What You Need to Know About Joint Commission’s National Performance Goal #12

Change is scary. Compliance-related change can be even scarier. Fortunately, it doesn’t have to be. At the start of the year, Joint Commission rolled out its newly bundled National Performance Goals (NPGs) as part of its broader shift to simplify the accreditation process, called Accreditation 360. Among the most-talked-about has been NPG #12: Health professional resource management. 

One of the first criteria within NPG #12 is to ensure staffing needs are adequate for the patient population. Of course, this raises questions. Will there be nurse-to-patient ratio requirements? What changes are there to staffing rules for surveys? What does this mean for training and competency evaluation? 

Recently, representatives from Relias, Kahuna, and Joint Commission itself hosted an hourlong webinar to discuss NPG #12 and the philosophy that Joint Commission surveyors are using to evaluate compliance in general. 

NPG #12: The essentials 

First, a quick overview of NPG #12. 

To meet Joint Commission’s requirements for health professional resource management, hospital leadership must ensure that: 

• Staffing needs are adequate for the patient population.  

• Nurse executive(s) direct the use of nurse staffing plans.  

• Psychiatric hospitals are in compliance with all local, state, and national regulations.  

• Staff have completed all requirements for their respective positions.  

• Education, training, and evaluation of staff for their respective competencies are provided and conducted. 

• Staff are evaluated during performance improvement activities.  

• Defined care delivery models are evaluated. 

NPG #12’s requirements have actually existed for a long time as part of Joint Commission accreditation — as well as CMS compliance.  

“The only thing that we’ve done is bundled them together in a way that they’re grouped around care delivery and resource management, and we’ve elevated them to a National Performance Goal,” says Ken Grubbs, DNP, MBA, RN, Executive Vice President, Accreditation and Certification Operations, and Chief Nursing Officer of Joint Commission. 

It’s important to stress that adequate staffing is just one part of NPG #12. Other questions include: 

• Do nurses have a leader with a voice?  

• Have you asked your bedside clinicians what is and what isn’t working?  

• Are role-based competencies being measured?  

• Are you consistently evaluating your care delivery model? 

Where to start meeting NPG #12 

The philosophical bedrock for NPG #12 is the community your organization serves.  

Your community should also guide the type of care your organization offers. Then, hiring practices and competency measurements spring from there. 

“Once you know that you’ve determined those things, then you get into, ‘Well, what should the skill mix be within a particular department within the organization?’” Grubbs says. 

Hospitals should have staff with a skill mix that meets the needs of the services offered both in terms of scope and complexity. And your care delivery model should emerge from that line of thinking. 

“The ‘why’ is never ‘Because Joint Commission requires,’” Grubbs says.  

Patient safety, patient outcomes, and models of care that are safe and effective for the healthcare team are the goal. 

As an example of NPG #12’s staffing focus in action, Grubbs used a fictional multistory hospital with clinical units on each floor. Someone needs to be immediately available to help direct care to patients in those units. 

“The other thing I think we would all agree on as well is, if you’re a hospital, it’s probably pretty important that there’s a registered nurse in the building,” Grubbs says.  

Maybe your organization does have an RN on hand, but only on the first floor. Meanwhile, the clinical units on the second floor don’t have one ready to take charge of care. That requires the RN on the first floor to travel. And that means the RN is not immediately available. 

Organizations have the power 

Joint Commission conducts two types of surveys: 

• The standard accreditation survey every three years 

• For-cause surveys, after receiving many complaints about an organization — particularly around staffing 

However, no matter which survey you’re facing, your organization holds many of the keys.  

Unit layouts? How med reconciliation is handled? Discharge education? There aren’t prescriptive means to ensure how all that is handled. It’s simply up to your organization to ensure that you’re handling those tasks in a way that helps patients and staff.  

Obviously, it’s critical to be sure to keep up with state and local regulations, in addition to federal laws and Joint Commission accreditation requirements. 

Grubbs added that surveyors look for concerns to guide them through their compliance checks. If any issues over safety and quality arise, Joint Commission will follow those threads and see where they go. 

Are adverse events investigated? Were any lessons learned? Were any opportunities found and followed? 

“If there is an event, did you look at your care delivery models and say, ‘Is there a possibility that our nonalignment with the care delivery model (or what we’ve determined to be our care delivery model) created an opportunity or process value?’” Grubbs says. 

Education, training, and competency 

Robert Campbell, PharmD, BCSCP, VP of Accreditation/Certification Program Development and Accreditation Management Division of Accreditation and Certification Operations of Joint Commission, broke the focus of improvement into three categories: education, training, and competency. 

• Education: general knowledge 

• Training: teaching a specific skill set (tying knots, medication dispensation, etc.) 

• Competency: applying what’s been learned 

Managing and mastering the combination of education, training, and competency is essential in delivering the best care possible in the eyes of NPG #12. But again, there is no prescriptive way to handle them. 

“We allow the organization to determine how they do all of that,” Campbell says. 

Grubbs seconded the thought, adding, “And competencies and training, and education should be a living discussion, if you will, based off of the population you served.” 

So, when it comes to measuring skills and competencies, it comes back to the community, its needs — and the care model you’ve developed to serve those needs. 

“Be meaningful in determining what are the ongoing skills that need to be verified,” Grubbs says. 

That doesn’t mean throwing massive skill set checklists at staff every year. Instead, it’s about being mindful of core competencies and changing needs and offerings. 

“If you open up a new service at some point in time during a year, or you bring in a new procedure, or you bring in a new piece of equipment, that’s when you need to ask yourselves, ‘Okay, what’s going to be the initial competency for the team that we have today?’” Grubbs says.  

Once a change does happen, move on to teaching and training. 

