February 06, 2012 | | Comments 0
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Book Excerpt: Tracking required staffing effectiveness standards

The requirements of standard LD.04.04.05 EPs 1, 7, and 13 mandate that governance receives an annual report encompassing not only system and process failures, but also sentinel event information, degree of family involvement, and actions taken to improve safety as well as the adequacy of staffing. Although the former indicators are available to track, such as patient/family complaints and a number of falls, it is not necessary to track them specifically. However, incorporating staffing effectiveness information and analysis data already being collected in the organization makes a lot more sense than the previous requirements. For example, when you are assessing patient flow issues or evaluating a patient fall, you can determine whether staffing issues such as volume, workload, complement of staff members on duty, and  competencies play a role in the analysis.

In conjunction, staffing effectiveness EPs were added to PI.02.02.01. EPs 12 through 14 address patient safety leadership notification of issues related to the analysis of undesirable patterns or trends as well as the inclusion of this information in an annual report.

Tip for success: After the overwhelming experience of complying with this standard in the past, the advice to you is to keep it simple by considering your organization’s needs. You can compile one report incorporating all the features required in the EPs to involve leadership as well as your governing board. The adequacy of staffing notation can be a simple checkbox or column added to your postevent or trends assessments and your root cause analyses as you consider staffing levels and competencies affecting the identified failure. The column or checkbox cam simply state whether staffing effectiveness was an issue. Or you could take the EPs and build these questions into your root cause analysis worksheet and other postevent or trends assessments.  They key is to aggregate this data to determine whether or not any patterns or trends are developing.

Don’t forget to educate your leadership about the importance of understanding the renewed focus on staffing effectiveness as it relates to analysis of data and opportunities for improvement. There could easily be related questions asked by surveyors during the Leadership Interview at the time of an on-site survey.

Editor’s note: This post is an excerpt from The Joint Commission Survey Coordinator’s Handbook, 13th Edition by Jean S. Clark, RHIA, CSHA, and Jodi L. Eisenberg, MHA, CPHQ, CPMSM, CSHA.

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Jackie Zagami About the Author: Jaclyn Beck is the associate director of the Association for Healthcare Accreditation Professionals (AHAP) where she manages AHAP Accreditation Connection, the annual AHAP conference, and contributes to the monthly publication Briefings on The Joint Commission.

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