This webpage has Frequently Asked Questions (FAQs), which is one of several tools the department uses to share its interpretation of law with the public. The department is charged with implementing the hospital staffing laws, which requires the department to interpret those laws. FAQs do not change the law.
- Where can I read the legislation for hospital staffing committees?
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You may read the legislation on hospital staffing committees on the Washington State Legislature website. RCW 70.41.420: Hospital staffing committee.
- What documents are all hospitals required to submit to the Department of Health?
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All hospitals are required to submit a hospital staffing committee charter and a hospital staffing plan to the DOH.
- Where do I submit my Hospital Staffing Committee Charter?
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Hospital staffing committee charters should be emailed to hospital staff members by July 1, 2024 and then resubmit any time the charter is updated.
- Where do I submit my Hospital Staffing plan?
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Hospital staffing plans should be emailed to hospital staff members by January 1, 2025 and then submit annually or any time the plan is updated.
- Do hospitals that have more than one branch, location, or campus under a single hospital license need a hospital staffing committee for each location?
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No, only one hospital staffing committee is required for all locations that fall under a single hospital license.
- Do hospitals that have more than one branch, location, or campus under a single hospital license need a hospital staffing plan for each location?
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No, only one hospital staffing plan is required to be submitted for all locations that fall under a single hospital license. If the hospital has more than one branch, location, or campus the staffing plan needs to address the needs of each location and should include information for all units at each location.
- Do critical access hospitals need to have a hospital staffing committee?
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Yes, all acute care hospital licenses are required to have a hospital staffing committee.
Critical access hospitals may develop flexible approaches to accomplish the requirements pertaining to hospital staffing committees in RCW 70.41.420 that may include but are not limited to having hospital staffing committees work by video conference, telephone, or email.
- Who determines the total number of committee members that are on a hospital staffing committee?
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Hospitals have authority to establish hospital staffing committees and can at the outset choose the total number of committee members. Once the hospital staffing committee is established, the hospital staffing committee chooses how many members will be on the committee as part of its charter.
- Do clinics need to be included in a hospital staffing plan?
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A clinic’s information needs to be included in a hospital staffing plan when they are operating under a hospital license, billing with the hospital’s CMS code, and nurses or nursing staff are providing direct patient care.
- When are hospitals required to have Hospital Staffing committee members appointed?
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Each hospital was required to form a hospital staffing committee by January 1, 2024, by creating a new committee or assigning the functions of the hospital staffing committee to an existing nurse staffing committee. The appointment of committee members is part of the process of establishing a committee.
- Who appoints the 50 percent frontline hospital staffing committee members if they aren’t represented by a union?
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If there is any collective bargaining representative representing any category of nursing staff at a hospital, then that representative (or representatives) selects all the nursing staff members of the hospital staffing committee that are selected to fulfill the 50% nursing requirement, even if there are some nursing staff employed by the hospital that are not represented by any collective bargaining representative. The collective bargaining representative(s) may appoint non-represented nursing staff to the committee.
The nursing staff members of a hospital staffing committee shall be selected by their peers if there is no collective bargaining representative representing any category of nursing staff at the hospital.
- Can all the appointed hospital staffing committee members be RNs?
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Yes. The individual(s) appointing nursing staff to a hospital staffing committee determines the number of appointees from each type of nursing staff (RN, LPN, NA-C, unlicensed assistive nursing personnel). Appointees can be from one, some, or all of the above-mentioned nursing staff types.
- Which hospitals are exempt from some of the requirements of the hospital staffing laws?
