga campus) Angliss Hospital Bairnsdale Regional Health Service Castlemaine Health Central Gippsland Health Service (Sale campus) Echuca Regional Health Hamilton Base Hospital Monash Medical Centre (Moorabbin) Portland District Health Rosebud Hospital Sandringham Hospital Swan Hill District Health The Royal Victorian Eye and Ear Hospital Warrnambool Base Hospital West Gippsland Hospital Williamstown Hospital Wimmera Health Care Group (Horsham campus) level 4 hospital means a campus of any public hospital, denominational hospital, multi purpose service or public health service within the meaning of the Health Services Act 1988 other than a public hospital, denominational hospital, multi purpose service or public health service that is a level 1 hospital, level 2 hospital or level 3 hospital; level 4 hospital means each campus of a hospital that is defined under the Health Services Act 1988, but is not set out in the Schedules to the Bill as a level 1, level 2 or level 3 hospital. A level 4 hospital is generally a smaller hospital.
local dispute means a dispute between a nurse or midwife and the operator of a hospital initiated by way of a notification under section 41(1); midwife means a person registered in the Register of Midwives kept by the Nursing and Midwifery Board of Australia under the Health Practitioner Regulation National Law, other than as a student; midwife in charge means a midwife who is undertaking, whether temporarily or permanently, the role of (a) a midwifery unit manager or equivalent; or (b) an associate midwifery unit manager or equivalent; normal care nursery means a nursery for low risk newborns who are well or who have minor conditions and are medically stable; nurse means registered nurse or enrolled nurse; nurse in charge means a registered nurse who is undertaking, whether temporarily or permanently, the role of (a) a nurse unit manager or equivalent; or (b) an associate nurse unit manager or equivalent; occupied includes available to be occupied; operator, in relation to a hospital, means the entity that has day-to-day responsibility for managing and operating the hospital; local dispute is intended to mean a dispute between a nurse or midwife and the operator of a hospital that has been notified under clause 41(1) of the Bill. midwife means a midwife registered under the Health Practitioner Regulation National Law. midwife in charge means a midwife who is undertaking the role of a midwifery unit manager, or an associate midwifery unit manager either on a permanent basis as appointed by the operator of the hospital, or on a temporary basis due to covering a position vacancy, a roster vacancy or covering planned or unplanned leave. normal care nursery is intended to mean a nursery for low risk, uncomplicated newborns who are well, or who have minor conditions and are medically stable. This nursery is distinct from special care nurseries and neonatal intensive care units. nurse means an enrolled or registered nurse registered under the Health Practitioner Regulation National Law. nurse in charge means a registered nurse who is undertaking the role of a nurse unit manager, or an associate nurse unit manager either on a permanent basis as appointed by the operator of the hospital, or on a temporary basis due to covering a position vacancy, a roster vacancy or covering planned or unplanned leave. It is intended that only one nurse in charge is required per ward as requested by the ratios, irrespective of the mix or nature of beds that make up that ward. Example: A 28 bed ward in a hospital may have 8 acute beds, 8 rehabilitation beds, 4 geriatric assessment and management beds and 8 residential aged care beds that are all managed by one nurse unit manager. Despite the ratios outlined in Division 2 of Part 2 stating that for acute wards, rehabilitation wards, the geriatric assessment and management beds and residential aged care beds all requiring a nurse in charge for the morning shift and the afternoon shift, it is intended that only one nurse in charge is required per ward, irrespective of the mix or nature of beds that make up that ward. It is not intended that a nurse in charge is required for each different type of bed within a single ward. occupied is intended to include beds that have actual patients within the ward, as well as beds that are open and available to be occupied by patients. It is not intended to include beds that have been closed or otherwise are not utilised, either on a temporary or permanent basis, by the operator of the hospital. operator is intended to mean the entity that operates the hospital, including the Board of management and/or the Chief Executive Officer. It is not intended that the operator of the hospital extends to other managers.
