How to Make Complaints to the Joint Commission (JCAHO) About RN Safe Staffing, When Short-Staffing Endangers Patients
The Joint Commission on the Accreditation of Healthcare Organizations (Joint Commission) has an Office of Quality Monitoring that will investigate complaints regarding "safety and quality of care issues, such as patient rights, care of patients, safety, staffing, infection control, medication use and security." Complaints can be made anonymously or the complaining party may identify him/herself in order to receive follow-up information. In the latter instance, the Commission will keep the identity of the complaining party confidential, but the hospital may need to be informed about the nature or details of the complaint as the Joint Commission reviews the situation. The Joint Commission states that its "policy forbids accredited or certified organizations from taking retaliatory actions against employees for having reported quality of care concerns to The Joint Commission." ANA does not have information about the effectiveness of this policy.
For full information about the Joint Commission's complaint process, visit its website. The Joint commission has a toll free complaint hot line, (800) 994-6610, 8:30 a.m. to 5 p.m., Central Time, weekdays.
The Joint Commission has established quality review criteria, which include as high priority complaints those that involve jeopardy to the safety of patients. Medium priority complaints can include a delay in treatment or a series of related lower level complaints. The complaint process will not address individual personnel or labor complaints.
There is no specific RN staffing standard established by the Joint Commission. However, the CMS condition of participation for the Medicare Program requires RN staffing as follows:
Standard: Staffing and delivery of care. The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.
42 C.F.R. 482.23(b).
The Joint Commission standards do include: "The hospital provides an adequate number and mix of staff consistent with the hospitals staffing plan." HR 1.10. The performance element states that "The hospital has an adequate number and mix of staff to meet the care, treatment and service needs of the patients." CAMH Update 1, March 2007, at HR-3.
Accordingly, the typical RN staffing complaint would be likely to include language such as: "The hospital failed to meet the Medicare conditions of employment and the Joint Commission Standards HR1.10 by not having a sufficient number of RNs on duty and available to meet the care, treatment and service needs of the patients, thereby jeopardizing patient safety. Specifically, [details about the staffing deficiency]."
Resources
- The Joint Commission: Quality Incident Review Criteria
- The Joint Commission: How to Report a Complaint