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Critical Access Hospitals (CAH)
- Arbor Health Morton
- Astria Sunnyside
- Cascade Medical Center
- Columbia County Health System/ Dayton General Hospital
- Columbia Basin Hospital
- Coulee Medical Center
- East Adams Rural Healthcare
- Ferry County Memorial Hospital
- Forks Hospital
- Garfield County Memorial Hospital
- Jefferson Healthcare
- Kittitas Valley Healthcare
- Klickitat Valley Healthcare
- Lake Chelan Community Hospital
- Lincoln Hospital
- Lourdes Hospital
- Mason General Hospital
- Mid-Valley Hospital
- Newport Hospital
- North Valley Hospital
- Ocean Beach Hospital
- Odessa Memorial Healthcare Center
- Othello Community Hospital
- PeaceHealth Peace Island Medical Center
- PeaceHealth United General
- Providence Mount Carmel Hospital
- Providence St. Joseph Hospital
- Prosser Memorial Health
- Pullman Community Hospital
- Quincy Valley Medical Center
- Skyline Hospital
- Snoqualmie Valley Hospital
- St. Elizabeth Hospital
- Summit Pacific Medical Center
- Three Rivers Hospital
- Tri-State Memorial Hospital
- Whidbey Health Medical Center
- Whitman Hospital
- Willapa Harbor Hospital
Fewer than 25 Acute Care Licensed Beds
- Fred Hutch
Medicare and Medicaid Sole Community Hospitals
- Grays Harbor Community Hospital (Harbor Regional Health)
- Olympic Medical Center (Clallam County Public Hospital District No.2)
- Samaritan Hospital
- Confluence Health in Wenatchee*
On an Island in Skagit County
- Island Hospital in Anacortes**
A. Island Hospital** in Anacortes is exempt as the Hospital is located on an island operating within a public hospital district in Skagit county.
- Island Hospital is located on Fidalgo Island in Skagit County.
B. Confluence Health Hospital** is exempt as they are certified by the centers for Medicare and Medicaid services as sole community hospitals that are not owned or operated by a health system that owns or operates more than one acute hospital licensed under chapter 70.41 RCW.
- Confluence meets this requirement as they have merged their EIN numbers for hospitals Wenatchee Valley Hospital and Central Washington Hospital. Wenatchee Valley is no longer a separate Acute Care Hospital but is a branch site under Central Washington Hospital.
- Central Washington Hospital is now known as Confluence Health Hospital.
- Wenatchee Valley Hospital is now known as Confluence Health Hospital-Mares Campus.
- What requirements are some hospitals exempt from?
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Some hospitals are exempt from the requirements in RCW 70.41.420(7)(b) to document and report to the Department of Health (DOH) when the number of patients assigned to nursing staff is higher than allowed by the hospital staffing plan.
- What does it mean to have a 50% +1 vote?
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A 50% +1 vote means that 50 percent of the voting members plus one more voting member agree. For example, if a committee had 10 members, then 50 percent would be five members and +1 vote would add one member, for a total of six votes from any of the voting members for a vote to succeed.
- What are the requirements for filling out the hospital staffing plan?
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When filling out the hospital staffing plan, the staffing matrices must include any patient care area where direct care is provided by nursing staff, such as RNs, licensed practical nurses (LPNs), nursing assistant-certified (NA-Cs), and unlicensed assistive personnel (UAPs). The plan must also include and specify within the matrices the minimum number of nursing staff needed per shift, taking into account factors like patient acuity, staff skill level, and patient care activities.
For more information, see the department’s hospital staffing webpage, where you can find guidance documents for filling out the hospital staffing plan form.
- Do all required sections of the hospital staffing plan form need to be filled out?
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Hospitals are required to submit their hospital staffing plan on DOH’s form, and all the applicable sections must be filled out.
- What is an example of a section of DOH’s hospital staffing form that isn’t applicable to a hospital?
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If a hospital doesn’t have any union represented staff, they would not need to fill out any sections of the form related to a collective bargaining agreement.
- Do hospital staffing plan matrices need to include charge and resource nurses?
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Staffing plan matrices include nurses that provide direct patient care. Hospital staffing committees determine whether charge or resource nurses should be included in the matrices or the additional care team member section of the hospital staffing plan.
- Can a hospital make changes to the proposed staffing plan that has been approved by the staffing committee?
