Staffing Effectiveness

Q:

1. Which accreditation programs do the Staffing Effectiveness standard HR.1.30 requirements apply?
2. Must an organization collect data for all departments?
3. Is an organization required to collect indicators for all of its inpatients?
4. If my organization has outpatient clinics, do I need to collect indicator data for these patient populations?
5. Does the Joint Commission require a specific definition for each indicator?
6. At what frequency must an organization collect data for the clinical/ service & human resource indicators?
7. How should indicator data be collected and analyzed?
8. Does the Joint Commission specifically require human resource indicators for indirect caregivers?
9. What is the track record policy for introduction of these revisions to the staffing effectiveness standard?

A:

1. Hospital, Long Term Care (LTC), and Assisted Living (AL)
   
   
2. No. This is a patient-centered model. That is, the focus is on staffing effectiveness related to the units or divisions providing patient care, such as medical-surgical units, ICUs, and pediatric units. Data would not be required to be collected for laboratory, diagnostic testing or non-patient care areas such as Accounts Payable or Marketing. The organization identifies a minimum of two units/divisions (populations/settings for LTC/AL) based on assessment of relevant information or risk, including
   • Knowledge about staffing issues likely to impact patient/resident safety or quality of care
     • Patient/resident population served
     • Type of setting
     • Review of existing data (e.g., incident logs, sentinel event data, performance improvement reports)
     • Input from clinical staff who provide patient/resident care
       
       
3. No, the standard requires organizations to collect indicators for inpatients for a minimum of two units/divisions. Unit/division refers to the level at which staffing is planned and provided within the organization. For example, staffing may be planned for individual units or a group of units, such as all medical-surgical units. The standard requires data to be collected on four indicators for each of the identified units/divisions. Of the four indicators required for each unit/division (populations/setting for LTC/AL), two must be clinical/service indicators and two must be human resource indicators. At least one clinical/service and one human resource indicator must be selected from the Joint Commission list in the standard HR.1.30. The indicators should be relevant to the patients served, for example, falls would not be relevant to the nursery. The indicators should also be sensitive to the patient/resident population served on the specific unit/division selected. For example, if it is known that a specific unit/division has a low number of pressure ulcers it would not be an appropriate indicator to select. The indicators selected may be the same or different for each unit selected as appropriate or relevant and sensitive.
   
   
4. No. The current Joint Commission list of indicators relates to inpatient populations and selection of units should be based upon risk assessment. Research and field review were conducted to identify appropriate indicators for other populations, i.e., ambulatory, home care, and behavioral health, but no specific indicators have yet been conclusively identified for ambulatory patients and other accreditation programs. Hospital-based ambulatory areas do not have to collect indicators for staffing effectiveness. When ambulatory indicators have been identified, they will be included in the hospital manual in order to address those organizations with hospital-based ambulatory care.
   
   
5. Yes. Each organization is required to establish a clear definition for each selected indicator. The organization also needs to define a numerator and denominator for each indicator chosen.
   
   
6. The organization determines the detail and frequency of data collection. Items to be considered in making the decision on data collection are:
   • Annual data analysis limits timely & effective evaluation of staffing, and restricts the ability to take action needed.
   • Shorter time periods (ie. monthly or quarterly) are of more practical use to evaluate staffing effectiveness. Quarterly may be acceptable to improve outcomes, but monthly is more useful in facilitating timely and appropriate action as needed based upon the data collected and analyzed.
     
     
7. Indicator data should be collected for a minimum of two units and at the unit/division level(s) defined by the organization. The data should be collected and analyzed at the unit/division level where staffing is planned. Staffing may be planned for individual units or for a group of units such as all medical/surgical units. If organization-wide indicators are selected, the ability to "drill down" to specific areas where staffing is planned will be needed. Analysis of indicator data at high levels, such as at the organization level, may be of little value since it may dilute specific staffing effectiveness issues.
   
   The data for each screening indicator are analyzed to identify any variations from desired performance (organization defined acceptable ranges/parameters/trigger levels) by an individual measure. Variations in performance should trigger further analysis to determine causes of the variation and whether staffing effectiveness issues might be affecting the outcomes of care. When variation from desired performance is detected in one indicator, other indicator results are reviewed to identify information that may assist in clarifying the potential cause.
   
   
8. No, data collection is only specifically required for direct nursing staff (registered nurses, licensed practical nurses, nursing assistants or aides). The organization may choose to include other staff such as therapists (RT, PT, OT, & SLP), lab, pharmacists, & etc. if their absence may impact clinical outcomes.
   
   
9. Generally, a 12-month track record is required when a standard is assessed. The Joint Commission Board of Commissioners approved the use of the new staffing effectiveness standard (HR.1.30) for hospitals effective July 2002 and January 1 of 2004 for LTC and July 1, 2004 for Assisted Living. Compliance with the new standard is expected from the effective date. Revisions to the staffing effectiveness standard to became effective July 1, 2005 have been introduced into the existing staffing effectiveness standard. In January 2006 we would expect a six month track record. From July 2006 and forward, a 12-month track record would be expected.