The National Union of Healthcare Workers (NUHW) represents 19,000 healthcare workers across California in hospitals, nursing homes, outpatient medicine and psychiatry clinics, correctional facilities, and home health and hospice. Four hundred of our members–registered nurses, licensed vocational nurses, social workers, mental health technicians, and patient care support specialists–work at acute psychiatric hospitals (APHs).

On behalf of these behavioral healthcare workers, I would like to provide input on revisions to the Title 22 regulations governing acute psychiatric hospitals. In the two APHs we represent, Sacramento Behavioral Healthcare Hospital and Sutter Center for Psychiatry in Sacramento, our members report that understaffing is a chronic problem that creates unsafe conditions for both patients and workers. Understaffing also compromises the quality of care delivered to patients who are suffering from serious mental illness. These patients have complex and high-risk presentations that necessitate interdisciplinary team-based care, close monitoring (and, in some cases, one-to-one, continuous observation), frequent communication with family members, frequent changes to medication regimens, and specialized support, education, and care planning and coordination.​

This vulnerable patient population should be cared for in settings that have at least as much–if not more–oversight and regulatory protections as psychiatric units in general acute care hospitals.

NUHW urges the Center for Health Care Quality (CHCQ) Regulation Development Section to take the following actions to protect workers and patients:​

• Establish a minimum ratio of one registered nurse to every six patients or fewer at all times on adult units and one registered nurse to every four patients or fewer at all times on adolescent units.
  
• Establish a numeric staffing ratio for unlicensed support staff (mental health technicians or patient care support specialists) that is separate and in addition to the nursing ratio. With regards to this ratio, APHs should be required to:
  
• Maintain the ratio at all times including when staff members have to take meals or breaks or move between units or different areas of the facility.
  
• Maintain the ratio even when one or more patients require one-to-one continuous monitoring. Staff assigned to one-to-one observation should not be assigned other patients or additional duties related to the care of other patients.
• Assess and adjust staffing throughout each shift to best manage the acuity mix and changes in the patient census. APHs shall ensure that additional staff are immediately available to maintain ratios when more patients are admitted.
  
• Post daily staffing ratios in a location visible to all staff and patients.
  
• Require all APHs to implement a safe staffing committee composed equally of licensed and unlicensed caregivers and management. The safe staffing committee should develop an acuity based staffing tool and respond to staffing-related safety concerns. The committee should meet at least quarterly or within five days of a concern identified by either staff or management.