Legislative Analysis
Phone: (517) 373-8080
MINIMUM NURSE-TO-PATIENT RATIOS
http://www.house.mi.gov/hfa
House Bill 4550 as introduced Analysis available at
Sponsor: Rep. Stephanie A. Young http://www.legislature.mi.gov
House Bill 4552 as introduced
Sponsor: Rep. Carrie Rheingans
Committee: Health Policy
Complete to 11-8-23
SUMMARY:
House Bills 4550 and 4552 would amend the Public Health Code to require hospitals to
implement specified minimum ratios of direct care registered professional nurses (RNs) to
patients in different hospital units, provide administrative fines and sanctions for a violation,
require records to be kept, provide for notice and a complaint process, and create a fund through
which fines imposed for violation of the bills can be used to support their administration.
House Bill 4550 would amend Part 215 (Hospitals) of the Public Health Code to require
hospitals to implement the minimum direct care registered professional nurse-to-patient ratios
described below within one year after the date the bill takes effect or, for hospitals located in a
rural area, within two years after that date. 1 However, if a collective bargaining agreement
that prevents compliance with the bill is in effect for hospital employees when the bill takes
effect, the bill would not apply until after that agreement expires.
Ratio requirements
Under the bill, a hospital could not assign more patients per direct care RN than indicated by
the ratios shown in the table below for each of the corresponding hospital units.
Acute rehabilitation One RN to four patients (1:4)
Behavioral health/psychiatric One RN to four patients (1:4)
Emergency department Nontrauma or noncritical care One RN to three patients, plus
one RN for triage duties (1:3, +1)
Trauma or critical care One RN to one patient, plus one
RN for triage duties (1:1, +1)
Intensive/critical care Includes coronary care, acute One RN to one patient (1:1)
respiratory care, medical,
burn, pediatric, or neonatal
intensive care patients
1
Rural area would mean an area that is located either outside of a metropolitan statistical area as defined by the U.S.
Office of Management or Budget or in a city, village, or township with a population of 12,000 or less that is in a
county with a population of 110,000 or less (using the most recent federal decennial census).
House Fiscal Agency Page 1 of 5
 Labor and delivery Antepartum One RN to three pregnant
patients (1:3)
Antepartum (if continuous One RN to two pregnant
fetal monitoring is required) patients (1:2)
Active labor One RN to each birthing patient
(1:1)
During birth One RN to each birthing patient
and one RN to each baby
(1:1,1:1)
Immediate postpartum One RN to each birthing
(within two hours after birth) patient/baby couplet plus one
RN for each additional baby
(1:1[2], 1:1)
Unstable newborn One RN to one newborn (1:1)
Intermediate care newborn One RN to two newborns (1:2)
Postpartum/postsurgical One RN to two birthing
patient/baby couplets (1:2[2])
Medical/obstetric One RN to one patient (1:1)
complications in labor and
delivery (including an
epidural or a C-section)
Postpartum birthing patient or One RN to four patients (1:4)
well-baby care
Patient receiving conscious One RN to one patient (1:1)
sedation
Postanesthesia care One RN to one patient (1:1)
Medical/surgical One RN to four patients (1:4)
Operating room One RN to one patient, as long
as at least one additional person
serves as a scrub assistant 2 in
the unit (1:1, +1)
Pediatrics One RN to three patients (1:3)
Stepdown or intermediate One RN to three patients (1:3)
intensive care unit
Telemetry One RN to three patients (1:3)
2
Scrub assistant would mean an individual functioning in a role that is also known as a surgical technician, operating
room technician, surgical tech, first assistant, scrub tech, or scrub. A scrub assistant could be a direct care registered
professional nurse.
House Fiscal Agency HBs 4550 and 4552 as introduced Page 2 of 5
 All of the following would apply to the requirements described above:
• If a unit not listed above provides a level of care to patients whose needs are similar to
those in a unit that is listed, the hospital would have to apply that listed minimum ratio.
• The required minimum RN-to-patient ratios would have to be in effect at all times,
including during breaks, meals, and other routine and expected absences from a unit.
• A hospital could increase the number of RNs above a required minimum ratio at any
time before or during a shift and for any reason.
• The minimum direct care RN-to-patient ratio established for each unit under the bill
would not limit, reduce, or otherwise affect the need for other licensed or unlicensed
health care professionals, assistants, or support personnel necessary to provide safe
patient care within the unit.
Prohibitions
A hospital could not do any of the following:
• In computing a required minimum direct care RN-to-patient ratio, include an RN who
is not assigned to provide direct patient care in that unit or is not oriented, qualified,
and competent to provide safe patient care in that unit.
• Average the number of patients and the total number of direct care RNs assigned to
patients in a unit during a single shift or over a period of time to meet a required
minimum direct care RN-to-patient ratio.
• Except during a declared state of emergency, impose mandatory overtime to meet a
required minimum direct care RN-to-patient ratio.
Declared state of emergency would mean an emergency declared by a person
authorized by the state, the federal government, or a local government that is related to
an unpredictable or unavoidable circumstance that affects the delivery of medical care
and requires an immediate or exceptional level of emergency or other medical services
at the hospital. It would not include an emergency that results from a labor dispute in
the health care industry or consistent understaffing in the hospital.
Mandatory overtime would mean a mandated assignment for a direct care RN to work
more than their regularly scheduled hours according to their predetermined work
schedule.
Notification and complaints
A hospital would have to post in each unit, in a visible and conspicuous location accessible to
hospital staff, patients, and the public, a notice in a form approved by the Department of
Licensing and Regulatory Affairs (LARA) that contains all of the following information:
• The requirements of the bill.
