All the Psychiatric Hospital and Community Behavioral Health & Human Resources program accreditors and regulators require the investigation of patient/client safety events. If there is an incident, staff effectiveness is one element that is crucial to assess. This not only includes the number of staff but also their skill mix and competency. In addition, staff turnover, vacancy, overtime, absentee rates, and the use of temporary staff, as well as the services provided and the patient/client population’s acuity are factors to examine. After the evaluation, the findings and trends must be communicated to leadership responsible for the organization’s patient/client safety program. This enables leaders to identify and mitigate similar factors in other areas of the organization. Leaders should review an annual report on staffing adequacy and actions taken to address contributing factors to patient/client safety incidents.

Although specific standards may differ, there are clear common themes across TJC, DNV, CHIQ, ACHC, CARF and COA, based on leading industry practices related to staffing effectiveness and patient/client safety incidents.  

Quality/Performance Improvement Data Analysis

All accreditors and regulators agree that healthcare organizations must compile and analyze data. When undesirable patterns, trends, or variations related to the safety or quality of care are identified, leading practices dictate that organizations take specific steps. This includes an analysis of staffing adequacy, considering the number, skill mix, and competency of staff. In addition, workflow processes, competency assessments, credentialing, staff supervision, and training are other details to review. 

Some common issues found on survey have included failing to consider staffing adequacy in patient/client safety incident reviews, not analyzing whether staffing impacted the increased use of restraints and seclusion, increased hospital-acquired infection, patient/client falls, and missed medication doses. 

Staffing Effectiveness Measures

Staffing effectiveness measures are metrics used to evaluate the adequacy and impact of staffing levels on patient/client care and organizational performance. These measures help ensure that the right number of staff with the appropriate skills are available to provide safe and effective care. Here are some common staffing effectiveness measures

Quantitative Measures:

1. Staffing Ratios:
   • Nurse-to-patient/client ratio
   • Staff-to-patient/client ratio in other departments (e.g., physical therapy, dietary)
2. Hours per Patient/client Day (HPPD):
   • Total nursing hours divided by the number of patient/client days.
3. Overtime Hours:
   • The number of overtime hours worked by staff.
4. Staff Turnover Rate:
   • The rate at which staff leave and are replaced within a specific period.
5. Vacancy Rate:
   • The percentage of unfilled positions.
6. Absenteeism Rate:
   • The rate of staff absences.
7. Use of Temporary or Agency Staff:
   • The proportion of temporary staff compared to permanent staff.

Qualitative Measures:

1. Skill Mix:
   • The proportion of registered nurses (RNs), licensed practical nurses (LPNs), and unlicensed assistive personnel (UAPs).
2. Staff Competency:
   • Assessment of staff skills and competencies through evaluations and continuing education.

Outcome Measures:

1. Patient/client Outcomes:
   • Patient/client fall rates
   • Medication error rates
   • Use of restraint and seclusion rates
   • Patient/client elopement rates
2. Patient/client Satisfaction:
   • Scores from patient/client satisfaction surveys.
3. Staff Satisfaction:
   • Scores from staff satisfaction or engagement surveys.
4. Adverse Events:
   • The frequency and severity of adverse events, such as sentinel events or near misses.

Operational Measures:

1. Response Time:
   • Time taken to respond to patient/client/cient needs or call lights.
2. Patient/client Throughput:
   • Efficiency in patient/client admissions, transfers, and discharges.
3. Quality of Care Metrics:
   • Compliance with care standards and protocols.

Financial Measures:

1. Cost per Patient/client Day:
   • Total staffing costs divided by the number of patient/client days.
2. Return on Investment (ROI):
   • Financial return from investments in staffing initiatives (e.g., additional training, hiring more staff).

Taking Action

When analysis shows a problem with staffing adequacy, leading practices require that leaders responsible for the organization’s patient/client safety program are informed of the analysis results and actions taken to resolve the issue. Some common issues found on accreditation and regulatory surveys have included: 

• No evidence that leadership had been informed about inadequate staffing contributing to a patient/client safety incident.
• When leadership was informed, there was no evidence of actions taken to resolve the issue.
• When trends and patterns occur, the organization has not taken action to reduce the patient/client safety incidents for the population served

Annual Reporting

Leaders responsible for the organization’s patient/client safety program must review a written report annually on the staffing adequacy analyses and actions taken to resolve identified problems. The report should include findings related to the staffing adequacy issues identified and the actions taken to address individual problems and to improve the overall staffing effectiveness of the population served.  The Annual Report is included in the written report to the governing body on system/process failures, sentinel events, patient/client/family notifications, and actions taken to resolve identified problems.  

Helpful Resources

• National Quality Forum Nursing Sensitive Measures: System Centered Measures
  • Skill mix (Registered Nurse [RN], Licensed Vocational/Practical Nurse [LVN/LPN], unlicensed assistive personnel [UAP], and contract) 
  • Nursing care hours per patient/client day (RN, LPN, and UAP)
  • Practice Environment Scale—Nursing Work Index (composite and five subscales) 
  • Voluntary turnover
• American Nurses Association (ANA)
• Agency for Healthcare Research and Quality (AHRQ
• Institute for Healthcare Improvement IIHI)
• National Database of Nursing Quality Indicators (NDNQI)

Barrins Healthcare Consulting

Barrins stays up to date with current accreditor and regulatory requirements and leading industry practices.  By conducting mock surveys, we enable your organization to remain in continuous compliance with accreditation and regulatory requirements and up-to-date leading practices. Contact us today to schedule a 2024 Mock Survey.

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