Measure Information Form

Measure Set: Health Care Staffing Services (HCSS)

Set Measure ID: HCSS-7

Performance Measure Name: Completeness of Personnel File - Travel

Description: This measure captures the proportion of travel clinical placements with a personnel file meeting the requirements for job appropriate credentials, competency and background check.

The HCSS-7 measure is reported as a percentage which includes travel clinical placements only. Firms may provide per diem staffing assignments only, travel staffing assignments only, or both per diem and travel staffing assignments. Data are reported monthly. NOTE: This measure is NOT reported by healthcare staffing firms with no travel clinical staff.

Data are reported based on the size of the firm as determined by the total number of clinical placements identified for each site requesting certification in the certification application. The size of the firm is defined as the total number of clinical placements (i.e., employees) placed in a 12 month period by each site listed in the application, including allied health professionals, nursing professionals, and licensed independent practitioners (LIPs); excludes independent contractors, if the firm requested in its application that these individuals should not be included in the scope of the certification review.

The Joint Commission Connect® e-app should be used as a reference to select the appropriate size category for reporting. Only one category may be selected for each review cycle.

GROUP 1 < 40 clinical placements
GROUP 2 40 to 99 clinical placements
GROUP 3 100 to 349 clinical placements
GROUP 4 >= 350 clinical placements

Rationale: The current health care staffing shortage has created considerable competition for qualified nurses and other clinical professionals. Many hospital executives regard today's shortages of qualified personnel as one of their chief concerns. Due to the urgency in meeting staffing needs, HCSS firms may often streamline the application process by taking application information by phone and accepting verbal references.

One of the nine principles identified by the American Nurses Association (ANA) Board of Directors for nurse staffing indicates: “All institutions should have documented competencies for nursing staff, including agency or supplemental and traveling RN's, for those activities that they have been authorized to perform.” The Joint Commission's 2007 Comprehensive Hospital Accreditation Manual states in standard HR.1.20: “Staff qualifications are consistent with his or her job responsibilities.” Additionally, standard LD.3.50 states: “Services provided by consultation, contractual arrangements, or other agreements are provided safely and effectively.”

Reputable staffing services understand that a part of the service they provide is to supply documentation on their staff. Sound quality assurance guarantees that staff supplied by health care staffing services meets government and accrediting body standards. Specific regulations may differ from state to state; however, some basic requirements for health care staffing employees generally apply. Health care staffing firms that provide patient care staff must therefore be able to demonstrate due diligence in assuring their staff's competence and ability to practice safely and legally.

Type Of Measure: Structure

Improvement Noted As: Increase in the rate

Risk Adjustment: N/A.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and, if applicable, medical record documents. Concurrent and retrospective data sources for required data elements include administrative (electronic) databases or hard copy (paper)records and files.

Data Accuracy: Variation may exist in electronic software tools used by healthcare staffing firms; therefore, specific data fields used to abstract personnel files may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. For additional information please refer to the sampling methodology.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Setting: Health Care Staffing Services

Report Period: Quarterly with monthly data points

Selected References:

• The Joint Commission. Health Care Staffing Services Certification Manual: Human Resources Management (HSHR) Chapter. Oakbrook Terrace, IL: Author. July 2021.
• American Nurses Association. ANA Applauds Nurse Staffing Bill Introduced In U.S. House of Representatives. Retrieved June 29, 2007 from the World Wide Web: http://www.nursingworld.org/pressrel/2003/pr1209.htm.
• American Nurses Association. Safe Staffing Bill Introduced in the Senate: Much more than a numeric ratio. The American Journal of Nursing, 2003;103(7). Retrieved June 29, 2007 from the World Wide Web: http://www.nursingworld.org/ajn/2003/july/wawatch.htm.
• American Nurses Association. Principles for Nurse Staffing,1999. Retrieved January 14, 2005 from the World Wide Web: http://www.nursingworld.org/readroom/stffprnc.htm.
• American Nurses Association. Safe Staffing Bill Introduced in the Senate: Much more than a numeric ratio. The American Journal of Nursing, 2003;103(7). Retrieved June 29, 2007 from the World Wide Web: http://www.nursingworld.org/ajn/2003/july/wawatch.htm.
• Contract Staff and Patient Safety. Oakbrook Terrace, IL; Joint Commission Resources, 2005.
• Shoemaker, P, Schuhmann TM. Trends in Hospitals' Use of Contract Labor. Healthcare Financial Management, April 2007.
• Shoemaker, P, Howell, DH. Trends in the Use of Contract Labor among Hospitals, 2004, American Hospital Directory, Inc. Retrieved January 14, 2005 from World Wide Web:

http://www.google.com/search?hl=en&q=Trends+in+the+Use+of+Contract+Labor+among+Hospitals&spell=1.

• Stiehl, RR. Quality Assurance Requirements for Contract/Agency Nurses. JONA's Healthcare Law, Ethics, and Regulation, 2004;6(3): 69-74.
• Taylor, LE. Life as a Traveling Nurse. AJN, 1998;98(7): 62-63.