Hospital administrators and clinicians who don't know how staffing affects patient outcomes in their organizations have less than three months to figure it out. This summer, amid the specter of worsening nurse shortages, new but largely untested staffing standards are set to take effect.
For many hospitals, the staffing-effectiveness standards promulgated by the Joint Commission on Accreditation of Healthcare Organizations represent actions they're already taking: collecting data on patient falls, pneumonia infection rates and the amount of overtime nurses work. But as of July 1, hospitals will have to demonstrate to the JCAHO that they not only collect such data but also use it to assess and adjust staffing for optimal patient care.
The new standards, which the JCAHO first proposed in March 2001, require acute-care hospitals to select two clinical indicators and two human resource indicators-from 21 total choices-that demonstrate how well staffing is calibrated to achieve patient and employee satisfaction (See chart, p. 32). Most important, according to the JCAHO, the new standards are tied to patient outcomes rather than to hard-and-fast staffing rules that would be difficult to standardize and would emphasize the wrong side of the staffing equation.
"The focus needs to be on the outcome in order to understand the staffing, not on the staffing to produce an outcome," says Russell Massaro, M.D., the JCAHO's executive vice president of accreditation operations. Previously, Massaro says, "our process required organizations to have a staffing plan and then stick to it. But we never had tied that staffing plan to any particular outcome. You could have had a lousy staffing plan but if you followed it, you would have been in compliance."
The JCAHO's standards come on the heels of state government efforts to take on healthcare staffing independently. California in 1999 enacted the nation's first nurse-to-patient-ratio law, mandating certain staffing levels in hospital units (See Web survey results, p. 35). Meanwhile, several other states including Florida, Massachusetts and Rhode Island are considering similar legislation. California officials are still drafting regulations as hospitals wonder how the JCAHO's new standards will mesh with the forthcoming ratio requirements.
As hospitals in California and elsewhere prepare their organizations for the new standards, most see them as part of data-collection efforts that many organizations already have started. One potential pitfall, however, is the degree to which hospitals are prepared to turn reams of data into meaningful information that can be used to determine appropriate staffing levels. Though some organizations have advanced clinical-decision support systems in place, others track staffing with Microsoft Excel spreadsheets or pencil and paper.
Hospital officials also express concern about whether it's even possible to link clinical outcomes to a specific staffing indicator, especially when so many factors contribute to the outcome of each unique patient in each unique hospital. The JCAHO's intentions are good, providers say, but the possibility that staffing can be directly linked to outcomes is questionable.
The JCAHO "put these new standards together with the hope and expectation that they may work," says William Thomas, M.D., executive vice president of medical affairs at seven-hospital MedStar Health, based in Columbia, Md. "There is no evidence of that. We can't conclude there's a relationship between staffing and outcomes; no one has been able to prove that in the past."
Thomas and others say it's still a valuable exercise to determine if such a relationship exists. For MedStar, complying with the standards involves a "marginal increase in the amount of data that needs to be collected and analyzed," Thomas says.
Having intentionally constructed the new staffing guidelines to be adaptable to any organization, regardless of patient mix and other factors, the JCAHO believes hospitals are already positioned to comply-and with minimal new expense. Although the healthcare systems contacted by Modern Healthcare say they are indeed ready, most agreed that only when hospitals are surveyed by the JCAHO will it become clear if their data analysis capabilities are up to par.
"If hospitals are not already participating in some type of staffing project, then (compliance with the new JCAHO standards) is going to entail some more costs," says Dorel Harms, vice president of professional services at the California Healthcare Association, the state's hospital group. "If you have a lot computerized, the costs will be less than if you don't have that infrastructure."
Complying with the new standards will require two steps: collecting and aggregating data on selected indicators, and then using that information to see where staffing needs to be adjusted to improve patient care. The first step, experts say, is the easy part. But the data analysis and follow-up could be another story.
According to the JCAHO's written guidance to hospitals, surveys after July 1 will seek "evidence of action taken, as appropriate, in response to analyzed data."
Patient falls is an example of an indicator that hospitals might select for tracking and analysis. If that analysis uncovers problems relative to staffing, the hospital is required under the JCAHO's new standards to report such problems to the organization's leaders and to take corrective action.
Those familiar with information processing say the analysis requirement could be difficult for many organizations where data manipulation tools are archaic or nonexistent.