ratio means a staffing requirement set out in a provision of Division 2 or 3 of Part 2; ratio variation means a variation to a ratio implemented under Division 4 of Part 2; redistribution principles means the principles prescribed under section 33(1); registered nurse means a person registered in Division 1 of the Register of Nurses kept by the Nursing and Midwifery Board of Australia under the Health Practitioner Regulation National Law, other than as a student; relevant union means an organisation within the meaning of the Fair Work (Registered Organisations) Act 2009 of the Commonwealth that represents or is entitled to represent a nurse or midwife in a ward; safe patient care compliance direction means a direction given under section 37(1); Secretary means the Department Head (within the meaning of the Public Administration Act 2004) of the Department; special care nursery means a discrete ward in which any of the following are cared for (a) newborn infants who are unwell; (b) newborn infants who require a higher level of care or treatment than newborn infants in a normal care nursery; ward means a ward, unit, department or component of a hospital managed by a nurse or midwife who is undertaking, whether temporarily or permanently, the role of (a) a nurse unit manager or equivalent; or (b) a midwifery unit manager or equivalent. ratio means a nurse to patient or midwife to patient ratio set out in Division 2 or 3 of Part 2 of the Bill. ratio variation means a variation to a nurse to patient or midwife to patient ratio that has been varied through the operation of the mechanisms set out in Division 4 of Part 2 of the Bill. redistribution principles means the principles prescribed under clause 33(1) of the Bill. registered nurse means a nurse registered under the Health Practitioner Regulation National Law. relevant union is intended to mean an organisation within the meaning of the Fair Work (Registered Organisations) Act 2009 (Cth) that represents or is entitled to represent a nurse or midwife in a ward in a relevant hospital that is covered by the Bill. The Australian Nursing and Midwifery Federation is currently the only registered organisation that has coverage of registered nurses and midwives within these wards. There are two unions that have coverage of enrolled nurses on these wards, namely the Australian Nursing and Midwifery Federation and the Health Services Union (Victorian Number 1 Branch), trading as the Health Workers Union. safe patient care compliance direction is a direction issued by the Secretary under clause 37(1) of the Bill. Secretary is intended to mean the Secretary of the Department of Health and Human Services. special care nursery is intended to mean a discrete ward that is used to care for unwell newborn infants where the care requirements of the newborn infant are higher than can be provided within a normal care nursery, but do not require the critical care provided by a neonatal intensive care unit. ward is intended to mean a ward, unit, department or component of a hospital that is managed by either a nurse unit manager or a midwifery unit manager either on a permanent basis or temporary basis as appointed by the operator of the hospital. A ward is usually, but not always, a geographically discrete area within the hospital. It is intended that that despite anything to the contrary in this Bill, a ward is only required to have one nurse in charge where required by the ratios, irrespective of the types of beds that make up that ward. It is not intended that a ward which consists of a number of different types of beds requires to be split into sub-sections for the purposes of meeting the provisions of the Bill, rather it is intended that a ward is able to operate as a cohesive unit under the management of one nurse in charge or midwife in charge where required by the Bill. 4 Objective Clause 4 sets out the objective of the Bill. The objective of the Bill is to provide for safe patient care in hospitals by
(1) The objective of this Act is to provide for safe patient care in hospitals by establishing requirements for a minimum number of nurses or midwives per number of patients in specified wards or beds, recognising that nursing workloads impact on the quality of patient care. (2) In meeting the objective of this Act, the operator of a hospital may apply the ratios in a flexible manner having regard to the following (a) variations in the number of patients who occupy or are expected to occupy beds; (b) variations in patient numbers that may lead to a period of peak demand. 5 Change in name of hospital If the name of a hospital changes, the requirements of this Act continue to apply to that hospital after the change of name despite the change of name. 6 Crown bound This Act binds the Crown in right of Victoria and, to the extent that the legislative power of the Parliament permits, the Crown in all its other capacities. 7 Act not to affect employment contracts or workplace instruments Nothing in this Act is intended to constitute a term of or to alter or vary, or authorise or require the alteration or variation of (a) any employment contract; or (b) any workplace instrument within the meaning of the Fair Work Act 2009 of the Commonwealth. establishing requirements for a minimum number of nurses or midwives per number of patients in specified wards or beds. Subclause (2) provides that in meeting the objective of the Bill, the operator of the hospital may apply the ratios in a flexible manner having regard for variations in the number of patients who occupy or are expected to occupy beds, and variations in patient numbers that may lead to a period of peak demand. This means that the operator of the hospital, in meeting the ratio provisions in the Bill, may apply them in a flexible manner to meet the care requirements of patients, taking