1. Mooney, Mary Carol RN, MSN


Get the latest information on the Joint Commission's staffing effectiveness standards.


The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) staffing-effectiveness standards apply to hospital inpatient units, long-term care, and assisted living facilities. Long-term care and assisted living staffing effectiveness standards became effective January 2004, while the hospital manual staffing effectiveness standard took effect in July 2002.


Q Should my organization collect indicators for all inpatients?


A Yes, and the indicators should be relevant to the patients served. If your organization wishes to collect one set of clinical indicators for all patients, select an indicator pertinent to all inpatients, such as medication errors and patient satisfaction.


Q At what frequency must my organization collect data for the clinical/service and human resource indicators?


A Your organization determines the detail and frequency of data collection. Keep in mind:


[white diamond suit] Annual data analysis limits timely and effective evaluation of staffing and restricts the ability to take the necessary action.


[white diamond suit] Shorter time periods are more practical for evaluating staffing effectiveness.



Q How should we collect and analyze indicator data?


A Collect indicator data at the level(s) your organization deems most appropriate (for example, at the unit, department, or multiple unit level). Analyze indicator data individually and in combination with each other. If you select organization-wide indicators, you'll need the ability to "drill down" to specific areas where staffing is planned. Analysis of indicator data at high levels, such as at the health care system level rather than the unit level, may be of little value because it dilutes specific staffing effectiveness issues.


Q How and when should we collect data on indirect caregivers?


A First, determine which indirect caregivers impact patient care. Absence of an indirect caregiver may transfer responsibility to direct caregivers. Next, identify human resource indicators sensitive to these indirect caregivers. These indicators may differ from those identified for the direct caregivers. Collect indicator data during the same time period for both direct and indirect caregivers.


Q What's the track record policy for introduction of this new standard?


A JCAHO expects compliance with the new standard from the implementation date. For example, during a survey conducted one month after implementation (February 2004), surveyors will look for a one-month track record. Generally, JCAHO requires a 12-month track record to assess a standard.


Q Does JCAHO require a specific definition for each indicator?


A Yes. Each organization must establish clear definitions for each selected indicator. These definitions should include:


[white diamond suit] a numerator[white diamond suit] a denominator[white diamond suit] instructions for data collection and indicator calculations.



Medication errors and patient satisfaction are examples of relevant indicators appropriate for all patients.