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.
For this year, a set ratio for each unit in the hospital must be met at all times, with no exceptions. The patient-to-staff ratios for each unit include:
- Critical care: 1:2
- Neonatal ICU: 1:2
- Postanesthesia care unit: 1:2
- Labor and delivery: 1:2
- Postpartum (moms only): 1:6
- Pediatrics: 1:4
- Step-down: 1:3
- Telemetry: 1:4
- Med-surg: 1:5
- Specialty care: 1:4
- ED: 1:4, 1:2, 1:1
"In the ED, the patient census is always changing, so three different ratios are set up," says Cole. "On an hour-by-hour basis, we are checking and making sure we are adequately staffed." To help with the ED's unpredictability, Cole developed two tools over a three-year period, to work together to help ensure that the patient-to-staff ratios are always met.
The first tool is an hourly census that requires the charge nurse to document the patients in the ED and those patients in the emergency room waiting area. By tracking the patients in the ED and those waiting, the tool helps determine when the ED census will be at its highest and helps the facility call more nurses to meet the patient-to-staff ratio.
In addition to the hourly census, facilities utilize an Excel spreadsheet that automatically determines variance in the ratios.
"This gave us a tool to show where our major hours of being under the ratio occurred, and allowed us to present to our fiscal people hard evidence the times when we need more nurses," says Cole.
The importance of staffing effectiveness
Staffing effectiveness is being addressed at a national level, with the possibility of all hospitals one day being required to meet a nurse-to-patient ratio.
"Staffing effectiveness in a hospital, meeting ratios, and meeting acuity plans is a day-by-day process," says Cole. "It is something we have all worked hard to do, but it is still not perfected."
Even with time, Hendrickson believes that it is still important for hospital leaders to look at staffing issues. "We need to understand how staffing affects outcomes, because we are all held accountable for patient safety," she says.
Most importantly though, Hendrickson says, it is necessary for organizations to develop the evidence for their own practices. "We need to work together in order to determine what practices will improve the outcomes. And then we have to spread that information across our profession."
This article was adapted from one that originally appeared in the March 2010 issue of Briefings on The Joint Commission, an HCPro publication.