Accreditation

From the AHAP Blog: Book Excerpt: Tracking required staffing effectiveness standards

Accreditation Insider, February 7, 2012

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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.

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