HELP! Where can I find patient/ratio standards?

  1. Hello:
    I know there is JCAHO standards for patient/ratio for nurses. I looked under the ANA website but couldn't find it.
    I would really appreciate if somebody knew where to find it. I really want to know because my DON stated that there is not such a thing as a recommendation by JCAHO and I know there is.
    Thanks guys!
  2. Visit Pamelita profile page

    About Pamelita

    Joined: Apr '02; Posts: 92; Likes: 6
    RN-Vent Unit


  3. by   ANnot4me
    There is no such ratio. Supposedly, supposedly, supposedly JCAHO will site an institution that consistently does not staff according to the institution's own policy. It must be insignificant or never enforced because it makes no difference. Isn't odd they don't seem to be interested in one of the most important factors in patient care and safety -- nurses.

    I think JCAHO is a Farce, a scam and a big crock of bull anyway.
  4. by   pickledpepperRN
    I don't think the JCAHO has ratios (Oh would that they did). They DO require adequate staffing which is unfortunately subjective. Lots of links below and an example of the "ventilator Related Sentinel Event" which the #1 root cause was inadequate orientation/training. #2 root cause was insufficient staffing levels.
    The JCAHO is paid by the hospital!
    Preventing ventilator-related deaths and injuries
    As of January 2002, the Joint Commission has reviewed 23 reports of deaths or injuries related to long term ventilation--19 events resulted in death and four in coma. Of the 23 cases, 65 percent were related to the malfunction or misuse of an alarm or an inadequate alarm; 52 percent were related to a tubing disconnect; and 26 percent were related to dislodged airway tube. A small percentage of the cases were related to an incorrect tubing connection or wrong ventilator setting. None of the cases were related to ventilator malfunctions. As the percentages indicate, ventilator-related deaths and injuries are often related to multiple failures that lead to negative outcomes. The majority of the cases occurred in hospital Intensive Care Units (ICUs), followed by long term care facilities and hospital chronic ventilator units.
    Root causes
    Root cause analysis of the 23 cases reveals the following contributing factors:
    Inadequate orientation/training process 87 percent
    Insufficient staffing levels 35 percent
    Communication breakdown
    Among staff members 70 percent
    With patient/family 9 percent
    Incomplete patient assessment
    Room design limits observation 30 percent
    Delayed or no response to alarm 22 percent
    Monitor change not recognized 13 percent
    Alarm off or set incorrectly 22 percent
    No alarm for certain disconnects 22 percent
    Alarm no audible in all areas 22 percent
    No testing of alarms 13 percent
    Restraint failure (escape) 13 percent
    Distraction (environmental noise) 22 percent
    Cultural (hierarchy/intimidation) 13 percent
    In addition, several organizations found that during the use of low airway pressure alarms only, some ventilators did not always respond to tubing disconnects at all levels of the airflow circuit. For example, the disconnected airway tube may fall into the bedding or against the patient's body, ventilation cycling continues and the ventilator continues to receive indications of correct air pressure.
    "The AARC has long held that death and injury due to faulty alarms, inadequate alarm systems, alarm misuse, and airway disconnect is avoidable. The key are an informed and alert caregiver team."
    --Sam Giordano, executive director, American Association of Respiratory Care
    Risk reduction strategies
    Both the Food and Drug Administration (FDA) and the American Association of Respiratory Care (AARC) have published guidelines for testing and evaluating ventilators. The FDA's Draft Reviewer Guidance for Ventilators1 covers continuous ventilators, critical care ventilators, and electrically powered home care ventilators. The AARC is a professional membership association of respiratory therapists that focuses primarily on respiratory therapy education and research. The AARC Clinical Practice Guideline-Patient-Ventilator System Checks2 cover the breadth of respiratory care procedures, including guidelines related to care of patients using mechanical ventilator support.