into consideration known factors that influence changes in patient numbers and demand for the hospital's services and beds. Clause 5 provides that in the event that a hospital changes its name the requirements of the Bill will continue to apply to that hospital despite the change of name. Clause 6 provides that the Bill binds the Crown in right of Victoria and, to the extent that the legislative power of the Parliament permits, the Crown in all its other capacities. Clause 7 provides that the Bill is not intended to constitute a term of or to alter or vary, authorise or require the alteration or variation of, any employee's employment contract, or any workplace instrument within the meaning of the Fair Work Act 2009 (Cth) Part 2 Nurse to patient and midwife to patient ratios Division 1 General Part 2 Nurse to patient and midwife to patient ratios Division 1 General It is intended that Division 1 of Part 2 imposes the same general provisions on how to apply the nurse to patient and midwife to patient ratio requirements within hospital wards and departments as has been required by the Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement 2012 2016. 8 Ratio includes ratio variation ratio variation means a variation to a ratio implemented under Division 4 of Part 2; Clause 8 sets out that within Division 1 of Part 2, the term "ratio" includes a staffing requirement that applies under a ratio variation, subject to any terms of
In this Division, ratio includes a staffing requirement that applies under a ratio variation, subject to any terms of that variation. 9 Application of ratios (1) Except as otherwise provided (a) a ratio applies to every ward in each hospital to which it is specified to apply; and (b) a ratio must be applied on the basis of the actual number of patients in each ward to which it applies; and that variation arrangement. This means that if a hospital implements a variation from ratios under the provisions in Division 4 of Part 2 of the Bill, whereby the staffing arrangements within a ward or wards may legitimately vary from the requirements outlined within Division 2 and Division 3 of Part 2, the general requirements outlined within Division 1 of Part 2 continue to apply to the ward or wards where these alternative arrangements have been implemented. Clause 9 provides that the intent of the legislation is that the ratios are applied to the wards within the hospital that are covered by the Bill, on the basis of actual patient numbers, or occupied beds within a particular hospital ward. Examples: 1 If a hospital has 28 actual patients within a ward, but knows that it is expecting a further 4 patients throughout that shift then the hospital must apply the appropriate ratio based on 32 patients being within that ward to be able to admit those 4 additional patients onto the ward. An example of how a hospital may expect patients is that the patient may be in the Emergency Department currently, or in a Short Stay Unit, but has been allocated a bed on the ward by the hospital and will transfer once medically stable and emergency care is no longer required. Similarly, a patient may be booked in to undergo a surgical procedure, and be in the operating theatre currently, but has been allocated a bed on that ward by the hospital to receive post-operative care. 2 If a ward within a hospital has the physical capacity for 32 patients, and normally has 32 actual patients however at the start of a shift there are only 28 patients with no additional patients expected, the hospital may legitimately choose to make those beds unavailable for admission for that next shift. This may be undertaken if there is no demand for those beds to be utilised. If this is undertaken, then the hospital may apply the appropriate ratio based on 28 patients being within that ward for that shift. 3 If a ward of 30 physical beds usually has only 26 of these beds occupied by patients, as the ward would normally only plan to have nurses to cover the 26 occupied beds, the 4 unused beds may only be opened and used if they are staffed with additional nurses to meet the ratio requirements for 30 occupied beds, subject to the rounding of ratios as set out in clause 12 of the Bill. (c) a ratio is a minimum requirement only and is not intended to prevent the operator of a hospital from staffing a ward with additional nurses or midwives beyond the number required by the ratio; and (d) a ratio may be applied in a flexible way in order to evenly distribute the workload, having regard to the level of care required by patients in a ward. Examples 1 For subsection (1)(b), in a ward with 30 beds where only 26 beds are usually occupied, the operator of the hospital must not use the other 4 beds unless additional staff are available to meet the ratio requirements. 2 For subsection (1)(d), in a ward with 8 patients and a 1:4 ratio, Subclause (1)(c) states that the ratios contained in the Bill are only the minimum requirement, and the Bill is not intended to prevent an operator of a hospital from staffing a ward with additional staff beyond that required by the ratio provisions of the Bill. Subclause (1)(d) provides that the ratios can be applied in a flexible way in order to evenly distribute workload for nurses and midwives having regard to the care requirements for the patients within a ward. The example provided within the Bill demonstrates that the ratio requirements within the Bill is only a means to establishing the minimum number of nurses or midwives that staff a ward based on the number of actual patients. The number of patients that each individual nurse cares for is not a requirement of the Bill; rather the hospital having met the minimum staffing requirements may allocate work to the nurses or midwives in any way to meet the care requirements of the patients and evenly distribute workload.