"I think that if hospitals sit down and actually implement this, they're going to have a tough time figuring out how to get data in a form that's useful for them to assess effectiveness," says Dean Souleles, chief technology officer of QuadraMed Corp., a San Rafael, Calif.-based healthcare information system vendor. "It's not so much the collection of the data but what do you do after that?"
The JCAHO's answer to that question is that there is no standard answer. "We don't specify what an analysis should find," Massaro says. "We specify that you should have an analysis. That process, if done properly and thoroughly, will speak for itself."
In preparing to roll out its standards, the JCAHO conducted pilot tests at 43 hospitals around the country last spring. According to officials, 79% of those pilot sites said they believe the standards add value to the accreditation process. Some 84% believed the standards would benefit their hospital in other ways, such as better communication. On the cost front, 80% anticipated an increase, but 58% of those hospitals said such an increase would be justified by the resulting staff improvements.
JCAHO officials declined to disclose the names of any pilot sites. By the end of the year the accrediting group will include the new staffing-effectiveness standards in about 800 hospital surveys.
"I don't believe there will be a need for any new dramatic resources to do the analysis," Massaro says. "I absolutely feel hospitals have in place what they need. If they don't have the systems we're talking about for this analysis, they don't have the systems they need to run their hospital."
Hospital and health officials agreed the new standards represent data collection and analyses efforts that are already a part of many organizations' independent performance-improvement initiatives. In that sense, the JCAHO's new standards formalize such activities but don't necessarily represent much that's new.
Two sets of standards
Hospitals in Florida have been monitoring many of the JCAHO indicators for some time but perhaps not as specified by the new standards, says Susan White, vice president of quality management at the Florida Hospital Association. Similarly, 100 of California's 470 hospitals now participate in the California Nursing Outcomes Coalition, a group that is attempting to improve outcomes by analyzing indicators, including those on the JCAHO list.
"California is kind of ahead of the curve," Harms says. California is also in an unparalleled position when it comes to staffing-it is the only state in the nation to have passed a mandatory nurse-to-patient-ratio law, for which preliminary regulations are scheduled to be released this spring.
Under California's novel but controversial law, nurses in medical-surgical units are allowed to care for no more than six patients at a time, with other proposed ratios mandated for various units.
When the JCAHO adopted its new staffing standards, it considered ratios as a way to improve staffing but opted for a different approach. "Fixed ratios were not the solution long term," Massaro says. "They could in some cases exacerbate the situation. If you simply adhere to ratios fixed in regulation you may be at some times understaffed and at other times overstaffed."
For California hospitals, the greatest challenge under the JCAHO's new standards may be reconciling them with the state's ratio law. "We're going to be a little hampered because we're going to have to adhere to the (JCAHO) staffing standards and the ratios on the other side," Harms says.
Part of the rationale for ratios, proponents in California and elsewhere argue, is improving working conditions so that more nurses are attracted to and stay in the profession. The JCAHO's standards, Massaro contends, could have a similar effect at a time when nurse shortages are reported to be on the rise.
If nurses are given "sufficient autonomy commensurate with responsibility" and work in a satisfying environment, "attrition goes down, and the relative shortage begins to abate, even in the absence of supply," Massaro says.
To build a truly effective staffing model takes more than slicing and dicing data, say nurses and others contacted for this story.
"Staffing calculators and models are absolutely imperative to make sure we can validate and justify the cost of patient care," says Debbi Honey, vice president of clinical operations at Denver-based Catholic Health Initiatives, a 63-hospital system. However, she says, nurses' judgment, as well as other difficult-to-measure factors such as the spiritual and psychosocial needs of the patient, are not reflected in number-crunching exercises.
In January CHI embarked on an effort to develop a central data repository its hospitals can use to enter and view data on quality indicators. Most CHI facilities have collected such data for some time, Honey says, but aggregating that data across the health system is a new initiative.
Even if they monitor only those indicators recommended by the JCAHO, hospitals will face varying degrees of difficulty implementing the staffing-effectiveness standards, sources say. In addition to their divergent information systems capabilities, hospitals will work to comply with almost experimental standards that have been minimally tested in real care settings.
"We are at the very beginning phase of trying to understand how the particular indicators will reflect on staffing and staffing effectiveness," says White of the Florida Hospital Association. "I don't believe the research is clear on how the particular indicators proposed for selection will actually correlate with staffing effectiveness."