    "The AARC has long held that death and injury due to faulty alarms, inadequate alarm systems, alarm misuse, and airway disconnect are avoidable," says Sam Giordano, executive director of the AARC. "The key are an informed and alert caregiver team." The AARC recommends that health care organizations undertake efforts to assure that:
    * Professionals responsible for application, adjustment and monitoring of ventilators, alarm systems and airways, possess relevant education, and have undergone validated competency testing.
    * Systems are in place to check ventilator and monitoring system performance before and during clinical use.
    * All devices and systems are maintained according to manufacturers' specification. This includes medical gas systems.
    * A tracking system is in place to identify, analyze and remedy all ventilator-related incidents that lead to serious injury or death.
    * Protocols for the application and discontinuance of mechanical ventilation are in place.
    * A mechanism is in place to track outcomes of all ventilator patients.
    * Organized, periodic, ventilator-related continuing education is accessible to those professionals responsible for the many components of care directed to ventilator patients.
    The AARC recommendations are in-line with the following risk reduction strategies identified by JCAHO-accredited organizations that experienced a sentinel event related to ventilators:
    1. Improve and expand staff orientation and training on ventilators.
    2. Upgrade alarms and monitoring systems on ventilators.
    3. Institute team training.
    4. Establish new processes for alarm testing and verification of alarm settings.
    5. Establish new or redesigned alarm response procedures.
    6. Redesign rooms or units to improve observation of patient and ventilator.
    7. Improve and expand preventive maintenance on ventilators.
    JCAHO makes the following recommendations to help prevent ventilator-related deaths and injuries:
    1. Review orientation and training programs for job-specific, ventilator safety-related content and include in competency assessment process.
    2. Review staffing process to ensure effective staffing for ventilator patients at all times.
    3. Implement regular preventive maintenance and testing of alarm systems.
    4. Ensure that alarms are sufficiently audible with respect to distances and competing noise within the unit.
    5. Initiate interdisciplinary team training for staff caring for ventilator patients.
    6. Direct observation of ventilator-dependent patients is preferred in order to avoid over dependence on alarms.
    1Food and Drug Administration, Draft Reviewer Guidance for Ventilators,
    2American Association of Respiratory Care, AARC Clinical Practice Guideline-Patient-Ventilator System Checks,
    Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alert identifies specific sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future.
    During the on-site survey of accredited organizations, JCAHO surveyors assess, for consultative purposes, the organization's familiarity with and use of Sentinel Event Alert information.
  5. by   Pamelita
    Really?there is not such a thing? I asked my teacher and she reassured me that it exits. I think I am going to ask her where I can go. She told me the ANA website.
    Oh well, thanks again
  6. by   rck213
    There are no ratios set anywhere but in California, Check out the California Nurses Association Website. The ANA has PROPOSED ratios be set but none are. NY State Nurses Association and a few other state nursing associations have also proposed legislation. I have been looking for ratios for years, I think the AORN may have some set for OR nurses and PACU , ICU's usually are 1:2 but that's it. I was looking for Pediatric ratios to help save our unit from harm by a new manager, couldn't find any.
  7. by   pickledpepperRN