if 3 patients require a higher level of care and 5 patients require a lower level of care then one nurse may be assigned to care for the 3 patients requiring the higher level of care and the other nurse to the other 5 patients. (2) Despite anything to the contrary in this Act, a ratio does not apply in respect of any ward that is being predominantly utilised for the care of persons being treated for a mental illness within the meaning of the Mental Health Act 2014. The Bill is intended to enshrine the ratios where they are currently described in the Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement 2012 2016. Clause 9(2) specifies that the Bill is not intended to apply to any mental health wards, departments or services within Victorian public hospitals, health services, publicly operated denominational hospitals or multi purpose services. The staffing arrangements for health professionals working within mental health areas and wards (including nurses) are not intended to be covered by this Bill, but rather by an enterprise agreement where ratios are not utilised 10 Application of ratios in small hospitals (1) Despite anything to the contrary in a ratio applying to a level 4 hospital with one ward, the operator of the hospital must staff that ward with (a) one registered nurse on all shifts; and (b) one After Hours Coordinator or equivalent position (who is not supernumerary) during all off-duty periods of the Director of Nursing or Director of Midwifery. (2) The operator of a hospital with only 2 wards may count one After Hours Coordinator (who is not supernumerary) towards meeting any ratio during all off-duty periods of the Director of Nursing or Director of Midwifery. 11 Out of hours coordination of hospitals The operator of a hospital with 3 wards or more must staff the hospital with one After Hours Coordinator during all off-duty periods of the Director of Nursing or Director of Midwifery, in addition to any ratio that applies. Clause 10 sets out specific requirements for how the ratios are to be applied within the smaller level 4 hospitals. Subclause (1) provides that level 4 hospitals with only one ward are required to staff that ward with one nurse and one registered nurse, referred to in the Bill and often referred to in practice (although this is not required) as an After Hours Coordinator, during the off-duty periods of the Director of Nursing/Midwifery. This applies to each campus of those hospitals under the definition in the Bill. Subclause (2) provides that a level 4 hospital with only two wards may count one registered nurse, referred to as an After Hours Coordinator, towards meeting any of the ratio requirements within the Bill during the off-duty periods of the Director of Nursing/Midwifery. The off-duty periods of the Director of Nursing/Midwifery are usually the periods outside of business hours Monday to Friday, and all shifts on the weekend. The After Hours Coordinator working within hospitals that have only one or two wards are not supernumerary, and can be counted as part of meeting the ratio requirements within the Bill. Example: The operator of a hospital with 2 wards may choose to have the After Hours Coordinator meet any ratio requirement during the off-duty periods of the Director of Nursing/Midwifery. During the evening shift, the operator of the hospital may choose to have the After Hours Coordinator fulfil the in-charge provision of one of the wards during the evening shift. As there are no requirements to have a separate nurse in charge overnight, the operator of the hospital may choose to have the After Hours Coordinator fulfil the position of a nurse on one of the wards overnight, to fulfil that ratio requirement. Clause 11 sets out the requirements for hospitals to engage a senior registered nurse, referred to as an After Hours Coordinator, to manage the hospital in addition to the ward ratios. This means that a hospital that has three or more wards is required to have one After Hours Coordinator working within hospitals in a supernumerary capacity during all off-duty periods of the Director of Nursing/Midwifery. The off-duty periods of the Director of Nursing/Midwifery are usually the periods
12 Rounding method (1) If the number of patients in a ward or the number of beds (as the case requires) is not divisible into a whole number when a ratio is applied, the number of nurses or midwives must be rounded in accordance with subsections (2), (3) and (4), as applicable. outside of office hours Monday to Friday, and all shifts on the weekend. The After Hours Coordinators cannot be counted as part of meeting the ratio requirements within the Bill. Clause 12 sets out the provisions to be applied when the number of patients in a ward is not evenly divisible by the number of nurses or midwives. (2) If the actual or expected number of patients in a ward or number of beds requires less than or equal to 50 per cent of one additional nurse or midwife to be rostered in applying a ratio, the operator of the hospital is not required to roster an additional nurse or midwife in order to comply with the ratio unless safe patient care may be compromised. Subclause (2) provides that