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Joint Commission Releases Interim Staffing Effectiveness Standards

Matt Phillion, for HealthLeaders Media, December 23, 2009

The Joint Commission has released a series of interim requirements to the staffing effectiveness standards, which are set to go into effect July 1, 2010.

The standards, approved by the Standards and Survey Procedures Committee, were first proposed in draft form in April 2009 and went through two field reviews, first in June 2009 and again in September.

These standards are intended to stay in effect as The Joint Commission examines and reassesses issues with the current staffing effectiveness standards. The Joint Commission announced earlier this year that it would examine and overhaul its staffing effectiveness standards after determining that, as they stand, the existing standards did not benefit hospitals sufficiently for the amount of time and effort put into complying with the standards. Staffing effectiveness standards had previously rated among the most commonly cited standards during Joint Commission surveys.

Until the review is completed, The Joint Commission has implemented the following requirements:

  • The hospital or organization must provide governance with written reports on the following at least once a year (LD.04.04.05 EP 13): all system/process failures; number/type of sentinel events; if the patients/residents and the families were informed of the event; all actions taken to improve safety, not only proactively but also when actual events occur; and the results of all analyses related to the adequacy of staffing. (Further details are available under PI.02.01.01, EP 14.)

  • The organization must include analyses of staffing when the organization identifies undesirable patterns, trends, or variations in its performance related to the safety or quality (PI.02.01.01, EP 12).

  • Leaders in charge of organization-wide patient and resident patient safety programs must be informed when problems are revealed involving the adequacy of staffing. Leaders must also be informed of actions taken to resolve the issues identified (PI.02.01.01, EP 13; see also LD.03.05.01, EP 7 and LD.04.04.05, EP 13).

  • Those responsible for the hospital-wide/organization-wide patient/resident safety program must, once a year or more, review a written report of the results of any analysis related to the adequacy of staffing and any actions taken to resolve identified problems (PI.02.01.01, EP 14).

The interim standards will first appear in the July 2010 update to the Comprehensive Accreditation Manual and E-dition. Additional information on these interim standards can be found on The Joint Commission's Web site.


Matt Phillion, CSHA, is senior managing editor of Briefings on The Joint Commission and senior editorial advisor for the Association for Healthcare Accreditation Professionals (AHAP).

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