    Sunday, 06/15/03 | Middle Tennessee News & Information

    Companies, union clash over costliest hospitals list

    Staff Writer
    Health-care consumers who aren't familiar with the terms used by the federal Medicare bureaucracy might have difficulty understanding the charges sailing back and forth in the public spat between a nurses union and the hospital industry.
    The union, the California Nurses Association, says it has identified the most-expensive hospitals in Tennessee and the rest of the country and has evidence that some facilities are reaping windfall profits by overcharging sick people.
    Industry spokesmen respond that the union is confusing consumers by misusing information provided by the hospitals to the federal agency that regulates Medicare and Medicaid.
    They also said the union has a motive for embarrassing the hospital industry, because it is trying to recruit nurses employed by Tenet Healthcare Corp.
    The report identified what the union calls the 100 most-expensive hospitals in the country. It compares total charges with costs.
    One Tennessee hospital, Harton Regional Medical Center in Tullahoma, ranked 81st on that list. The hospital has been put up for sale by Tenet, its owner. The hospital's total charges were 440% of its costs.
    Harton is also on the nurses union's list of the 10 most-expensive hospitals in Tennessee. So is another for-sale Tenet hospital, University Medical Center in Lebanon. It had charges that were 409% of costs.
    The report also lists these Midstate hospitals: Medical Center of Manchester, owned by Medical Associates, with charges 362% of costs; Baptist DeKalb Hospital, owned by Saint Thomas Health Services, with charges 331% of costs; and Summit Medical Center in Hermitage, an HCA Inc. hospital, with charges 310% of costs.
    The union based its conclusions on reports filed with the federal government by almost 4,300 hospitals in the years 2000 and 2001, said California Nurses Association spokesman Charles Idelson.
    Of the 100 most-expensive hospitals, 64 are owned by Tenet and eight are owned by HCA.
    Spokesmen for both companies said the union's conclusions are not supported by the facts. Santa Barbara, Calif.-based Tenet, with 144 hospitals, is the industry's No. 2 company. The No. 1. company, Nashville-based HCA, has 200.
    ''The whole argument is a ludicrous argument,'' HCA spokesman Jeff Prescott said Friday.
    The union based its study on each hospital's official list of charges for each health-care procedure it offers. Hospitals are required to keep such lists and include them in reports submitted to the federal agency that regulates Medicare and Medicaid, the health programs for the elderly and the poor.
    In the real world, Prescott said, no one actually pays the prices on those lists, which are referred to inside the industry as a ''charge master.'' Medicare and Medicaid demand, and get, discounts. Managed-care plans negotiate their own prices, which are lower than the list price.
    ''Studies like this take that 'charge master' and assume it's real,'' Prescott said. ''Charges are entirely irrelevant. That is not what hospitals get paid.''
    Tenet spokesman Steven Campanini said the report is misleading.
    Carmela Coyle, senior vice president for policy at the American Hospital Association, agreed that what consumers actually pay is different from a hospital's list of charges.
    ''Charge information is not useful to consumers,'' she said. ''It doesn't reflect what they pay.''
    California Nurses Association spokesman Idelson said the report is based on bills sent to consumers.
    ''It includes bills they send to Medicare and private insurance,'' he said. ''It's an average of all bills they send out.''
    The report is relevant, he said, because overcharging by hospitals contributes to health-care inflation, which makes health insurance more expensive and less available for consumers.
    The union's only agenda is to address the ''health-care crisis'' in the United States, not to attack Tenet, he said.
    But Campanini, Tenet's spokesman, said the company has another reason for distrusting the report, which was prepared for the California Nurses Association by the Institute for Health and Socio-Economic Policy.
    The institute's executive director, Don DeMoro, is married to the union's director, Rose Ann DeMoro, Campanini said.
    ''Tenet views any report coming from this husband-and-wife team as suspect because of the bitter ongoing campaign'' by the nurses union to recruit nurses at Tenet's California hospitals, Campanini said.
    Idelson said the DeMoros' relationship isn't the issue. ''That issue is a red herring,'' Idelson said.
    Prescott disagreed.
    ''One has to question whether or not the study and the organizations doing the study are objective and independent,'' he said.
    Arguments over prices are not very useful to consumers, said Coyle, of the American Hospital Association.
    Instead, they need information about quality of care. She said the association plans to begin providing that kind of information later this year.
    Bill Lewis can be reached at 259-8075 or at
  8. by   pickledpepperRN

