cient for the workload, and patient safety is endangered (Rozich and Resar, 2002). A similar approach has been used elsewhere (Knaus et al., 1986).

Minimize staff turnover and use of nursing staff from external agencies. As discussed in Chapter 3, high turnover of nursing staff and the use of temporary staff from external agencies threaten patient safety by decreasing the continuity of patient care and introducing personnel with less knowledge of nursing unit policies and practices. All of the above observations regarding the use of temporary external staff apply as well to situations of high staff turnover. Both reducing staff turnover and limiting use of registry personnel are priority strategies for achieving adequate staffing.

Continually assess staffing methodologies and their relationship to patient safety. HCOs should not assume that their staffing work is done once they have complied with state and federal staffing regulations, purchased a proprietary PCS, or successfully negotiated staffing standards with their labor partners. Ongoing research is producing better information about the relationship between staffing and patient outcomes, and the science of measuring workload and estimating staffing is still evolving. Moreover, the costs of implementing sophisticated staffing technologies for application across every nursing unit may be prohibitive for many HCOs, and the nurse workforce (as discussed in Chapter 3) is characterized by high rates of turnover. For these reasons, HCOs need to continually assess the effectiveness of their approach to staffing and its effect on patient safety. This precept is similar to that contained in JCAHO’s accreditation standards, which require hospitals to use data on clinical services in combination with personnel resource data to assess their own staffing effectiveness and identify and implement strategies for improvement (JCAHO, 2003). The JCAHO standards became effective for hospitals in July 2002 and are currently being tested in nonhospital programs (e.g., nursing facilities).

The committee believes that, in addition to evaluating the effect of staffing on certain clinical and human resource outcomes, HCOs need to frequently evaluate the overall process used for determining staffing levels. Doing so is important because studies of health care quality have well documented that the outcomes measured by a subset of clinical quality indicators cannot be generalized to health care quality overall (Brook et al., 1996). It is possible for an HCO to score highly on its chosen clinical indicators and still have staffing that contributes to poor outcomes as measured by other indicators.

In sum, the committee strongly believes that safe patient care requires frequent and ongoing review of staffing methods and patient care outcomes and efficient use of staff. Regardless of the approach used by hospitals (and nursing homes, for which there is no comparable literature describing the methods used to predict staffing needs), the committee recommends that all



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