JCAHO Update for Infection Control

Nurses charge JCAHO lax on staffing standards

Raises risk of hospital-associated infections

The Joint Commission on Accreditation of Healthcare Organizations is embroiled in a legal battle with the American Nurses Association (ANA) over the issue of hospital staffing levels.

The ANA, the New York State Nurses Association (NYSNA), and the Washington State Nurses Association (WSNA) recently filed a lawsuit in a U.S. district court against the Department of Health and Human Services (HHS). The nursing groups seek to remedy perceived violations of laws that require minimum standards for participation in the federal Medicare program. Specifically, the groups claim that HHS allows hospitals that fail to meet federal nurse staffing requirements to participate in Medicare, thereby endangering patients. The lawsuit seeks to prevent HHS from allowing JCAHO, which accredits 82% of all hospitals, "to use its own, minimal standards" for nurse staffing in its accreditation of hospitals. As part of the lawsuit, the NYSNA and the WSNA claim that hospitals in both states have failed to hire and assign enough nurses to meet HHS standards for participation in Medicare, and this failure has resulted in nurses working in situations that "jeopardize the health and safety" of nurses and patients.

"The number of Medicare patients is increasing at the same time nurse staffing shortages are growing," says Verlia Brown, MA, RN, president of the NYSNA. "This is a dangerous combination. It is critical that hospitals adhere to the highest possible nurse staffing standards for the sake of nurses and patients."

According to the lawsuit, HHS has "unlawfully delegated its authority to JCAHO by allowing it to use standards that are not equivalent to standards set by HHS for participation in the Medicare program." The lawsuit seeks a court order to require that HHS assures that JCAHO uses standards that are "at least equivalent" to HHS standards. The lawsuit asks the court to order the following actions to prompt adherence to HHS regulations while ensuring continuing access to health care services:

  • require HHS to comply with the registered nurse staffing regulation;
  • require HHS to designate provisional approval of hospitals that rely on JCAHO accreditation for participation in the Medicare program.

Demanding RNs at the bedside

HHS and JCAHO guidelines both include requirements for nurse supervisory personnel. But HHS requirements also call for nurse staffing levels that ensure the "immediate availability" of a registered nurse for the bedside care of any patient. In addition, HHS requires that staffing schedules be reviewed and revised to meet patient care needs and nursing staff absenteeism. The lawsuit charges that JCAHO's standards are "devoid" of any requirements for the immediate availability of nurses to provide bedside care to patients and also do not address with sufficient specificity the requirements of staffing plans.

"Plaintiffs and the public are harmed by a failure to require adequate staffing on medical/surgical units where registered nurse-to-patient staffing ratios of 1:8 result in patients being 31% more likely to die within 30 days than those in units with RN-to-patient ratios of 1:4, and complications such as urinary tract infections, pneumonia, shock, and gastrointestinal bleeding are much more prevalent," the suit charges.

Indeed, clinical investigators have found that inadequate health care staffing can spark nosocomial outbreaks when rising patient census or acuity outstrip nursing resources. Though it can be difficult to establish a clear epidemiological link between such conditions and subsequent infections, the general consensus is that staffing problems — particularly if they occur in conjunction with an increase in patient acuity — may undermine aseptic technique, catheter care, and hand washing compliance by harried health care workers.

JCAHO infection control standard IC.9.10 requires hospital leaders allocate adequate resources that include sufficient staff as reflected by "numbers, competence, [and] skill mix." In response to the lawsuit, JCAHO emphasized that its accreditation standards meet or exceed HHS requirements. Moreover, numerous HHS validation surveys demonstrate the adequacy of Joint Commission standards in the area of nurse staffing, JCAHO said in a statement.

In addition, the new survey process, "Shared Visions — New Pathways," pays particular attention to the important role of nurses by shifting the focus from survey preparation to continuous improvement of operational systems that directly impact the quality and safety of patient care. Moreover, the Joint Commission argues that it has established "cutting-edge staffing standards that create a framework for measuring and improving nursing care."

Hospitals may participate in the Medicare program either through JCAHO accreditation or through accreditation by a state agency approved by HHS. A 2004 U.S. Government Accounting Office (GAO) report concluded that JCAHO had "unacceptable performance" in identifying hospitals that did not comply with Medicare requirements, the ANA charges. Prior to 2006, JCAHO accreditation surveys were scheduled. The GAO acknowledged that by conducting unannounced surveys beginning this year, JCAHO likely would improve its performance.

References

  1. Fridkin SK, Pear SM, Williamson TH, et al. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996; 17:150-158.
  2. Haley RP, Bregman DA. The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis 1982; 145:875-885.
  3. Kidd F, Heitkemper P, Kressel A. A neonatal intensive care unit outbreak of S. aureus associated with inadequate staffing. Abstract S74. Presented at the Conference of the Society for Healthcare Epidemiology of America. San Francisco; April 18-20, 1999.