Hospitals must use indicators in clinical/services and human resources to assess their staffing effectiveness under JCAHO standards
The Joint Commission on Accreditation of Healthcare Organizations is launching a new approach to help hospitals and other health facilities determine staffing effectiveness.
Instead of using staffing ratios as the standard for evaluating effectiveness, JCAHO wants organizations to probe deeper to see whether staffing deficiencies can be uncovered and fixed by analyzing data on a combination of clinical and human resource indicators, such as high medication-error rates and employee turnover.
Under the new JCAHO rule, hospitals will have to begin collecting the data in July. Other organizations, such as long-term care and assisted-living facilities, will have to follow suit in January 2003.
For hospitals, JCAHO has published a list of 11 clinical indicators and nine human resource indicators (see "Approved JCAHO screening indicators for hospitals"). On the clinical/service side, these include drug errors, patient falls, and postoperative infection rates. Human resource indicators include staff injuries, sick time, and vacancy rates. Healthcare organizations have to use at least two clinical and two human resource indicators, but the commission said organizations may select their own indicators, as long as they select at least one from each of the two lists.
Lucille Skuteris, associate director of the standards interpretation group at JCAHO, said organizations' original reaction to the new standards was that if they showed "a high fall rate or a high med-error rate," JCAHO would "give them a Type 1 [recommendation]," meaning something about their performance didn't meet commission standards. "We've tried to stress that this is really just to be used as a management tool. It's a performance improvement initiative," she said.
JCAHO wants organizations to use indicators that are more likely to uncover weaknesses than reaffirm strengths. Skuteris said, "Let's say you have a very self-contained critical care unit that's so high-tech you have a Pharm.D. working up in that area helping with meds, mixtures, whatever.... The med-error rate may be so low that why would you bother looking at HR data along with med-error rate data to assess your staffing? There has got to be a bigger fish out there for you to look at."
The new approach was pilot-tested in 43 hospitals around the country. "Organizations recognized that they're already collecting the data," she said. "The change for them is taking the data and looking at them in combinationHR with clinical. They felt that the value of the new standard really outweighs the burden that's being placed on them, particularly if they use it effectively."
Pharmacy representatives tended to support the new JCAHO approach in concept but wondered how it would work out as a practical matter.
"Conceptually, I'm in support of that because I think there is no doubt health care is getting more complex," said Marianne Ivey, Pharm.D., M.P.H., corporate director of pharmacy services for the Health Alliance, a network of six hospitals in the greater Cincinnati area. "Sometimes it's in the execution that you get bogged down."
One possible problem with the use of medication-error rates as a clinical indicator is that errors tend to be underreported because of a fear of disciplinary action. "There are effective ways to measure medication safety and establish error rates and implement improvement initiatives based on trend data gathered in an institution," said Kasey Thompson, director of the Center on Patient Safety at ASHP. But he added, "We don't do it very well. There's a knowledge void out there on how to do it effectively, so we have some work to do."
For pharmacy and nursing there is also the problem of shortages, which are not likely to go away soon, no matter how health organizations try to improve staffing effectiveness. "Shortages are a very real thing," said Thomson. "There are some institutions out there that could probably provide better environments for pharmacists and nurses to work in. But, by and large, we have a pretty significant shortage right now that is providing a very real challenge to everybody out there."
William Gouveia, director of pharmacy at the New England Medical Center in Boston, hadn't yet studied the specific new standards, but said, "I think the whole area of staffing standards in pharmacy is something we really need to work hard at, to think through pretty carefully." He added: "We've worked hard at trying to resolve issues related to the shortage, mostly salary and quality of workplace issues. If you address those issues forthrightly, then the problems are minimized. But you have to deal with both of those."
Gouveia believes using clinical outcome measures to assess staffing effectiveness "is a good idea. But unless you've studied carefully, with a well-controlled study, the relationship of A to B, you can't say B is a result of A."
Nursing care hours per patient day
On call or per-diem use
Staff turnover rate
Staff vacancy rate
Understaffing compared with staffing plan
Injuries to patients
Length of stay
Upper GI bleeding
Urinary tract infections
Bruce Buckley. JCAHO to zero in on staffing effectiveness as of July. Drug Topics 2002;12:HSE1.