    Special Report >> Written by Laura B. Benko Workforce Report 2003: Ratio daze in California State staffing law may exacerbate nursing shortfall Story originally published June 16, 2003 High above the busy streets of Los Angeles, billboards depict a smartly dressed woman behind the wheel of a plush car, her hand clutching the gearshift confidently. Its slogan reads, "Our nurses really enjoy their shifts."
    The ads are designed to promote Queen of Angels-Hollywood (Calif.) Presbyterian Medical Center and its new program offering free two-year auto leases to newly hired nurses.
    Four hundred miles north, Mercy Healthcare Sacramento is paying an extra $200 per month to six employees who have agreed to drive around town in cars shrink-wrapped with nurse hiring slogans, such as "Drive your career in the right direction."
    Just as a national nursing shortage has grown worse, California hospitals are facing an impending state law mandating higher nurse to patient ratios, a law that may threaten their very survival. That law has many facilities and systems taking drastic measures to compete for the dwindling pool of available registered nurses. Salaries and signing bonuses have shot up and education loan-repayment programs and employer-subsidized day care are now typical benefits offered by many hospitals. Recruitment efforts have intensified and expanded in the international nursing market. Advertising budgets have ballooned.
    "Hospitals are doing everything they can to recruit nurses, but there just aren't enough to go around," says Jan Emerson, spokeswoman for the California Healthcare Association, which represents 500 hospitals. "Everyone is scrambling."
    In 1999, California became the first, and so far only, state to pass a law requiring hospitals to maintain specific nurse-staffing levels to improve patient safety. Under guidelines proposed by Gov. Gray Davis in October 2002, hospitals would be required to staff one nurse for every six patients in general medical-surgical units, with that ratio rising to 1-to-5 within the next 18 months (Oct. 7, 2002, p. 17). Ratios would be 1-to-4 in pediatric units and 1-to-2 in intensive-care units.
    The state Department of Health Services has been reviewing testimony presented during several public hearings last fall and plans to release any revisions to the proposed regulations this month, followed by another public comment period. The law goes into effect in January 2004.
    Crackdown sought
    Meanwhile, the California Nurses Association is already pushing for tougher enforcement of the law. The 40,000-member union is sponsoring a bill that would levy steep penalties, including fines of up to $5,000 per day, on hospitals that fall short of the mandated ratios and would extend state health officials' ability to conduct unannounced inspections.
    The mandate comes amid a growing body of evidence showing a strong link between nurse-staffing levels and patient outcomes. Mandating ratios, proponents add, also will go a long way toward reducing hospital turnover and attracting more students to the field by improving working conditions for nurses.
    An October 2002 article published in the Journal of the American Medical Association, for instance, found that each additional patient assigned to a nurse who already has four patients represented a 7% increase in risk of death within 30 days of admission (Oct. 28, 2002, p. 14).
    "Ratios save lives-it's been proved. Yet hospitals have failed to police themselves adequately," says Jill Furillo, an RN and the CNA's director of national affairs.
    Hospitals, however, fear it will be nearly impossible to meet the mandated ratios in time because of the state's severe nursing shortage, and they worry that the cost of hiring more nurses could wreak financial havoc on budget-constrained facilities. The Department of Health Services estimates that California hospitals will have to hire 10,000 more nurses to meet the ratios at an extra cost of $500 million per year, with individual hospitals shouldering from $200,000 to $2.3 million annually at a time when most already are struggling to meet rigorous state seismic-safety standards and cope with cuts in government funding.
    Hospital officials also argue more flexibility is needed. The law doesn't count charge nurses-trained nurses who supervise the work of other nurses-in determining a ratio. That means they could not help with nursing duties while another nurse was on a break, Emerson says. The regulations also say hospitals must comply with the ratios at all times, something that's especially hard to do in ERs, where patient volume and acuity is constantly changing.
    "That's a big challenge," says Bill Littlejohn, chief executive officer of Sharp HealthCare Foundation, a unit of San Diego-based Sharp HealthCare, which recently expanded the intensive-care unit at its Sharp Chula Vista (Calif.) Medical Center to 28 beds from 15 as part of a $420 million, systemwide capital improvement project. "We've been expanding to meet the area's growing capacity crunch. But we can't operate the new units if we can't find enough nurses to staff them."
    Job satisfaction stressed
    To prepare for the law's enactment, hospitals have redoubled their recruitment and retention efforts, throwing generous-and often creative-benefit programs into place to attract new nurses.
    Kaiser Permanente, Oakland, began stepping up its efforts more than two years ago, when it launched a program emphasizing nurse job satisfaction. Besides offering nurses salary increases, improved benefits and new career-advancement opportunities, the health system also has adopted a stricter 1-to-4 staffing ratio and a no-cancellation policy in certain areas, bucking the industry practice of canceling shifts or sending nurses home when patient admissions are low. In addition, employees who refer nurses to the company receive bonuses of $3,000 to $5,000 per new hire.
    "It's not just about getting more nurses. We're really trying to develop an environment that's supportive of what they do," says Marilyn Chow, an RN and Kaiser's vice president for patient care. These efforts have helped Kaiser hire more than 1,000 new nurses since 2001 while reducing its turnover rate to 9.7% from 14%, she says.
    Alta Bates Summit Medical Center, Berkeley, has been sending recruiters to local colleges and offering to pay the student loans of newly graduated nurses in lieu of signing bonuses. The Sutter Health-owned hospital also is luring out-of-state nurses by paying their relocation costs and finding them affordable housing, and has hired a recruitment firm to hire nurses from Australia, Canada and Europe. The 468-bed hospital offers referral bonuses of up to $2,000 and scholarships for employees who want to attend nursing school.
    Although several states have adopted laws that address nurse staffing or working conditions, none have followed California's lead in dictating specific ratios, according to the National Conference of State Legislatures, Washington. For example, five states have laws requiring hospitals to develop their own "valid and reliable" staffing plans that reflect various factors, including patient acuity, the experience of the nursing staff, technology and available support services.
    "Most of the country is watching us to see what shakes out (in California)," the CHA's Emerson says.
  9. by   pickledpepperRN
    Often cited proof we need minimum nurse to patient ratios mandated!

    Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction

    Linda H. Aiken, PhD, RN; Sean P. Clarke, PhD, RN; Douglas M. Sloane, PhD; Julie Sochalski, PhD, RN; Jeffrey H. Silber, MD, PhD

    Context The worsening hospital nurse shortage and recent California legislation mandating minimum hospital patient-to-nurse ratios demand an understanding of how nurse staffing levels affect patient outcomes and nurse retention in hospital practice.

    Objective To determine the association between the patient-to-nurse ratio and patient mortality, failure-to-rescue (deaths following complications) among surgical patients, and factors related to nurse retention.

    Design, Setting, and Participants Cross-sectional analyses of linked data from 10 184 staff nurses surveyed, 232 342 general, orthopedic, and vascular surgery patients discharged from the hospital between April 1, 1998, and November 30, 1999, and administrative data from 168 nonfederal adult general hospitals in Pennsylvania.

    Main Outcome Measures Risk-adjusted patient mortality and failure-to-rescue within 30 days of admission, and nurse-reported job dissatisfaction and job-related burnout.

    Results After adjusting for patient and hospital characteristics (size, teaching status, and technology), each additional patient per nurse was associated with a 7% (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.03-1.12) increase in the likelihood of dying within 30 days of admission and a 7% (OR, 1.07; 95% CI, 1.02-1.11) increase in the odds of failure-to-rescue. After adjusting for nurse and hospital characteristics, each additional patient per nurse was associated with a 23% (OR, 1.23; 95% CI, 1.13-1.34) increase in the odds of burnout and a 15% (OR, 1.15; 95% CI, 1.07-1.25) increase in the odds of job dissatisfaction.

    Conclusions In hospitals with high patient-to-nurse ratios, surgical patients experience higher risk-adjusted 30-day mortality and failure-to-rescue rates, and nurses are more likely to experience burnout and job dissatisfaction.

    JAMA. 2002;288:1987-1993
  10. by   midwestnurse
    Patient caregiver ratios do not seem to exist, at least here in Illinois. My mother was in 3 different nursing homes, the last in which she choked to death. I sincerely believe had the nursing home been adequately staffed, this may not have happened.

    This week I had to place my stepfather in a nursing home. Once again, I find myself frustrated with the lack of staffing. I have written to legislator after legislator, spoken with state ombudsmen, etc., and always come up with the same answer, "There are no patient caregiver ratios, but nursing homes must MEET A PATIENT'S BASIC NEEDS." Patients deserve more than just a generalized statement. We MUST come up with numbers in order to protect our loved ones!

    Per Illinois 77 Administrative Code Chapter I, sec. 300.1230:

    Now, I ask, HOW can that possibly be measured?
  11. by   nursemomruns
    Quote from Pamelita
    I know there is JCAHO standards for patient/ratio for nurses. I looked under the ANA website but couldn't find it.
    I would really appreciate if somebody knew where to find it. I really want to know because my DON stated that there is not such a thing as a recommendation by JCAHO and I know there is.
    Thanks guys!
    The ENA has a recommendation for nurses in the ER. It's a number based on acuity, staff mix, etc. They don't come right out and say 3:1, 2:1, etc. There was an efficiency company that came to our hospital and gave a recommended ratio. Ha!
  12. by   NRSKarenRN
    jcaho does not have standards per se but did develop this "white paper" on recomendations to ease nursing shortage

    public policy initiative: nurse staffing crisis

    download the white paper

    health care at the crossroads:
    strategies for addressing the evolving nursing crisis
    , published 8/02

    (requires adobe reader)

    staffing ratios addressed starting pg 20.

    create a culture of retention (pg. 28-29)

    • [font=univers-bold][color=#005496]
      create a culture of retention for nursing staff.

