Hospital Staffing Committee Charter (2024 WhidbeyHealth Medical Center)

• Luka Cobb RN – Hospice
• Steven Caporgno RN – Emergency Department
• Gwen Parrick RN – Pharmacy
• Ellen Giles RN – Intensive Care
• Helen Paraiso RN – STAT RN
• Laura Black RN – Medical Surgical
• Cassie Matheson RN – Medical Ambulatory Clinic
• Angie Hansen RN – Medical Surgical
• Karen Carlson RN – Utilization Management
• Emily Barr CNA – Emergency Department

• Paul Rogers – Chief Financial Officer
• Curtis Shumate – Executive Director of Nursing
• Debbie Ries – Manager Emergency Department
• Lacie Freer – Manager Social Work/ Utilization Management
• Michael Aube – Manager OR/PACU
• Claire Milnes – Manager Hospice
• Susan Thomas – Manager M/S, ICU, RT
• Tabitha Sierra – Manager WFBP
• Dawn Sellgren – Manager Medical Ambulatory Care
• Kate Waterman – Emergency Department Supervisor

The HSC members collaboratively develop/implement the HSC charter. The charter is updated annually or more often as deemed necessary by the committee. The DOH and L&I provide technical assistance to the HSC on implementation of charter requirements.

Retaliation, intimidation, or otherwise adverse action against any individual performing duties or responsibilities in connection with the HSC or any employee, patient, or other individual who notifies the HSC or the hospital administration of concerns related to nurse staffing is not permitted.

Section 1 HSC Purpose
This hospital staffing committee (HSC) is established by WhidbeyHealth to convene direct care nursing staff and hospital administration to participate in a joint process regarding decisions about direct care nurse staffing practices to promote quality patient care, safety for patients and staff, and greater retention of nursing staff. The committee uses pertinent organizational and other data for consideration in developing the Hospital Staffing Plan and analyzing nurse staffing.

Section 2 HSC Responsibilities
The primary responsibilities of the HSC are:

1. Develop and oversee the annual patient care unit and shift-based hospital staffing plan (HSP) for nursing staff, including registered nurses, licensed practical nurses, certified nursing assistants, and unlicensed assistive nursing personnel providing direct patient care based on the needs of patients.
2. Review and evaluate the effectiveness of the staffing plan semi-annually against patient needs and known evidence based staffing information, including identified factors considered in staffing plan development and nurse-sensitive quality indicators collected by the hospital.
3. Review, assess, and respond to staffing variations, concerns, or complaints presented to the committee.

Hospital departments/units that require a staffing plan*: Medical Surgical Unit, Intensive Care Unit, Whidbey Family Birth Center, Nursing Administrative Emergency Department, Operating Room/PACU, Utilization Management, Medical Ambulatory Care, Hospice Care, Palliative Care, Pulmonary Rehab.

*The staffing plan includes acute care hospital areas (licensed under RCW 70.41) and state hospitals (as defined in RCW 72.23), where RNs provide patient care.

Section 3 HSC Membership
The HSC consists of 20 voting members comprised of 10 direct care nursing staff and 10 from hospital administration.

• At least 50 percent of the voting committee members are to be WSNA nursing staff who are, currently providing direct patient care.
• The selection of HSC nursing staff members is according to the collective bargaining representative(s).
• 50 percent of the total HSC voting members are from hospital administration and include the Chief Financial Officer, Chief Nursing Officer, and patient care unit directors or managers or their designee.
• HSC administration members are selected by the Executive Director of Nursing.

Co-Chairs

• The HSC is co-chaired by one direct patient care nursing staff representative and one representative from hospital administration.
• The nursing staff co-chair is selected under the direction of the collective bargaining agreement(s) as guided by the selected HSC nursing staff members.

The administrative co-chair is selected by the hospital administration.

• If an HSC co-chair or member is unavailable to fulfill the duties of their role, a new individual is selected using the process outlined above.

Other attendees
The following job classes will be represented on the HSC as nonvoting patient care staff members: WSNA Nurse Representative, Executive Director of HR, Emergency Room Nursing Supervisor, Medical Surgical Nursing Supervisor.

• Interested non-members who are unable to attend a meeting are encouraged to share their input with a HSC member who may represent their interests during the meeting.
• Committee co-chairs may limit HSC attendance to committee members for all or a portion of meetings as deemed appropriate by the co-chairs.

