Economic & general welfare report

Economic & general welfare report

Scholz, Jean A

JCAHO Survey Questions

Issue: What guidelines does the Joint Commission on Accreditation of Healthcare Organizations use to determine if a hospital has adequate staffing for patient care?

Answer: According to a 1998 publication developed by JCAHO, several questions will be asked during surveys to determine if the hospital is staffing for patient care. According to its guidelines, a variety of questions will be asked during interviews with nursing and hospital leadership. Questions during the assessment process may include:

How have the hospital’s senior leaders worked collaboratively to establish processes that define the qualifications, responsibilities, competencies, and staffing needed to carry out your organization’s mission?

How is staffing planned, and how are projected staffing needs tracked against the actual number of qualified staff provided?

What programs are in place to promote recruitment, retention, development and recognition of staff members, especially job-related educational programs?

How do you identify staff learning needs and prioritize educational efforts?

What aggregate data regarding staff competency patterns and trends are available on an ongoing basis for use to identify and influence staff learning needs?

How do you monitor and adjust staffing levels based on patient’s needs?

How do you address a request from a staff member not to participate in an aspect of patient care because of a conflict with the staff member’s cultural values, ethics, or religious beliefs?

How do you implement an effective, ongoing program to measure, assess, and improve the quality of nursing care delivered to patients?

How does your hospital provide adequate and appropriate staff coverage? How do you monitor staffing levels?

How do you promote recruitment, retention, development and recognition of staff members?

How does your hospital respond to department leaders’ recommendations relative to a sufficient number of qualified persons to meet patient needs?

What data, information, or indicators do you use to determine whether your hospital is adequately and appropriately staffed?

How do you determine nursing assignments?

Knowing that these questions will be asked will help you prepare for upcoming survey visits. All RNs working in hospitals are encouraged to assist in answering these questions to improve the delivery of care to patients in their hospital.

For more information about JCAHO and staffing, please refer to JCAHO’s book, Addressing Staffing Needs for Patient Care: Solutions for Hospital Leaders, or phone JCAHO’s customer services department.

Source: Written by Jean A Scholz, and reprinted from the May 1998 issue of the Ohio Nurses Review, the official publication of the Ohio Nurses Association.

Copyright Kansas State Nurses Association Apr 1999

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