The Joint Commission Approves Interim Staffing Effectiveness Standards for Hospitals, Long Term Care Organizations

February 17, 2010

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 standards manual.

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 standards:

  • 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.