    • [font=univers-bold][color=#005496]
      provide the management training and resources nurse executives need to attain and maintain a culture of retention.

    • [font=univers-bold][color=#005496]
      delegate authority to nurse executives and other nurse managers, and to staff nurses, for patient care and resource deployment decisions.

    • [font=univers-bold][color=#005496]
      recognize and reward hospitals that adopt the basic characteristics of"magnet" hospitals.

    • set staffing levels based on competency and skill mix applicable to patient mix and acuity.
    • [font=univers-bold][color=#005496]
      measure, analyze and improve staffing effectiveness.

    • [font=univers-bold][color=#005496]adopt zero-tolerance policies for abusive behaviors by physicians and other health care practitioners.

    • [font=univers-bold][font=univers-bold][color=#005496]
      minimize the paperwork and administrative burden that takes nursing time away from patient care.

    • [font=univers-bold][font=univers-bold][color=#005496]
      limit the use of mandatory overtime to emergency situations.

    • [font=univers-bold][font=univers-bold][color=#005496]
      diversify the workforce to broaden the base of potential workers and to improve patient safety and health care quality for patients of all originsand backgrounds.

    • [font=univers-bold][font=univers-bold][color=#005496]
      adopt information, ergonomic and other technologies designed to improveworkflow and reduce risks of error and injury.

    • [font=univers-bold][font=univers-bold][color=#005496]
      adopt fair and competitive compensation and benefit packages for nursing staff.

    from pg 35:

    there are no incentives or even expectations built in to the payment system-either through public or private payers-that encourage an optimal number of nurses or even safe care.

    tatics pg 38:[font=univers-bold][color=#005496]

    • make new federal monies available for hospitals and other health care organizations for investment in nursing services.
    • condition the continued receipt of new federal monies by hospitals and other provider organizations on the demonstrated achievement of specified quantifiable and standardized criteria and goals.
    • base the new reimbursement incentives on evidence-based, nursing-sensitive indicators.
    • align private payer and federal reimbursement incentives to reward effective nurse staffing.

    legislation introduced aligning tatics with medicare/medicaid funding:

    from nursing activism forum:
    2005: hot nursing topics

    the registered nurse staffing act of 2005(s 71/hr 1372)

    s. 71, the registered nurse safe staffing act of 2005 and hr 1372, the qualtiy nursing care act of 2005, allow for the development of staffing systems that require the input of direct care registered nurses (rns) and provides for whistler-protection for rns who speak out about patient care issues. s. 71, sponsored by sen. daniel inouye (d-hi), and hr 1372 sponsored by reps. lois capps (d-ca) and rob simmons (r-ct) were developed and introduced at the urging of ana and its members in response to the current nursing crisis.
    • a study published in the journal of the american medical association (jama) found that registered nurse (rn) staffing levels have a significant effect on preventable hospital deaths among surgical levels. according to researchers, the odds of patient mortality rose 7 percent for every additional patient added to the average nurses' workload.additional information:

    • s 71/hr 1372, require the establishment of a staffing system that ensures a number of registered nurses on each shift and in each unit of the hospital to ensure appropriate staffing levels for patient care.

    • the bills requires public reporting of staffing information. hospitals must post daily for each shift the number of licensed and unlicensed staff providing direct patient care, specifically noting the number of rns.

    • the staffing system takes into account the following: account for architecture and geography of the environment and available technology; reflect the level of preparedness and experience of those providing care; reflect staffing levels recommended by specialty nursing organizations; account for ancillary staff support; provide that an rn not be assigned in a particular unit without first having established the ability to provide professional care in such a unit; be based on methods that assure validity and reliability.

    Last edit by NRSKarenRN on Sep 9, '05