if the number of patients is equal to or less than 50 per cent of the number of patients that would require an additional nurse or midwife, the operator of the hospital is not required to engage an additional nurse or midwife. (3) In addition to any requirement under subsection (2), the operator of a hospital may assign a nurse or midwife to care for patients (a) across multiple wards at night; or (b) in the case of a nurse, across multiple beds in aged high care residential wards on any shift. (4) If the actual or expected number of patients in a ward or number of beds requires more than 50 per cent of one additional nurse or midwife to be rostered in applying a ratio, the operator of the hospital must roster an additional nurse or midwife to comply with the ratio. Subclause (3) provides some flexibility in the application of the ratios overnight, where the rounding provisions under subclause (2) have been applied. This means that the operator of the hospital may, at their discretion, assign an additional nurse or midwife to work across multiple wards at night on top of the minimum requirements. In addition, the operator of the hospital may, at their discretion, assign an additional nurse on top of the minimum requirements, to work across aged care wards on any shift. This provision allows for a nurse or midwife to fulfil a part-ratio by working across multiple wards. The operator of the hospital will usually undertake this provision if it deems that a proportion of an additional nurse is required to provide safe and effective patient care after applying the rounding provisions in subclause (2), where they have "rounded down". Example: A hospital with 2 aged high care residential wards of 35 beds each. For the night shift, the ratio requirement is one nurse for every 15 patients. As 35 is not evenly divisible by 15 the operator of the hospital may apply the rounding provisions set out in clause 12(2) of the Bill to determine the minimum staffing requirements under the Bill. For the night shift 35/15 = 2, with 5 beds remaining as the 5 beds are less than or equal to 50% of the number of patients that would require an additional nurse, the operator of the hospital may "round down" and staff that ward with 2 nurses for the night shifts. This is the minimum staffing requirement under the Bill. However, the operator of the hospital may, at its discretion, choose to assign an additional nurse to work across the 2 aged high care residential wards to assist with the nursing workload and the care requirements of the residents. Subclause (4) provides that if the number of patients is more than 50 per cent of the number of patients that would require an additional nurse or midwife, the operator of the hospital must engage an additional nurse or midwife to comply with the ratio requirements. Example:
In a 30 bed general medical or surgical ward in a level 1 hospital, the ratio requirements on a morning and afternoon shift are one nurse for every 4 patients and one nurse in charge. As 30 is not evenly divisible by 4, then the rounding provisions can be applied. For the morning and afternoon shift 30/4 = 7, with 2 beds remaining as the 2 beds are equal to or less than 50% of the number of patients that would require an additional nurse, the operator of the hospital may legitimately "round down" and staff that ward with 7 nurses and one nurse in charge for the morning and afternoon shifts. On the night shift the ratio requirement is one nurse for every 8 patients. As 30 is not evenly divisible by 8, then the rounding provisions can be applied. For the night shift 30/8 = 3, with 6 beds remaining as the 6 beds are more than 50% of the number of patients that would require an additional nurse, the operator of the hospital must "round up" and staff that ward with 4 nurses for the night shifts. 13 Demand higher or lower than expected (1) Beds in addition to the beds that have been staffed under a ratio may only be occupied if nurses or midwives are available to comply with the ratio. (2) If the actual or expected number of patients on a particular day falls below the number of patients for which a ward is staffed in accordance with a ratio, the number of nurses or midwives may be adjusted down before the commencement of a shift. Note 14 Skill mix See also section 7. The operator of a hospital, other than a hospital specified in Schedule 2, may use no more than 20 per cent enrolled nurses in meeting ratios in an acute ward or a general medical or surgical ward. occupied includes available to be occupied; Clause 13 subclause (1) sets out requirements that operators of hospitals may only open additional beds if the additional nurses or midwives required under the ratio provisions are available and engaged to ensure ongoing compliance with the ratio requirements. Example: If a ward of 30 physical beds usually has only 26 of these beds occupied by patients, as the ward would normally only plan to have nurses to cover the 26 occupied beds that are normally occupied, if the operator of the hospital wished to open the 4 beds that are normally unused, this can only occur if any additional nurses are assigned to the ward to meet the