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Joint Commission Issues Interim Staffing Effectiveness Standards

Matt Phillion, for HealthLeaders Media, February 10, 2010

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).

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