Joint Commission Issues Interim Staffing Effectiveness Standards

Matt Phillion, February 10, 2010

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.

Matt Phillion 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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