“How do we make sure that the individuals that are in the four walls of our organization today can do this safely? So that’s No. 1,” Grubbs says. “Then, No. 2, you’ve got to ask, ‘Well, how do we incorporate that into our onboarding for all new team members that will be coming into our organization, particularly if it’s something they’re going to be doing?’” 

NPG #12 and (potentially) adverse events 

What happens when things go wrong? Or nearly go wrong?  

Are you examining near-miss data? Are you drawing conclusions from near-misses and working to improve your processes and education? 

When an adverse event does occur, are you examining it? 

“The lens that we look at is, ‘Did the organization conduct a credible review, first and foremost?’” Grubbs says, adding, “Don’t skim the surface. Keep asking, ‘Why?’” 

Does your organization have good answers to these questions when it comes to adverse events? 

• Is there a safe environment for staff to voice concerns?  

• If it was a competency/skill issue, can it impact the larger organization?  

• If it’s an equipment issue, how was training conducted?  

• If an outside person came in to do the training, how familiar were they with the equipment’s actual operational components?  

• Did the trainer bring and provide clear instructions/manuals to make sure steps aren’t skipped? 

“Because there’s times that we all try to find efficiencies, but sometimes, those efficiencies can be at the detriment of the organization,” Grubbs says. 

Education is important. Function is the ideal. 

NPG #12 in practice 

To get more of a real-world look at how NPG #12 could look in day-to-day operations, the webinar panel discussed common compliance concerns and occurrences in hospitals. 

Planning around scheduling 

Tonya Coram, BSN, RN, NPD-BC, Director of Healthcare Practice at Kahuna, put herself in the shoes of a scheduler. 

“If we think about a med surg telenurse manager who’s creating next month’s schedule, for example, thinking about (NPG #12), there’s really no way to anticipate future patient acuity when the schedule is being created. Do you have any advice on strategies that you would recommend to ensure that safe staffing decisions still align with the essence of that no. 12?” 

Grubbs stressed again that Joint Commission is not advancing staff-to-patient ratios. But staff and leadership need to be aware of how effective their care delivery model is. There needs to be thought put into patient populations of each unit and the demands on clinical teams. 

Sometimes, having a nurse for every two patients works fine. For more acute populations, one nurse per patient might be required to maintain a proper standard of care. For more intensive situations, more might be needed.  

That isn’t a prescription for a ratio. It’s being aware of how many people are needed to take care of patients safely and effectively. 

“So, the point is there should be an evaluation,” Grubbs says. “There should be an understanding, and there should be adapting of the delivery model, the team based off of what’s going on in the unit, what’s going on with patients. And that pretty much is operationalized in many healthcare organizations that we accredit.” 

Crash cart chaos: A lesson in competency 

As another example, Grubbs cited his own work as a surveyor. He pointed out that, as surveyors enter a building, it’s common to see staff scrambling to check that egresses are clear and crash carts are stocked.  

Those should be everyday occurrences. Crash carts should always be ready to go. Not because of any Joint Commission requirements, but because lives may be in jeopardy. 

“When we look at education competencies and training around crash carts, what’s important is that team members know how to use the crash cart, to use the defibrillator when they truly need it to save a life,” Grubbs says. “That’s the ‘why.’ They need to know how to get that defibrillator to work.” 

Modern times and modern healthcare solutions 

As part of the rollout of Accreditation 360 and the National Performance Goals, Grubbs pointed out where Joint Commission has fallen short in recent years. 

Namely, catching up with the times (both technologically and in how healthcare workers operate day to day) has been a top priority. 

Tinkering with new tech 

Joint Commission is aware that technology is moving full speed ahead. However, Joint Commission has made it a goal to meet healthcare organizations where they are. 

For example, it has made a big push to modernize data collection, such as permitting organizations to submit materials electronically. 

Surveyors have also been supportive of efforts to reduce administrative burden to clinicians at the bedside. As artificial intelligence and other technological solutions arise, Joint Commission can see their value. Whether it’s helping with education, medication reconciliation, admission history, or other tasks, they’re aware of both the need to enforce a floor of quality while embracing the time and cost savings those tools bring. 

“We’re supportive of those as long as we meet certain things, scope of practice, licensure, all of that stuff,” Grubbs says. 

Upskilling and cross-skilling 

Coram pointed out that, since the pandemic, there has been a big focus on skill enhancement, especially within nursing. She asked how hospitals can be ready for surveys in a world of increased nurse mobility. 

Grubbs maintained Joint Commission’s philosophical foundation for NPG #12. 

“The most important thing is that when you’re looking at skills, when you’re looking at competency, when you’re looking at education, you do have to think about the population that is being served, the individuals that are being served on a particular unit,” Grubbs says. 

If your hospital is going to encourage nurse mobility, you need to have a program that identifies individuals who can float to ensure they have the skills and training necessary to make that shift.  

For example, if someone is moving from a nontelemetry unit to a telemetry unit, “They’re having responsibility for any type of interpretation of rhythm strips or knowing cardiac rhythms,” Grubbs says. “That’s probably a pretty important competency that needs to be in that individual’s wheelhouse or knowledge as they’re being floated to that particular unit.” 

Conclusion 

Times are changing, and change can always be daunting. But it’s important to keep up with the times to pave a better future. 

As part of its push toward Accreditation 360 and the NPGs, Joint Commission unified its internal process guides with those they give to hospitals, retired obsolete standards, began offering optional continuous engagement with organizations, eliminated more than 200 nonregulatory requirements, and compiled performance benchmarking for hospitals to compare with their peers.   

NPG #12 might look intimidating to hospitals on the surface, but at the end of the day, no new requirements were added. Instead, it’s important to look at your services from a holistic perspective, starting with the community and your patients. 

Then, with a firm focus on safety and outcomes for patients and staff alike, you can implement and refine a model that works best for everyone.