; findings. Sec. 2. Minimum direct care registered nurse staffing requirement. Sec. 3. Enforcement of requirements through Federal programs. Sec. 4. Nurse workforce initiative. (c) Findings Congress finds the following: (1) The Federal Government has a substantial interest in promoting quality care and improving the delivery of health care services to patients in health care facilities in the United States. (2) Recent changes in health care delivery systems that have resulted in higher acuity levels among patients in health care facilities increase the need for improved quality measures in order to protect patient care and reduce the incidence of medical errors. (3) Inadequate and poorly monitored registered nurse staffing practices that result in too few registered nurses providing direct care jeopardize the delivery of quality health care services. (4) Numerous studies have shown that patient outcomes are directly correlated to direct care registered nurse staffing levels, including a 2010 Health Services Research study that concluded that implementation of minimum nurse-to-patient staffing ratios in California has led to improved patient outcomes and nurse retention and a 2014 Agency for Healthcare Research and Quality study that concluded increases in nurse staffing and skill mix lead to improved quality and reduced length of stay at no additional cost. (5) Requirements for direct care registered nurse staffing ratios will help address the registered nurse shortage in the United States by aiding in recruitment of new registered nurses and improving retention of registered nurses who are considering leaving direct patient care because of demands created by inadequate staffing. (6) Establishing adequate minimum direct care registered nurse-to-patient ratios that take into account patient acuity measures will improve the delivery of quality health care services and guarantee patient safety. (7) Establishing safe staffing standards for direct care registered nurses is a critical component of assuring that there