The Joint Commission (TJC) recently released interim staffing effectiveness
standards (Interim Standards) applicable to its hospital and long term care
certification programs that will become effective July 1, 2010.
Draft Interim Standards were first proposed by TJC in April 2009, and
underwent field engagements in June 2009 and September 2009. The Interim
Standards were then approved by TJC’s Standards and Survey Procedures Committee
on Dec. 9, 2009. The Interim Standards will replace currently suspended staffing
effectiveness standards PI.04.01.01 (hospitals) and HR.1.30 (long term care
facilities), while more extensive research is performed to improve staffing
effectiveness requirements. The Interim Standards will first appear in the July
2010 update to the Comprehensive Accreditation Manual and E-dition electronic
Originally introduced by TJC in July 2002, “staffing effectiveness” is
generally defined as the appropriate level of staffing to provide the best
possible patient outcome in a particular care setting. When the standard was
first introduced, accredited organizations were required to track certain
indicators for purposes of detecting staffing problems, and determining if any
correlations existed between staffing levels and patient outcomes.
However, in early 2009, the public was invited to comment on whether it
believed TJC’s staffing effectiveness standard met TJC’s objectives of value and
achievability to accredited organizations. Feedback indicated the standard did
not significantly impact patient quality of care or safety, and also showed that
the standard consumed an extensive amount of resources and was among the most
commonly cited standards during TJC surveys. As a result, TJC decided to suspend
its staffing effectiveness standards until it had examined reported issues.
The suspension, however, was short-lived and TJC has approved the following
Interim Standards for accredited hospital and long term care organizations,
until such time as it completes its review of current staffing effectiveness
- At least once a year, an organization must
provide its board of directors with written reports on: (i) all system or
process failures; (ii) the number and types of sentinel events; (iii)
whether the patient/resident and their families were informed of the event;
(iv) all proactive and responsive actions taken to improve staffing safety;
and (v) all results of analyses related to the adequacy of staffing.
[LD.04.04.05 EP 13].
- When an organization identifies undesirable patterns, trends, or
variations in its performance related to the safety or quality of care, it
includes the adequacy of staffing in its analysis of possible causes.
[PI.02.01.01 EP 12].
- When analysis reveals a problem with the adequacy of staffing, an
organization’s leaders responsible for patient/resident safety are informed
of the results of this analysis, and action is taken to resolve the
identified problems. [PI.02.01.01 EP 13].
- At least once a year, an organization’s leaders responsible for the
patient/resident safety program review a written report of the results of
any analysis related to the adequacy of staffing and any actions taken to
resolve identified problems. [PI.02.01.01 EP 14].
The Interim Standards broadly tie the adequacy of an organization’s staffing
to patient outcomes, and place accountability for compliance upon its board of
directors and other leadership. Please contact one of the authors or a member of
McGuireWoods’ healthcare or long term care practice group, if you have questions
about methods for achieving compliance with the Interim Standards.