Originally introduced by The Joint Commission 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 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 for Via Christi Wichita (KS) Health Network.
Hendrickson says that even if hospitals did find what they believed to be a correlation between staffing and 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 because of the debate of the results from across the country.
This suspension was short lived as The Joint Commission recently announced the approval of its interim staffing effectiveness standards for 2010. The new staffing effectiveness standards will become effective July 1, 2010, 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 EP 13 and states that at least once a year, the hospital/organization must provide written reports on all system or process failures, the number and type of sentinel event, 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 that instead of reporting individual system or process failures annually to the board, hospitals should submit the reports to the board either quarterly or monthly. Hendrickson warns that reporting every time a medical error occurs can lead to a lengthy report for the board to comprehend.
Rather than compile an itemized list of failures, hospitals should instead classify the events and then 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 EP 12-14.
EP 12 states that any time the organization has an undesirable event, it needs to evaluate the staff and their effectiveness. PI.02.01.01 EP 13 says 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 a 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 new interim requirements include four new EPs, all of which are A- structure or a policy or plan, and three of them are direct impact standards," 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 needs to come up with a solution within 45 days.
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).