ceptable levels of risks for untoward events. These standards could be phased in over time such that a greater level of risk would be tolerated in the first year, requiring somewhat lower minimum standards, with decreasing tolerance for errors and hence increasing minimum staffing levels in subsequent years. Any such strategy should be accompanied by an evaluation of the number of facilities affected, the staffing changes that occur in these facilities, and the changes in the rates of untoward events.

At the same time, a number of nursing organizations, policy experts, and HCOs point out the limitations of staffing ratios. While they may help ensure a baseline level of staffing in HCOs that may be outliers, they are poor instruments for achieving optimal staffing. Depending on the skill mix and expertise of nursing staff and patient acuity (defined below), minimum ratios may still not provide the needed levels of safety. Moreover, counts of patients needed to calculate nurse staffing levels consistent with a ratio must be taken at a point or points in time. Yet patient admissions, transfers, and discharges are frequent; therefore, an adequate nurse-to-patient ratio at 7 A.M. may be inadequate at 10 A.M., and an organization that has satisfied a nurse-to-staffing ratio at one point in time may still have inadequate staffing at another point. Thus, while staffing ratios can help protect against the most egregious staffing deficiencies, HCOs will need to employ more sensitive approaches internally to fine-tune staffing levels.

More-Effective Internal Staffing Practices by HCOs

Problems in the application of widely used tools to predict hospital staffing Many hospitals determine the amount of nursing staff they need to provide care on individual patient care units and shifts through the use of staffing tools collectively referred to as patient classification systems (PCSs). PCSs are quantitative formulas that measure patient acuity, translate this measure into projections of actions that need to be performed and the time it will take to perform them (nurse workload), and use those projections to estimate nurse staffing needs. Acuity in PCSs refers to the amount of nursing time required to care for an individual patient given that patient’s care needs (which may or may not correspond to the severity of the person’s medical illness) (Norrish and Rundall, 2001).

In PCSs, the nursing care requirements of individual patients are summed to estimate the total patient care needs for a particular nursing unit. Staffing projections are then based on predetermined time standards for each type of patient or patient-care task. These time standards are intended to be either derived empirically and uniquely for each institution based on work sampling measures, or adopted from standards inherent in a particular PCS.

During the 1980s, the emphasis on PCSs increased as a result of Joint



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