A plan to exempt Mayo Clinic in Rochester from Minnesota nurse staffing legislation is gaining traction, but the special treatment is upsetting the rest of the state's hospitals.

Negotiations accelerated last week after Mayo threatened to relocate a billion-dollar expansion project outside Minnesota if it was subject to the staffing legislation and another proposal to penalize hospitals with excessive spending growth.

House Speaker Melissa Hortman said on WCCO-TV Sunday that an exemption would be appropriate for the internationally renowned medical provider.

"Mayo is different," said Hortman, DFL-Brooklyn Park. "Mayo is an asset that is known all over the world. There are not other hospitals in the state that have kings and princes flying in to stay to get treatment."

The bill would require committees of executives, nurses and other providers in Minnesota hospitals to agree on nurse staffing levels in their units or to resolve their differences through arbitration. Mayo lobbied for an exemption because it has an automated system that determines staffing needs faster than any committee — and argued that any other hospital with a similarly sophisticated system should be able to opt out.

The staffing proposal is one of several reforms that the DFL-led legislature has urged this session to fix a health care system that is growing in cost even as it becomes less accessible. Nursing shortages are leading to overcrowded nursing homes and hospital units, which has resulted in backlogs in emergency departments.

A Mayo-only compromise upset leaders of the Minnesota Hospital Association, which has predicted that hospitals will be forced to close units and deny admission to patients when they cannot meet legally binding committee staffing requirements. The association estimated disruptions for 70,000 Minnesota patients per year.

"Any alternative pathway that works for one health care system must work for all," said Dr. Rahul Koranne, chief executive of the trade group that represents most Minnesota hospitals, but not Mayo. He argued that the rules under which health care is provided to kings should be the same for farmers and seniors.

The Minnesota Nurses Association, which represents nurses at most Twin Cities and Duluth hospitals, has lobbied for years for staffing legislation to ease the growing workload and burnout that is contributing to the nursing shortage. Prospects appeared favorable when both the House and Senate approved bills that included the staffing language. Then came Mayo's threat.

The union responded last week by highlighting Mayo nurses from Austin and Fairmont who reported poor working conditions, despite Mayo's staffing system. Nurses also lined Capitol hallways all week last week to lobby for the staffing legislation.

"There are many times when we have taken more than we should," said nurse Kari Wilkemeyer, recalling night shifts at Mayo's Austin hospital, "but in the back of our minds we were hoping and praying and crossing our fingers that we would make it to 7:05 when the day staff arrived."

Chief executives of every Minnesota hospital system, including Mayo, signed a Star Tribune opinion article warning that "if these bills pass as they are written, Minnesota's nonprofit hospitals are in trouble."

A compromise appears to have addressed one of their concerns, the creation of a state health care affordability board that could fine hospitals up to $500,000 if they exceeded and ignored spending growth limits. Lawmakers have discussed eliminating the penalties and growth targets, for now, but empowering the Minnesota Department of Health to watch hospital spending levels closely.

One draft compromise on the staffing legislation would exempt hospitals if they operate outside the Twin Cities, use an electronic staffing system that considers the number and acuity of patients, and have more than 40% of patients coming from outside Minnesota. Only Mayo in Rochester fits these criteria. The requirements would still apply to Mayo's other hospitals across southeast Minnesota.

The lead author of the staffing legislation, Sen. Erin Murphy, DFL-St. Paul, predicted that the final bill will require compromise but give nurses more authority.

"A sophisticated tool of acuity — which I understand and appreciate — cannot replace the eyes, the critical thinking and the judgment of a professional registered nurse," she said. "So we need both."

Mayo intends to invest billions in next generation hospital facilities and technologies — beyond the Destination Medical Center improvements to infrastructure in Rochester that included $585 million in state funds. Whether that will happen in Minnesota is unclear. Mayo's board voted last week on the project.

"The Board of Trustees reviewed and agreed on action on a number of items," said a statement provided by Mayo spokeswoman Kristy Jacobson. "But action is pending outcomes of the legislative session before determining next steps."

Staff writer Jessie Van Berkel contributed to this report.