October 7, 2024
Purpose
To inform hospitals of two new staffing plan compliance reporting forms issued by the Department of Health (DOH): 1) Monthly report forms; and 2) Semiannual reporting forms. This bulletin also highlights important deadlines for hospital staffing plan development and compliance reporting.
Applicability/Scope
The requirement to report staffing plan non-compliance applies to Urban/system (Track A) hospitals.
Requirements to submit hospitals’ staffing plan compliance data start July 1, 2025:
- Semiannual reporting: Each hospital must report: 1) the total number of nurse staffing assignments in the reporting period; and 2) the total number of assignments that are out of compliance with the staffing plan. Reports must be submitted to DOH January 31 and July 31 of each year, starting January 31, 2026. January reports cover the previous July – December and July reports cover January – June.
- Monthly reporting: For hospitals unable to meet 80 percent of the nurse staffing assignments in the hospital staffing plan in any single month, a monthly report must be submitted to the DOH seven days after the end of the month.
Beginning July 1, 2025 and thereafter, except in instances of unforeseeable emergent circumstances, each acute care hospital must implement their most recent adopted hospital staffing plan and assign nursing staff to each patient care unit in accordance with the adopted plan. If a hospital was unable to achieve adoption by the hospital staffing committee, the 2023 staffing plan will be in effect until the staffing committee can adopt a plan.
Overview
Semiannually, each Urban/system (Track A) hospitals must report compliance with the adopted staffing plan to Department of Health (DOH) using the Hospital Staffing Semi-Annual Compliance/Non-Compliance Report:
According to the hospital staffing law:
Each hospital must report to the department on a semiannual basis the accurate percentage of nurse staffing assignments where the assignment in a patient care unit is out of compliance with the adopted nurse staffing plan. Beginning in 2026, semiannual reports are due on July 31st and January 31st each year. The first report is due January 31, 2026, and must cover the last six months of 2025. RCW 70.41.420 7(b)(i)
Monthly reporting is required to be submitted using the Hospital Staffing Monthly Non-compliance Report form when compliance is less than 80 percent of nurse staffing assignments in a month.
According to the hospital staffing law:
Beginning July 1, 2025, if a hospital is in compliance for less than 80 percent of the nurse staffing assignment in a month, the hospital must, within seven calendar days following the end of the month in which the hospital was out of compliance, report to the department regarding lack of compliance with the nurse staffing patient care unit assignments in the hospital staffing plan. RCW 70.41.420 7(b)(ii)
Hospitals must have adopted policies and procedures related to staffing plan compliance documentation and reporting by October 1, 2024. Guidance for developing written policies and procedures can be found in WSHA’s Staffing Plan Compliance Policy Development Checklist. For a copy of the checklist, please contact Gena Cooper at genac@wsha.org.
Hospitals that meet one of the following criteria (Track B) are exempt from documenting and reporting staffing plan compliance and developing written policies and procedures for these processes:
- Certified as critical access hospitals
- Have fewer than 25 acute care licensed beds
- Certified as sole community hospitals and are not owned by a system that owns more than one acute care hospital; or
- Island Hospital (previously certified as a Medicare dependent hospital).
Recommendations
- Review this bulletin and other WSHA compliance resources and consider preparations necessary for meeting hospital staffing plan compliance reporting requirements.
- Review the DOH Hospital Staffing Semiannual Report form and the Hospital Staffing Monthly Non-compliance Report
- Consider how the DOH reporting requirements may impact your hospital staffing plan and data collection processes.
- Participate in WSHA webinars, advisory and workgroups, and other educational offerings related to staffing law implementation.
- Urban/system hospitals: Develop policies and procedures for documenting and reporting compliance data, including how compliance will be measured and reported to DOH in accordance with the requirements of RCW 70.41.420 and the elements of the DOH approved report forms.
Background
Washington’s hospital staffing law outlines requirements for all acute care hospitals related to establishing a hospital staffing committee, developing and implementing annual hospital staffing plans, and reporting compliance. Hospitals are required to document when a patient care unit is out of compliance with the adopted hospital staffing plan. Non-compliance is defined as the number of patients assigned to the nursing staff exceeding the patient care unit assignment as directed by the nurse staffing plan.
References
DOH Hospital Staffing Semiannual Compliance/Non-compliance Report
DOH Hospital Staffing Monthly Non-compliance Report
DOH staffing website
Hospital Staffing Plan Form Instructions
Hospital Staffing Plan Form
RCW 70.41.420
RCW 70.41.425
Additional WSHA resources are available to hospitals. Contact Gena Cooper at genac@wsha.org.