• An explanation of the rights of direct care RNs, patients, and other individuals under
the bill.
• A statement that a direct care RN, patient, or other individual may file a complaint with
LARA against a hospital they believe to have violated the bill.
• Instructions on how to file a complaint with LARA for a violation of the bill.
LARA would have to establish and maintain a toll-free telephone number to provide
information regarding the required minimum direct care RN-to-patient ratios and to receive
complaints alleging violations of the bill. A hospital would have to provide the number to each
House Fiscal Agency HBs 4550 and 4552 as introduced Page 3 of 5
 patient admitted for inpatient care and inform each patient that the number may be used to file
a complaint alleging a violation of the bill.
A direct care RN, a patient, or another individual could file a complaint with LARA against a
hospital they believe to have violated the bill. LARA would have to investigate each complaint
received and notify the complainant in writing of the results of a review or investigation of the
complaint and any action proposed to be taken. 3
Violations and fines
A hospital that does not comply with a minimum direct care RN-to-patient ratio required under
the bill would be in violation of the bill. Each shift that does not comply with a required
minimum ratio for that shift would be a separate violation. If LARA determines that a hospital
has not complied with the minimum direct care RN-to-patient ratio required for each unit
during each shift under the bill, it would have to require the hospital to establish a corrective
action plan to prevent a recurrence of the violation. LARA would have to consider each
violation of the bill by a hospital when making licensure decisions.
A hospital that violates the bill would be subject to an administrative fine of $10,000 to $25,000
for each violation or, if hospital has shown a pattern of violations (a finding by LARA of two
or more violations in one calendar year), an administrative fine of $25,000 to $50,000 for each
violation. LARA would have to publish on its website the names of hospitals it imposes an
administrative fine on under these provisions, the violation the fine is imposed for, and any
additional information it considers appropriate.
Other provisions
The bill would create the Nurse-to-Patient Ratio Regulatory Fund in the state treasury, and the
state treasurer would have to credit to the fund the administrative fines described above. The
state treasurer would direct the investment of money in the fund and credit to it interest and
earnings from those investments. LARA would be the administrator of the fund for auditing
purposes. LARA could expend money from the fund, upon appropriation, only to administer
the bill.
LARA would have to develop and issue rules to implement the bill.
Proposed MCL 333.21525 and 333.21525a
House Bill 4552 would amend the Public Health Code to require hospitals to create an accurate
record of actual direct care RN-to-patient ratios in each unit for each shift and maintain that
record for at least three years. The record would have to include the number of patients in each
unit and the identity and duty hours of each direct care RN assigned to each patient in each unit
for each shift. The record would have to be made available to LARA, RNs and their collective
bargaining representatives, and the public under rules promulgated by LARA.
Proposed MCL 333.21525a
Each bill would take effect 90 days after it is enacted.
3
For provisions concerning confidentiality and appeals, see http://legislature.mi.gov/doc.aspx?mcl-333-20176
House Fiscal Agency HBs 4550 and 4552 as introduced Page 4 of 5
FISCAL IMPACT:
House Bills 4550 and 4552 would have an indeterminate fiscal impact on the Department of
Licensing and Regulatory Affairs and publicly owned hospitals.
House Bill 4550 would require LARA to establish and maintain a toll-free telephone number,
conduct complaint investigations related to nurse-to-patient ratio violations, publish
information regarding administrative fine assessments, and promulgate rules. The magnitude
of these costs is currently indeterminate, as it is unclear whether a new system would be
required for the toll-free phone line and because the costs related to any complaint
investigations would depend on the volume of complaints. In addition to the existing resources
appropriated for the department, funding could be appropriated in the future from the Nurse-
To-Patient Ratio Regulatory Fund created under the bill. It is unclear at present whether
revenue from that fund would be sufficient to offset LARA’s incurred costs under the bill.
If publicly owned hospitals are not currently in compliance with the staffing requirements
established under House Bill 4550, those hospitals could incur staffing costs in order to achieve
compliance. The cost of compliance would vary by facility, based on each facility's staffing
situation, and the cost is therefore indeterminate. If a hospital was in violation of nurse-to-
patient staffing ratios, the hospital would be subject to an administrative fine of between
$10,000 and $25,000 for each violation, but if a pattern of violations exists, the fine would be
between $25,000 and $50,000.
As mentioned previously, House Bill 4550 would create the Nurse-To-Patient Ratio
Regulatory Fund, which would be a state restricted fund that would receive the administrative
fines for nurse-to-patient ratio violations. Funding could only be used, on appropriation, for
administration of nurse-to-patient ratio regulation. The amount of revenue that would be
deposited into the fund would depend on the volume of administrative fines assessed, and is
therefore indeterminate.
In addition, the bills would have an indeterminate, but possibly significant, fiscal impact on the
state Medicaid program. The primary fiscal cost driver would be any overall hospital cost
increases based in the hiring of additional nurses in order to meet the mandatory patient to
nurse ratios and the degree in which Medicaid provides reimbursements for the overall hospital
cost increase. For fiscal year 2023-24, any fiscal impact related to Medicaid reimbursements
would be financed with federal and state funds at 64.94% and 35.06%, respectively.
Legislative Analyst: Rick Yuille
Fiscal Analysts: Marcus Coffin
Kevin Koorstra
■ This analysis was prepared by nonpartisan House Fiscal Agency staff for use by House members in their
deliberations and does not constitute an official statement of legislative intent.
House Fiscal Agency HBs 4550 and 4552 as introduced Page 5 of 5


Statutes affected:
House Introduced Bill: 333.1101, 333.25211