ratio requirements for 30 occupied beds for the period that the additional 4 beds are open and occupied, subject to the rounding of ratios as set out in clause 12. Subclause (2) allows hospitals to adjust down the number of nurses or midwives before the commencement of a shift if there are staff who are surplus to the ratio requirements for the actual numbers of patients on a ward. Example: If a ward within a hospital has the physical capacity for 32 patients, and normally has 32 actual patients however if before the commencement of a shift there are only 28 patients with no additional patients expected, the hospital may legitimately choose to make those beds unavailable for admission for that next shift. If this is undertaken, then the hospital may apply the appropriate ratio based on 28 patients being in that ward for the next shift, and may adjust down the number of nurses or midwives in accordance with the ratio requirements before the commencement of that shift. Clause 14 sets out the skill mix requirements for the operators of all hospitals relating to the nurses used to fulfil the acute ward and general medical or surgical ward ratio requirements, whereby the operator of the hospital may only utilise up to 20% enrolled nurses to fulfil the ratio requirements. The hospitals listed in Schedule 2, are excluded from this skill mix limitation, and it is intended that these hospitals are unrestricted in the proportion of enrolled nurses that they may utilise to fulfil the ratio requirements, provided other requirements in the Bill are also met. It is not intended that this skill mix requirement will apply to any other type of ward
other than acute wards and general medical or surgical wards. Examples: 1 A hospital that is not listed in Schedule 2 may only have enrolled nurses make up 20% or less of the staff rostered to work within a general medical or surgical ward for any shift. Registered nurses must make up 80% or more of the staff rostered to work within a general medical or surgical ward for any shift. 2 A hospital that is listed in Schedule 2 is unrestricted in the number of enrolled nurses that it rosters to work within an acute or a general medical or surgical ward. In theory, and as an extreme example, these hospitals could roster only enrolled nurses to fulfil the ratio requirements on general medical or surgical wards, except where a role is required to be filled by a registered nurse (e.g. the nurse in charge or the After-Hours Coordinator). Division 2 Nurse to patient ratios Division 2 Nurse to patient ratios 15 Level 1 hospitals The operator of a level 1 hospital must staff a general medical or surgical ward as follows (a) on the morning shift or the afternoon shift (i) one nurse for every 4 patients; and (ii) one nurse in charge; (b) on the night shift, one nurse for every 8 patients. Part 1 Level 1 hospitals Alfred Hospital Austin Hospital Box Hill Hospital Dandenong Hospital Footscray Hospital Frankston Hospital Heidelberg Repatriation Hospital Monash Medical Centre (Clayton) Northern Hospital Peter MacCallum Cancer Centre St Vincent's Hospital The Royal Children's Hospital This Division sets out the nurse to patient ratios for different types of wards. It is intended that Division 2 of Part 2 imposes the same numeric nurse to patient ratio requirements within hospital wards and departments as has been required by the Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement 2012 2016. It is not intended for the commencement of this Bill to introduce any additional, amended or new ratio requirements for hospitals. Additionally, it is intended that the Bill imposes nurse to patient ratio requirements on all multi-day inpatient wards within those hospitals and health services and to emergency departments. Any same-day wards, including day procedure, day surgery, day oncology, dialysis or admission centres are not intended to be covered by the Bill, and therefore hospitals are not required to have nurse to patient ratios within those wards. The Bill is not intended to specify or limit the starting time or ending time of shifts, or to limit the length of shifts. It is intended that the minimum ratio requirements are maintained throughout a particular shift as rostered by the operator of the hospital, while not curtailing or constraining meal and other reasonable breaks available to be taken by nurses and midwives during that shift. Clause 15 sets out the ratio requirements for general medical and surgical wards within level 1 hospitals, as set out in Schedule 1. The levels of hospital defined within the Bill replicate the levels of hospital specified in the Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement 2012 2016 and are intended to maintain the nurse to patient numeric ratios as are currently required under that enterprise agreement, and enshrine them in the Bill. All general medical or surgical wards within level 1 hospitals are intended to have a minimum requirement of one nurse for every 4 patients and one nurse in charge on a morning shift; and one nurse for every 4 patients and one nurse in charge on an afternoon shift; and one nurse for every 8 patients on a night shift.
