JCAHO hopes to convey that staffing is more than just numbers’
During a mock survey at NorthEast Medical Center in Concord, NC, a nurse was asked how she determined whether her unit had effective staffing, and replied, "When I get to go to lunch."
"In the real world of professional nursing, she was right," says Karen Holtz, MS, CPHQ, the facility’s education and accreditation specialist. "But I want the nursing staff to understand that the Joint Commission [on Accreditation of Healthcare Organizations’] new staffing effectiveness standard is one way in which we’re targeting specific areas for improvement to achieve and maintain effective staffing," she explains.
The new staffing effectiveness standard is effective as of July 2005. The Joint Commission found that organizations didn’t understand the intent of the original standard, which has been in place since July 2002, according to Carol J. Gilhooley, director of survey methods, development, and testing in the Joint Commission’s division of standards and survey methods.
For example, the use of the word "correlation" caused a lot of confusion. "We didn’t mean that in the statistical sense — we meant it in the process improvement sense," she says. "But this really caused a lot of confusion for organizations, who were looking at this from a statistical correlation perspective."
The Joint Commission expects you to collect data on key indicators, track that over time, and if there is variation from what you are expecting, to drill down and find out if the root cause of this variation is staffing-related, Gilhooley explains. "We added a rather lengthy rationale so that organizations would understand the performance improvement [PI] approach and the need to incorporate this into their daily activity."
Here are key changes in the standard:
• Data collection efforts will be focused on a minimum of two units or divisions.
Instead of asking for data to be collected on units organizationwide, the new standard asks you to focus your efforts on at least two units. "Those two units should be based on some information that identifies those areas as being particularly vulnerable," Gilhooley notes. These factors may include patient population, sentinel event data, incident reports, PI reports, or previously identified staffing issues likely to affect patient safety.
The approach is similar to the targeted surveillance concept that JCAHO uses for infection control, she adds.
NorthEast’s nursing and PI departments will identify units with the lowest compliance for human resources (HR) indicators and the highest fall rates. "From there, we’ll select at least two units to write Plan, Do, Study, Act’ reports. These same units will bubble to the top on both the HR reports and falls reports," says Holtz. "This allows us, as an organization, to focus on unit-specific improvements and really make a difference."
Since data collection efforts are targeted toward specific units, the burden of analysis and report writing will be reduced, although the organization still plans to continue to collect and disseminate data for other unit PI projects, notes Holtz.
"All units report a PI indicator to the PI committee, and some report their fall-rate data," she explains. "Therefore, we will still collect and disseminate the fall rate data by unit and for the organization. However, staffing effectiveness data reporting will be more focused."
• The list of approved screening indicators will include the National Quality Forum (NQF) nursing-sensitive patient care measures.
"This will streamline data collection efforts that we already have in place," says Missi Halvorsen, RN, BSN, senior consultant for JCAHO/regulatory accreditation at Baptist Health in Jacksonville, FL. Since data already are collected for NQF, additional sets of indicators will not be required, she explains.
This change will make the quality manager’s job "much easier," Halvorsen predicts.
"However, we are still challenged by submission requirements, as each agency and accrediting body has a different format for data submission," she says.
The Joint Commission has received grant support from the Robert Wood Johnson Foundation to create a technical implementation guide for the NQF national voluntary consensus standards for nursing sensitive care, reports Sharon L. Sprenger, project director for the group on performance measures in the JCAHO’s division of research.
The standardized guide is expected to be available in November 2005 and will include a specification manual with an individual measure information form with measure name, rationale, numerator, denominator, and population inclusions/exclusions, a data dictionary with data elements, definitions and allowable values, measure calculation algorithms, and any applicable tables such as medication lists.
"We are hearing from a lot of quality managers who ask if JCAHO can give more information about exactly what data should be collected and how terms should be defined," Gilhooley says. "Soon, we will have clearly defined specifications for those indicators."
This will allow organizations to benchmark their performance against other organizations, she notes.
"If everybody is speaking the same language, you will be able to use that data not only for your own PI throughout the organization, but you will also be able to look across organizations — which is the ultimate goal," Gilhooley adds.
The new standard gives you more specific guidance and direction for data collection and reporting, says Patti Muller-Smith, RN, EdD, CPHQ, a consultant for Shawnee, OK-based Administrative Consulting Services. Muller-Smith works with hospitals on performance improvement and regulatory compliance.
"Although this may not lessen the complexity of your job, it should answer questions regarding what data to collect and report," she says. "Many of the revised performance measures are already in place and will support and validate the work that is done by quality managers."
• Input from clinical staff for the selection of indicators to be measured now is required.
"We really want this to be part of the organization’s day-to-day activities, and we want the people involved in patient care to be involved in this," Gilhooley adds. "They are the ones who know where there could be risks."
Staff also can give valuable insights as to which indicators are not worth looking at, she notes. "It wouldn’t make sense to collect indicators for patient falls if you are a nursery — and we’ve actually had people do that. We don’t want you collecting information for the JCAHO that is useless. We want the data to be of value to the organization in improving safety and quality care."
