Health Care Staffing Services Measures (v2025A)
Posted: 09/13/2024

Release Notes:
Measure Information Form
Version 2025A

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

Numerator Statement: HCSS-7 Travel clinical placements with a personnel file meeting all required components of a complete personnel file:
  • Job Appropriate Credentials
  • Evidence of Current Competency
  • Background Check

HCSS-7a Firms in Group 1: Travel clinical placements with a personnel file meeting all required components.

HCSS-7b Firms in Group 2: Travel clinical placements with a personnel file meeting all required components.

HCSS-7c Firms in Group 3: Travel clinical placements with a personnel file meeting all required components.

HCSS-7d Firms in Group 4: Travel clinical placements with a personnel file meeting all required components.
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Travel clinical placements for the reporting month.
Included Populations:
  • Travel assignments, AND
  • Clinical placements, AND
  • Placements in a Service Setting

Excluded Populations:
  • International placements
  • Non-clinical placements
  • Per diem staff assignments

Data Elements:

Risk Adjustment: Yes.

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.

Measure Algorithm:
Graphic depiction of the Measure Algorithm. Refer to the Algorithm Narrative for each detailed step. Graphic depiction of the Measure Algorithm. Refer to the Algorithm Narrative for each detailed step.

HCSS-7: Completeness of Personnel File - Travel Algorithm Narrative

Numerator: Travel clinical placements with a personnel file meeting all required components of a complete personnel file.
  • Job Appropriate Credentials
  • Evidence of Current Competency
  • Background Check
Denominator: Travel clinical placements for the reporting month.

Stratification table:
If Measure ID is HCSS-7a and Number of Clinical Placements less than 40, then Firm Group equals 1.

If Measure ID is HCSS-7b and Number of Clinical Placements is greater than or equal to 40 and less than or equal to 99 then Firm Group equals 2.

If Measure ID is HCSS-7c and Number of Clinical Placements is greater than or equal to 100 and less than or equal to 349 then Firm Group equals 3.

If Measure ID is HCSS-7d and Number of Clinical Placements is greater than or equal to 350 then Firm Group equals 4.

1. Start processing. Review each assignment completed by the last calendar day of reporting month.

2. Check Assignment Type.
  1. If Assignment Type is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Proceed to Step 8.
  2. If Assignment Type equals 1 or 3, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Proceed to Step 8.
  3. If Assignment Type equals 2, continue processing and proceed to check Placement Type.

3. Check Placement Type.
  1. If Placement Type is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Proceed to Step 8.
  2. If Placement Type equals 2, 3 or 4, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Proceed to Step 8.
  3. If Placement Type equals 1, continue processing and proceed to check Service Setting.

4. Check Service Setting.
  1. If Service Setting is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Proceed to Step 8.
  2. If Service Setting equals No, the case will proceed to a Measure Category Assignment of B and will not be in the Measure Population. Proceed to Step 8.
  3. If Service Setting equals Yes, continue processing and proceed to check Background Check.

5. Check Background Check.
  1. If Background Check is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Proceed to Step 8.
  2. If Background Check equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Proceed to Step 8.
  3. If Background Check equals Yes, continue processing and proceed to check Competency.

6. Check Competency.
  1. If Competency is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Proceed to Step 8.
  2. If Competency equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Proceed to Step 8.
  3. If Competency equals Yes, continue processing and proceed to check Job Appropriate Credentials.

7. Check Job Appropriate Credentials.
  1. If Job Appropriate Credentials is missing, the case will proceed to a Measure Category Assignment of X and will be rejected. Proceed to Step 8.
  2. If Job Appropriate Credentials equals No, the case will proceed to a Measure Category Assignment of D and will be in the Measure Population. Proceed to Step 8.
  3. If Job Appropriate Credentials equals Yes, the case will proceed to a Measure Category Assignment of E and will be in the numerator population. Proceed to Step 8.

8. Initialize the Measure Category Assignment for each strata measure (a, b, c and d) equal 'B'. Proceed to Step 9 to assign the Overall Rate Category Assignment to the appropriate strata.

9. Check Firm Group.
  1. If Firm Group equals 1, set Measure Category Assignment for strata measure HCSS-7a equal Measure Category Assignment for measure HCSS-7. Stop processing.
  2. If Firm Group equals 2, 3 or 4, continue processing and proceed to Step 10 to check Firm Group.

10. Check Firm Group.
  1. If Firm Group equals 2, set Measure Category Assignment for strata measure HCSS-7b equal Measure Category Assignment for measure HCSS-7. Stop processing.
  2. If Firm Group equals 3 or 4, continue processing and proceed to Step 11 to check Firm Group.

11. Check Firm Group.
  1. If Firm Group equals 3, set Measure Category Assignment for strata measure HCSS-7c equal Measure Category Assignment for measure HCSS-7. Stop processing.
  2. If Firm Group equals 4, set Measure Category Assignment for strata measure HCSS-7d equal Measure Category Assignment for measure HCSS-7. Stop processing.

Measure Information Form HCSS-7
Health Care Staffing Services Measures (v2025A)
Applicable 01-01-25 (1Q25) through 06-30-25 (2Q25)

Questions? Ask Question to Joint Commission staff Copyright © 2024 by The Joint Commission.
^