Letter from ANNA to The Joint Commission expressing support of the American Nurses Association's proposed revisions to Joint Commission Standard NR.4.10

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March 10, 2008

Robert A. Wise, MD
Vice President, Division of Standards and Survey Methods
The Joint Commission
One Renaissance Blvd
Oakbrook Terrace, IL 60181

Dear Dr. Wise:

The American Nephrology Nurses' Association (ANNA) is a professional nursing organization of more than 12,000 registered nurses practicing in nephrology. ANNA members are intimately involved in the supervision and delivery of care to adults and children with kidney disease. Our members work in a variety of settings including dialysis facilities, transplant centers, Chronic Kidney Disease (CKD) clinics, acute care, ambulatory clinics and long-term care. ANNA’s purpose is to advance nephrology nursing practice and positively influence outcomes for patients with kidney disease through advocacy, scholarship and excellence.

On behalf of ANNA, I am writing to express our support for the American Nurses Association (ANA) proposed revisions to Joint Commission Standard NR.4.10 as outlined below.

I. Standard NR.4.10 shall be revised to read:

The nursing service must have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed. There must be registered nurse supervisors, registered nurses, and other personnel for each department and nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.  

II.  Principles for Assessing Compliance

Elements of Performance for NR.4.10 should ensure that

  1. Nurse staffing levels are determined and implemented based on factors present on each unit during each shift, including:
    • Numbers of patients.
    • Patient condition, including severity of illness.
    • Experience level and expertise of assigned staff.
    • Activity on the patient care unit, including admissions, discharges and transfers.
    • Availability of personnel and services (such as clerical, transport, housekeeping, pharmacy, laundry and laboratory) that enable nurses to devote more of their time to patient care.
    • Presence, numbers and needs for staff nurse oversight of nursing students, new graduates, orientees, float and agency nurses, as well as trainees in other disciplines who require nursing support.
    • Analysis of unit-level nursing-sensitive outcomes data.
    • Contextual issues including architecture and geography of the environment and available technology.
  2. In order to provide transparency and to provide a means to assist hospital leadership and the Joint Commission to ensure ongoing assessment and review of staffing adequacy, current unit-level data on nurse staffing levels are posted in locations that are available and accessible to patients, visitors and staff.
    • Posted data include actual numbers of patients, registered nurses, licensed practical nurses, unlicensed nursing staff providing direct patient care on each unit with comparisons to the unit’s normal staffing plan.
    • Posted data are updated on each shift.
    • Information posted shall include the name(s), contact telephone numbers and email addresses of individuals for patients and/or family members to contact to ask questions or voice concerns about nurse staffing levels, along with the telephone number to voice concerns or complaints to the Joint Commission.
    • Posted staffing plan shows the number and types of staff to meet patient needs.

III. In addition, Elements of Performance for Standard 1.10 shall ensure that the hospital’s nurse executive shall maintain a direct reporting relationship to the hospital’s Chief Executive Officer.

The data is clear that the presence of registered nurses is vital to improving patient safety and quality outcomes in acute care and ambulatory settings. Thank you for the opportunity to respond to The Joint Commission’s revisions to the Nursing Chapter. If you have any questions, or if we can be of assistance to you on kidney disease or related matters, please do not hesitate to contact me.


Sandra Bodin, MA, RN, CNN

cc:        Rita Gallagher, PhD, RN, ANA
            ANNA Board of Directors