New JCAHO staffing standards: You may be surprised at what you need to do
You’ll need new methods to assess whether your staffing is adequate
Do you have sufficient qualified staff to care for the patients who come to your ED? Do you use specific indicators to be sure your staffing is adequate? These are two things you must do to comply with new requirements from the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The standards, which are effective as of July 1, 2002, require you to assess staffing based on clinical/service and human resource outcomes.
The good news is that using the Joint Commission’s indicators will help you set effective benchmarks for your ED, according to Camilla L. Jones, RN, BBA, director of emergency and transfer services at Lewis-Gale Medical Center in Salem, VA. "However, the process will take some time and careful analysis of trended data," she says. The Joint Commission’s method uses a multidimensional approach, instead of focusing on a single indicator, Jones says. "This is good, because parameters with a narrow focus usually spell disaster for ED operational management," she says. "There are so many variables and few opportunities to control patient flow."
If you’re like most ED managers, you probably plan staffing according to trends in patient volume, notes Jones. "The most effective trending tools are electronic systems that allow the manager to monitor patient volume in small time frames, such as hourly," she says. However, Jones warns that the new Joint Commission indicators require you to monitor more than just volume. "They insist acuity and volume surges be taken into consideration, so dust off your crystal ball!" she says.
She adds that the new standards may make it possible for you to increase manhour per stat ratios to a more acceptable level. "This will better provide quality care and facilitate good outcomes for all patients, including those with higher acuities and longer ED lengths of stay," she says. "This in itself will promote improved patient outcomes and satisfaction, as well as staff satisfaction and retention."
Here are ways to comply with the standards:
• Ensure there is an adequate number of qualified staff to care for patients. Staff must have the requisite education and training, current licensure, certification or registration, and they must possess the knowledge and experience necessary to carry out their assigned responsibilities, advises Kathleen Catalano, RN, JD, director of administrative projects at Children’s Medical Center of Dallas. "The surveyors also will ask staff if they have age-specific competencies and what they are," she adds.
The standards address all patient care professionals, not just nurses, notes Patrice L. Spath, RHIT, a health care quality specialist with Brown-Spath & Associates, a Forest Grove, OR-based firm that provides performance improvement training for health care organizations. "The standards encourage an adequate skill mix of professionals to meet the needs of the population served by your ED," she says.
For example, if your ED has a high number of patients with mental or behavioral health problems, you are expected to have staff that can care for these patients, says Spath. "This may be psychiatric nurses, social workers, psychologists, or other people with appropriate training," she adds. Joint Commission surveyors want to see that you’ve gathered information to determine the clinical needs of your patients, adds Spath.
Catalano notes that direct and indirect caregivers should be included when using the human resources screening indicators. You must be certain that a nurse assigned to a patient has the skills to care for that patient, says Catalano. She recommends answering the following questions to assess this:
- Are the staff members licensed in Trauma Nursing Core Curriculum or the equivalent?
- Do you provide nurses with inservices to help them learn about trauma?
- Is pediatric advanced life support (PALS) training or the equivalent a requirement for nurses?
- What is the time frame within which they must achieve that training?
- Are other PALS-trained nurses available until that training has been accomplished?
Jones says she uses approximately 70% licensed personnel in the care of ED patients. "We only include RNs in our licensed mix. All other personnel are included in technical or support service mixes," she says. "However, I feel this can be a nebulous indicator for the purposes of JCAHO surveys," she says.
She argues that there is no consistency from facility to facility for training requirements, which employees are counted or not counted, and how they are placed into service, such as which skill mix is utilized during a shift or time frame. For instance, Jones says her ED counts environmental services personnel, but not registration personnel, she says. "Our tech staff is all EMT and largely EMT-paramedic, providing a highly skilled technical component," she says.
Nurse externs also are counted, Jones says. "These personnel are in the last six months of their senior year of nursing school and have worked previously in the ED, mostly in EMT tech roles," she adds. "They usually have an ED nursing job here when they graduate, so my recruitment and retention numbers are very low." Jones adds that nurses from the forensic program and the interfacility transfer program also are included in the staffing break-out. "So if our percentiles are stacked up against other facilities, or a national average, I feel the assessment of skill mix must be evaluated consistently to provide valid benchmarking," she says.
• Monitor indicators of staffing deficiencies. Closely monitor process or outcome measures that may be indicators of staffing deficiencies, Spath advises. "For example, if a significant number of ED patients must wait a long time before being evaluated by a caregiver, that can be a symptom of staffing problems," she says.
For the Joint Commission’s "clinical/service" indicators, Jones tracks patient/family complaints, staff satisfaction, sentinel events, and length of stay. To collect this data, the ED uses Meditech software (Medical Information Technology, Westwood, MA) and Logicare software (Logicare Corp., Eau Claire, WI), along with manual chart retrieval and analysis. To gauge patient and employee satisfaction, the ED uses hospital-based surveys, and the facility uses independently-conducted surveys from The Gallup Organization, based in Princeton, NJ. "These are broken down by department and compared," she says.
Spath recommends reviewing the staffing indicators suggested by the Joint Commission and determining which ones will be relevant to your ED. Ideally you should select at least two clinical/service indicators and two human resource indicators, says Spath. Evaluate these indicators at least quarterly to determine if staffing deficiencies are the root cause of any problem areas that may be identified, says Spath. "No single measure can reliably evaluate staff effectiveness," she acknowledges. "However, the measurement results may raise questions about staffing that need to be looked into in greater detail."
• Evaluate the system you use to make staffing decisions. Your decisions must be based on acuity of patients served and competence, education, and experience of staff, says Spath. "If not [being done], re-evaluate your method for staffing decisions so that all of these elements are considered," she advises.
The Joint Commission expects you to identify, quantify, and fix staffing problems yourself, by using outcome-based data analysis, says Jones. She recommends using staffing formulas based on previously accepted data to support changes in acuity and lengths of stay in ED settings. Jones created an adjusted outpatient census formula to adjust staffing to include patients that are held in the ED for more than six hours. "In addition, I have just created another acuity based formula to justify productivity for increased admission rates," she says. "Ours is currently 23%."
The new Joint Commission standards are a performance improvement process, says Catalano. "You need evidence that appropriate action is actually taken when data have been analyzed," she adds. For example, if your data reveal ineffective care of patients during specific time frames, you can change staff hours to correct this, says Catalano. "Someone may need to come in earlier to cover a three-hour block of time," she suggests. Next, use your performance improvement process to determine if that action is effective, Catalano says. "If not, it’s back to the drawing board," she says.
Sources
• Kathleen Catalano, RN, JD, Director, Administrative Projects, Children’s Medical Center of Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-8722. Fax: (214) 456-2772. E-mail: [email protected].
• Camilla L. Jones, RN, BBA, Director of Emergency and Transfer Services, Lewis-Gale Medical Center, 1900 Electric Road, Salem, VA 24153. Telephone: (540) 776-4850. Fax: (540) 776-4849. E-mail: [email protected].
• Patrice L. Spath, RHIT, Healthcare Quality Specialist, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116-0721. Telephone: (503) 357-9185. Fax: (503) 357-9267. E-mail: [email protected]. Web: www.brownspath.com.
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