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A hospital may not make any changes to a proposed staffing plan that was approved by the staffing committee. The hospital’s CEO may request that the committee make changes and resubmit a revised proposed plan for the hospital to adopt, but it’s up to the committee whether to make those changes and resubmit a revised plan to the CEO.
If the hospital disagrees with the final proposed plan submitted to the CEO, then the hospital has a choice of adopting the proposed plan as a whole or leaving in place the most recent staffing plan that was in effect as of January 1, 2023, or the plan that was most recently approved by the committee and adopted by the hospital.
- Do hospitals have to be in compliance with their hospital staffing plan for the entirety of a shift?
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Yes.
- What is a “break buddy?”
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When nursing staff take additional patients while a coworker is on a break, such as a lunch break.
- How is compliance determined?
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Hospital staffing plan compliance will be determined by what is in the hospital’s staffing plan. Compliance will be assessed by looking at the number of nursing staff and patient assignments throughout a shift and evaluating if that matches what is in the hospital’s staffing plan.
- If break buddies are included in a committee-approved hospital staffing plan, will a hospital be out of compliance with the hospital staffing laws for using them?
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No, it is not a violation of the hospital staffing plan if break buddies are included in a committee-approved hospital staffing plan and break buddies are used as outlined in the staffing plan.
- Will a hospital be out of compliance with their hospital staffing plan if nursing staff leave a unit to transfer a patient to another floor or respond to a code, like a code blue or rapid response?
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It depends on if the number of nursing staff and patient assignments match what is in the hospital staffing plan, throughout the shift.
If a hospital has the nursing staff per patient assignments working throughout the shift that is required in the hospital staffing plan and nursing staff leaving the unit does not result in a unit going below the minimum number of nursing staff required for the shift, the hospital would not be out of compliance.
If hospital staffing committees want to include in the hospital staffing plan that nursing staff can leave their assigned units and respond to codes, they can include this information in the “unit” section of the hospital staffing plan in the “other” text box.
- Does a hospital need to wait until January to submit an updated staffing plan to the department?
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A hospital, with approval of its hospital staffing committee, may make changes to its hospital staffing plan at any time. Hospitals are required to submit their staffing plans on an annual basis and at any time in between that the plan is updated.
- Can the “additional care team member” section on the hospital staffing form be used to list staff that aren’t optional?
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Staff can be written in the “additional care team members” section and then the “other” section can be used to clarify which staff are not optional.
- Do staffing plan matrices need to be filled out for every census number if the unit closes at a low census?
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If a hospital is going to close a unit at a specific census number, that information can be included in the “other” section of the hospital staffing form.
- How can hospital staffing plan matrices include nursing staff that work in more than one unit during a shift?
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Hospital staffing plans can include a matrix for staff that “float” between more than one unit, or floating staff can be written in the “additional care team members” section and then the “other” section can be used to clarify if they are not optional.
- Is there a standardized way of counting patient visits?
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Hospital staffing committees determine the methodology the hospital will use for counting patient visits.
- How frequently throughout each shift does a hospital need to document noncompliance?
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Hospitals are required to maintain compliance with their staffing plan throughout each shift and must document every time its staffing is out of compliance.
The hospital must have a written policy and procedure that describes how non-compliance with the hospital staffing plan assignment for each unit is identified throughout the entirety of each shift and how each instance of non-compliance is documented. Example processes for documenting non-compliance could include, but are not limited to:
- Having a staff person, like a charge nurse, whose duties include monitoring unit staffing levels and documenting if at any point staffing on a shift becomes non-compliant.
- Having a form available to all staff to identify noncompliance during a shift that is aggregated within a particular time frame.
- What staffing plan documents need to be posted in every unit of a hospital?
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Each unit must post a paper copy of their staffing plan, the staffing schedule for that shift on that unit, as well as the relevant clinical staffing for that shift. Hospitals can post a daily schedule that includes information for every shift that day, or they can change the schedule postings shift-by-shift.