July / September 2004
Case Study #2
Easing the Burden of Accreditation and Compliance Requirements
When the Joint Commission coordinator for a 300-bed community hospital in the South heard about JCAHO’s new staffing effectiveness standards, she knew that compliance would be hard work, requiring data collection across the organization. It was ironic that meeting JCAHO’s survey requirements for staffing would require additional staffing — at least a .5 FTE.
The JCAHO coordinator began her search for options. Because she had used Web-based tools to collect data and create reports for a Veterans Hospital Association (VHA) clinical affairs project, she requested a demonstration of a Web-based tool for staffing effectiveness. After viewing an online demonstration, the JCAHO coordinator concluded that the tool would meet her organization’s needs for the staffing effectiveness portion of JCAHO survey and would be more cost-effective than dedicating a full- or part-time staff member or hiring a consultant.
With only about six weeks to go before the JCAHO survey, the coordinator needed to implement the system immediately. Within hours of licensing the tool, she received access to the Web-based tool through a secure log-in and password. With direction from the vendor’s support team, within days she had assigned data collection for all of her organization’s chosen staffing effectiveness indicators — both hospital-wide and at department levels — throughout her organization. Soon, human resources, quality, and nursing department managers throughout the organization began completing their assigned data collection tasks by logging on to the tool and entering their data elements.
When the JCAHO survey arrived in November 2002, well past the July 1 deadline for implementation of the new staffing effectiveness standards, the hospital was prepared. Using the tool in conjunction with their staffing effectiveness committee, the hospital had successfully chosen, collected data for, and identified PI opportunities from trended and correlated HR and clinical/service indicators representing all of their patient populations. “The surveyors were impressed… The Web-based tool helped explain staffing effectiveness data from a PI perspective. We were able to identify hospital-wide trends and then drill down by department to pinpoint outliers,” the JCAHO coordinator said.
Since meeting their JCAHO survey requirements, the hospital has taken its staffing effectiveness efforts to the next level, aided by the tool’s easy-to-use real-time graphing and reporting. It has also begun using the tool for executive decision-support. The JCAHO coordinator reports, “We were able to quantify the risk of not having additional staffing to the administration of the hospital. Doing this in the past had not really been possible on a quantitative basis.”