The Joint Commission found that many organizations were collecting the same indicators throughout the whole organization. "This may not be appropriate, if the indicators are not relevant organizationwide. We want organizations to choose indicators that have a connection to the quality of care, in specific settings," Gilhooley explains. "The JCAHO doesn’t want people to be doing busy work."
At Baptist Health, input is solicited from staff through clinical practice committees based on service line, which include nurses and physicians. "Using the criteria of problem prone, high-volume, and high-risk, the committees make recommendations for indicator selection," Halvorsen notes. "We have had a lot of success obtaining input from our clinical staff."
Ultimately, the decision for indicator selection remains with senior leadership staff, who are very involved in indicator approval and in prioritization of performance improvement activities, she adds.
"Most likely, our indicators will change," says Halvorsen. "We will probably drop some of our previous indicators that have been stable over time, to study some of the new indicators that are in line with other national indicator projects."
At NorthEast, nurses are asked for feedback on indicators during staff meetings. "Staffing effectiveness graphs and data are posted on unit bulletin boards and in staff break rooms," says Holtz. "We also ask about staffing effectiveness in mock surveys."
Use comparison data gathered on various performance measures to provide a picture for clinical staff, so they can compare the quality of the care they provide to patients with other similar units or departments, Muller-Smith suggests.
"Most clinical staff are curious about how they measure up and are motivated to provide patients with the best care possible," she says.
Routinely report data during staff meetings, or post it in an area where staff can see the results of their efforts, Muller-Smith advises. "Looking at patient outcomes using comparison data can help the patient receive better care, without having to do investigation that has already been done."
• All nursing staff must be included in the HR indicators for all identified units.
The previous standard had asked organizations to include both direct and indirect caregivers, but it became clear that nursing was the area where staffing problems were identified most often, Gilhooley says. "When other disciplines were short, nursing seemed to pick up the slack in many instances," she adds. "So we have changed the standards to focus on nursing, but we are leaving the option for the organization to add other caregivers as they wish. We would certainly encourage that, of course."
More meaningful data
The new standard will make it easier to obtain meaningful analysis from the data collected, so appropriate change can be implemented, explains Halvorsen. "Hopefully, narrowing the focus of performance measurement will help organizations get to the heart of staffing effectiveness issues," she says.
The new standard will help target specific nursing units that need to improve their HR or clinical indicators, Holtz explains.
She adds that the organization’s nursing units already are aware of the NQF indicators and already collecting and reporting these to the PI committee on a quarterly basis. "This does make my job a little easier, but more meaningful work is the biggest benefit," she says.
The key is to determine whether the nursing units identified as having the lowest compliance with the chosen indicators have shown improvements after six months. "If so, we can then select another unit. If not, then we will continue to collect and measure data," she says.
Instead of focusing on the collection of data, surveyors want to see that you actually are making use of it to improve safety, Gilhooley emphasizes.
"We want to move the PI directors toward the analysis of the data, turning it into information that will improve the safety and quality of care," she says.
For instance, if you have two or three staffing-related indicators that vary at the same time, that should be a warning signal to drill down and determine the cause, says Gilhooley.
She points to an organization which saw an increase in patient falls during pilot testing of the new standard, but quality managers were perplexed as to the cause, since data showed that staffing numbers were not a problem.
"So we encouraged them to drill down further, and they found out that they had a high use of agency staff who had not been oriented properly to the falls risk assessment," she says. "To address this, they implemented a performance improvement process for orientation of their agency staff."
To address identified staffing issues, the Joint Commission suggests looking at whether staff have appropriate training for the patient population, service curtailment, increased technology support, adjustment of skill mix, additional ancillary or support staff, and reorganization of work flow.
"We want to make people understand that staffing is more than just numbers," Gilhooley says.
Staffing effectiveness is not just a numerical or competency exercise — it is effectively matching resources to patient needs, Muller-Smith underscores. "The challenge for organizations is to efficiently use available resources to provide quality care in a safe environment," she says.
Health care workers will continue to be in short supply, so other alternatives must be explored, Muller-Smith adds.
"The task for both clinical staff and quality managers is to work together to do things differently, use measures that will demonstrate the effectiveness of the changes they have made, and be able to compare themselves with other providers," she says.
[For more information on the JCAHO’s staffing effectiveness standards, contact:
• Missi Halvorsen, RN, BSN, Senior Consultant, JCAHO/Regulatory Accreditation, Baptist Health, 1325 San Marco Blvd. Suite 601, Jacksonville, FL 32207. Phone: (904) 202-4966. Fax: (904) 202-4920. E-mail: [email protected].
• Karen Holtz, MS, CPHQ, Education and Accreditation Department, NorthEast Medical Center, 920 Church St., Concord, NC 28025. Phone: (704) 783-1631. Fax: (704) 783-2080. E-mail: [email protected].
• Patti Muller-Smith, RN, EdD, CPHQ, Consultant, Administrative Consulting Services, P.O. Box 3368, Shawnee, OK 74802. Phone: (405) 878-0118. E-mail: [email protected].]
During a mock survey at NorthEast Medical Center in Concord, NC, a nurse was asked how she determined whether her unit had effective staffing, and replied, When I get to go to lunch.
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