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Nurse Staffing Effectiveness in 2010: The Interim Standards

Briefings on The Joint Commission, April 13, 2010

Originally introduced by The Joint Commission to the standards in July 2002, staffing effectiveness is the appropriate level of nurse staffing that will provide for the best possible outcome of individual patients throughout a particular facility.

When first introduced, hospitals were required to track two human resource indicators and two patient outcome indicators, track data, and determine whether the variation in performance caused by the number, skill mix, or competency of staff.

"Hospitals collected the data, nurse leaders looked for correlations, and no correlations have been found," says Susan W. Hendrickson, MHRD/OD, RN, CPHQ, FACHE, director of clinical quality and patient safety at Via Christi Wichita (KS) Health Network.

Hendrickson says even if hospitals did find what they believed to be a correlation between staffing and a patient outcome, when the information was examined more closely, it was not statistically valid.

Fast-forward to June 2009: The Joint Commission suspended these standards due to the debate of the results from across the country.

However, this suspension proved to be short-lived. In December 2009, The Joint Commission announced the approval of its interim staffing effectiveness standards for 2010.

The new standards will become effective July 1, and will remain in effect as The Joint Commission continues to research the issues of staffing effectiveness.

Interim standards at a glance
The first requirement affects LD.04.04.05, element of performance (EP) 13, and states that at least once per year, the hospital/organization must provide written reports on all system or process failures, the number and types of sentinel events, information provided to families/patients about the events, and actions taken to improve patient safety.

"In a broader sense, EP 13 ties staffing to outcomes and puts accountability at the leadership's feet," says Hendrickson. She suggests hospitals submit the reports to the board quarterly or monthly, rather than annually.

"Think about this: Every time a medical error occurs and you have to document it, this may be a long report for the board to get a grip on," says Hendrickson.

Rather than compile an itemized list of failures, hospitals should instead classify the events and report on them statistically.

"Sentinel events, you will want to try to discuss the events as soon as possible, and disclose general information to the board," says Hendrickson. "And if a sentinel event did occur, then disclose information on any action taken to prevent similar events."

In addition to EP 13, the new interim requirements affect PI.02.01.01, EPs 12–14.

EP 12 states that any time the organization has an undesirable event, it must evaluate its staff and their effectiveness. EP 13 states that if a negative trend in the staff is noted, a report must be provided to the leadership.

In EP 14, a written report of the identified issues must be provided at least once per year to the leadership in charge of the patient safety program.

"The organization needs to have a process or policy that speaks to this so the surveyor can review the information," says Hendrickson. "The Joint Commission believes that if you are not in compliance, this is an immediate risk to patient safety because there are few processes to intervene."

Now if an organization is cited for any staffing effectiveness, a short-term resolution is given, and the organization is required to come up with a solution within 45 days.

Turning to patient-staff ratio
In addition to the new interim standards, a more intricate part of staffing effectiveness under examination is the patient-to-staff ratio. However, California is no stranger to this because a staffing ratio has been imposed on all organizations in the state since 2004.

To meet the patient-to-staff ratio, many hospitals in the state used traveling nurses from all areas of the United States. By doing so, many of the new nurses ended up taking residency in California, skewing the numbers of the nursing shortage elsewhere.

Despite the additional nurses, the ratios between patients and staff were not always met.

"Meeting the ratio at all times was difficult," says Cyndie R. Cole, RN, MSN, CNO at the Ventura (CA) County Medical System. "Going from three RNs on the night shift to five RNs on the night shift added a tremendous cost, and then during the day shift staff were not used to being forced to take their lunch break at a specific time."

Over time, however, nurses managed to work together with the administration to come to a better understanding.

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