Release Notes:
Measure Information Form
Version 2010B
Measure Information Form
Measure Set: Health Care Staffing Services(HCSS)
Set Measure ID: HCSS-3
Performance Measure Name: Completeness of Personnel File
Description:
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: Personnel files meeting the minimum data set requirements for
all required components of a complete personnel file:
- Job Appropriate Credentials
- Current license for employees licensed / registered by state boards of Professional Regulation and Education, OR
- Verification of certification program completion for employees not licensed by state boards of Professional Regulation and Education (i.e. Clinical Nursing Assistants)
- Evidence of Current Competency
- Verification of prior work experience in the profession assigned, AND
- Clinical skills checklist(s) appropriate to the discipline and / or specialty at the time of hire / assignment and annually thereafter, AND
- OSHA and HIPAA compliance training at the time of initial assignment then annually thereafter or as dictated per specific regulation, AND
- Current CPR card for those categories of employees required under state law to be certified in basic life support (e.g., RN, LPN / LVN, etc.)
- Health Status
- TB test (PPD) annually OR documentation that employee previously tested positive (e.g., CXR report, physician note or physical exam)
- Background Check
- Verification of previous employers at the time of hire, AND
- Reference checks at the time of hire, AND
- Background check, including criminal records search, at the time of hire and rehire
Included Populations: Not applicable
Excluded Populations: None
Data Elements:
Denominator Statement: Total active clinical staff
Included Populations:
Active Clinical Staff
Excluded Populations: None
Data Elements:
Continuous Variable Statement:
Included Populations:
Excluded Populations:
Data Elements:
Risk Adjustment: .
Data Collection Approach: Retrospective.
Data Accuracy:
Measure Analysis Suggestions:
Sampling: Yes. For additional information see the Sampling Section.
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. 2007 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: Author. 2007.
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:
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