16 Level 2 hospitals 17 Level 3 hospitals 18 Level 4 hospitals The operator of a level 2 hospital must staff a general medical or surgical ward as follows (a) on the morning shift (i) one nurse for every 4 patients; and (ii) one nurse in charge; (b) on the afternoon shift (i) one nurse for every 5 patients; and (ii) one nurse in charge; (c) on the night shift, one nurse for every 8 patients. The operator of a level 3 hospital must staff a general medical or surgical ward as follows (a) on the morning shift (i) one nurse for every 5 patients; and (ii) one nurse in charge; (b) on the afternoon shift (i) one nurse for every 6 patients; and (ii) one nurse in charge; (c) on the night shift, one nurse for every 10 patients. (1) The operator of a level 4 hospital must staff an acute ward as follows (a) on the morning shift (i) one nurse for every 6 patients; and (ii) one nurse in charge; (b) on the afternoon shift (i) one nurse for every 7 patients; and (ii) one nurse in charge; (c) on the night shift, one nurse for every 10 patients. The Royal Melbourne Hospital University Hospital Geelong Part 2 Level 2 hospitals Ballarat Base Hospital Bendigo Hospital Goulburn Valley Health Latrobe Regional Hospital Maroondah Hospital Mercy Hospital for Women New Mildura Base Hospital Northeast Health Wangaratta Sunshine Hospital The Royal Women's Hospital Werribee Mercy Hospital Part 3 Level 3 hospitals Albury Wodonga Health (Wodonga campus) Angliss Hospital Bairnsdale Regional Health Service Castlemaine Health Central Gippsland Health Service (Sale campus) Echuca Regional Health Hamilton Base Hospital Monash Medical Centre (Moorabbin) Portland District Health Rosebud Hospital Sandringham Hospital Swan Hill District Health The Royal Victorian Eye and Ear Hospital Warrnambool Base Hospital West Gippsland Hospital Williamstown Hospital Wimmera Health Care Group (Horsham campus) level 4 hospital means a campus of any public hospital, denominational hospital, multi purpose service or public health service within the meaning of the Health Services Act 1988 other than a public hospital, denominational hospital, multi purpose service or public health service that is a level 1 hospital, level 2 hospital or level 3 hospital; Clause 16 sets out the ratio requirements for general medical and surgical wards within level 2 hospitals, as set out in Schedule 1. The levels of hospital defined within the Bill replicate the levels of hospital specified in the Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement 2012 2016 and are intended to maintain the nurse to patient numeric ratios as are currently required under that enterprise agreement, and enshrine them in the Bill. All general medical or surgical wards within level 2 hospitals are intended to have a minimum requirement of one nurse for every 4 patients and one nurse in charge on a morning shift; and one nurse for every 5 patients and one nurse in charge on an afternoon shift; and one nurse for every 8 patients on a night shift. Clause 17 sets out the ratio requirements for general medical and surgical wards within level 3 hospitals, as set out in Schedule 1. The levels of hospital defined within the Bill replicate the levels of hospital specified in the Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement 2012 2016 and are intended to maintain the nurse to patient numeric ratios as are currently required under that enterprise agreement, and enshrine them in the Bill. All general medical or surgical wards within level 3 hospitals are intended to have a minimum requirement of one nurse for every 5 patients and one nurse in charge on a morning shift; and one nurse for every 6 patients and one nurse in charge on an afternoon shift; and one nurse for every 10 patients on a night shift. Clause 18 sets out the ratio requirements for acute wards within level 4 hospitals. The levels of hospital defined in the Bill replicate the levels of hospital specified within the Nurses and Midwives (Victorian Public Sector) (Single Interest Employers) Enterprise Agreement 2012 2016 and are intended to maintain the nurse to patient numeric ratios as are currently required under that enterprise agreement, and enshrine them under this Bill. An acute ward within a level 4 hospital is intended to have a minimum requirement of one nurse for every 6 patients and one nurse in charge on a morning shift; and one nurse for every 7 patients and one nurse in charge on an afternoon shift; and one nurse for every 10 patients on a night shift.