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JCAHO to Formally Assess Hospital Staffing Adequacy

Kate Traynor

Starting next July, surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will assess whether hospitals maintain adequate numbers of staff members to effectively care for patients. 

New "staffing effectiveness" standards were approved during a JCAHO board meeting in July. The standards will appear in three chapters—management of human resources, improving organizational performance, and leadership—in the next edition of JCAHO’s Comprehensive Accreditation Manual for Hospitals.

An assessment of staffing effectiveness will be made on the basis of at least four indicators classified by JCAHO as "human resources" or "clinical/service" issues. Hospitals must choose at least one indicator on JCAHO’s nine-item human resources list and one on the 12-item clinical/service list. At least one additional human resources and one clinical/service indicator can be defined by the hospital but need not appear on JCAHO’s lists.

Human resources indicators identified by JCAHO include staff turnover rate, staff vacancy rate, and the use of overtime. Adverse drug events, patient falls, and postoperative infections are among the clinical/service indicators defined by JCAHO.

Hospitals that evaluate staffing effectiveness with indicators not on JCAHO’s lists must be able to justify the choice of those indicators to the accrediting organization.

JCAHO expects hospitals to gather and analyze data related to the chosen indicators and use the analysis to detect staffing problems. When a problem is identified, the hospital is expected to take action to remedy the situation.

Instead of using its full 5-point scale to assess compliance with the new standards, JCAHO will consider capping the standards at a 3 through 2002. This adjustment period, said JCAHO, would give hospitals time to become familiar with the new approach for documenting staffing effectiveness.

The new standard is available at

 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is removing "Type 1 Recommendations" from two categories of survey decisions. Starting January 1, the top two categories will be called "Accreditation with Full Standards Compliance" and "Accreditation with Requirements for Improvement." Also, a summary grid score of <79, not <75, will result in the decision "Conditional Accreditation."