Joint Commission Staffing Effectiveness Standard

In the new staffing effectiveness standard, which became effective July 2002, surveyors from the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, will look at actual vs. planned staffing in organizations. Through document review, interviews with leadership and staff, and visits to patient care units, the surveyors will look at these factors:

  • Screening indicators selected
  • Rationale for indicator selection
  • Data for the chosen indicators
  • Results of the organization’s analysis of the data
  • Actions taken on the basis of the analysis

Hospitals must choose a minimum of four screening indicators, two clinical/service-related and two human resource-related. At least one indicator in each category must be selected from these lists:

  • Human resource indicators
  • Nursing care hours per patient day
  • On-call or per-diem use
  • Overtime
  • Sick time
  • Staff injuries on the job
  • Staff satisfaction
  • Staff turnover rate
  • Staff vacancy rate
  • Understaffing as compared to organization’s staffing plan
  • Clinical/service indicators
  • Adverse drug events
  • Family complaints
  • Injuries to patients
  • Length of stay
  • Patient complaints
  • Patient falls
  • Pneumonias
  • Postoperative infections
  • Shock/cardiac arrests
  • Skin breakdowns
  • Upper gastrointestinal bleeding
  • Urinary tract infections