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Case study: Implementation of hospitals annual written reports

The Joint Commission’s staffing effectiveness standard requires that hospitals provide written reports annually on “all system or process failures, the number and type of sentinel event, information provided to families/patients about the events, and actions taken to improve patient safety” (see Phillion 2010). In turn, these undesirable events must be examined relative to staffing; if negative staff trends are observed, a report must be filed with the organization’s leadership. Most healthcare organizations must meet this requirement to receive Joint Commission accreditation, and that accreditation is paramount to the ability of hospitals to operate and receive reimbursement.


Visit two patient care units at a local hospital, and talk to the manager of each one. Ask the following questions of each manager:

1. How has your unit interpreted The Joint Commission’s staffing effectiveness standards?

2. How have unit operations changed as a result of this standard?

3. How has this implementation affected the quality of care delivered to patients on your unit?

4. How has the nursing staff on your unit responded to this implementation?

Following the interviews, compare and contrast the two managers’ approaches for meeting the required staffing effectiveness standards. Is one approach better than the other? How can you use the experiences of these two unit managers to inform your own nurse workload and staffing decisions in the future

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