Section 4 HSC Roles and Responsibilities

Co-chairs (or designee)
HSC co-chairs serve for a period of 2 years. Co-chairs duties include, but are not limited to:

• Schedule HSC meetings to optimize attendance. Ensure HSC member notification of accurate meeting date, time, and location.
• Provide new HSC member orientation and ongoing training to members.
• Track meeting attendance of members. Ensure adequate quorum for each meeting and address non-attendance (as specified by charter).
• Develop the agenda for each meeting with input from the HSC members.
• Acknowledge receipt of staffing complaints by communicating with the staff member who submitted the complaint.
• Extend a written invitation to the employee and manager 7 days in advance of the meeting when the complaint (involving the employee) is scheduled to be discussed. Include notification that a labor representative may attend at the employee’s request.
• Ensure closed-loop communication occurs following committee review of a staffing complaint via written response to the staff member who submitted the complaint including the outcome of the complaint after committee review.
• Facilitate development and semi-annual review of the HSP.
• (Other duties as determined by the committee)

Hospital Co-chair (or designee) – administrative duties

• Maintain complete and accurate committee documentation, including but not limited to meeting minutes, complaint review log, annual staffing plan, staffing plan updates, and actions taken. Comply with meeting documentation retention consistent with hospital’s policy.
• Facilitate review of factors to be considered in the development of the staffing plan. Ensure review of staff turnover rates (including new hire turnover rates during the first year of employment) quarterly, anonymized aggregate exit interview data on an annual basis, hospital plans regarding workforce development, and patient grievance submissions related to hospital staffing.
• Present the annual staffing plan and any semi-annual adjustments to the CEO for review and approval. Ensure timely submission of the plan to the DOH following HSC and CEO approval.
• Organize review of staffing complaints and ensure adherence to the complaint management process (specified in the charter) to facilitate the best use of time during the HSC.

Hospital Staffing Committee Members
HSC committee member responsibilities include, but are not limited to:

• Complete new member orientation and participate in on-going education as recommended by committee co-chairs.
• Attend committee meetings consistently.
• Notify committee co-chairs if unable to attend a HSC as specified by charter.
• For direct care staff, notify direct supervisor if HSC meetings are scheduled during a scheduled shift as outlined in the charter so that coverage can be arranged.
• Participate actively in committee meetings, including reading required materials in advance of the meeting as assigned, coming prepared for meetings, and engaging in dialogue.
• Remain open-minded and solution-focused and earnestly engage in collaborative/cooperative problem-solving process.
• Model solution-focused communication both in committee meetings and when discussing staffing concerns with peers.
• Serve as a committee ambassador to gather input from peers and share with the HSC to inform decisions and assist peers in understanding the process for developing staffing plans and reviewing complaints.
• Encourage peers to effectively communicate staffing concerns through the process established by the committee to best facilitate collaborative problem solving.
• Communicate urgent staffing concerns that arise between meetings with unit-based leadership and committee co-chairs.
• (Other duties as determined by committee)

Section 5 HSC Meetings, Management, and Attendance

Meeting Schedules and Notifications

• The HSC meets monthly, or more often if needed, to achieve objectives of the committee in compliance with RCW 70.41.420. Meeting dates and times are set by the committee co-chairs with input from committee members. Committee members are notified of meeting dates and times via Outlook/Teams Meeting invite at least 30-days in advance of regular meetings.
• Meeting participation by HSC members is scheduled work time and compensated at the appropriate rate of pay. Members are relieved of all other work duties during meetings. Whenever possible, meetings are scheduled as part of members’ normal full-time equivalent hours.
• It is understood that meeting schedules may require members to attend on their scheduled day off. In this case, staff may be given equivalent time off during another scheduled shift or are compensated at the appropriate rate of pay.
• Staffing relief is provided (when necessary) to ensure committee members are relieved of their duties to attend meetings. Members are responsible for notifying the HSC co-chairs if they are scheduled to work when a committee meeting is scheduled.
  – Notify co-chair 48 hours prior to meeting to allow for alternative to be invited in needed to preserve quorum.
• The HSC member works with their supervisor by requesting time off to attend no later than the 10th of the month prior to accommodate scheduling, published on the 20th of each month.
• Meeting invites for ADO’s will be provided 7 days prior to meeting when possible. Guest invites will be addressed at the beginning of the meeting with an anticipated time commitment of 15 minutes to review and discuss ADO. Leadership should make every effort to allow attendance of nursing when invited when possible.
• Meetings will be via TEAMS to promote the 75% attendance requirement of all committee members.
  – Attendance at the HSC meeting is a paid event and entry into the payroll system is to be recorded by HSC members as “meeting”.

Contingency Staffing Plan

• In the event of an unforeseeable emergent circumstance lasting for 15 days or more, the hospital incident command will provide a report to the hospital staffing committee co-chairs within 30 days including an assessment of the staffing needs arising from the unforeseeable emergent circumstance and the hospital’s plan to address the identified staffing needs.
• Upon receipt of this report the hospital staffing committee will convene to develop a contingency staffing plan.

HSC Member Orientation

• Newly selected staffing committee members receive basic orientation related to:
  – Hospital quality improvement strategy, organizational budgeting process and relevant reports, current applicable hospital staffing laws, ADO processing and recording, committee structure and function, and member duties.
  – Initial orientation is provided by committee co-chairs with ongoing education provided to all members as needed.
• Completion of new member orientation within 45 days of joining is a condition of committee membership.
• Committee co-chairs will review orientation materials annually and provide updates as needed to the entire committee.

Quorum

• A quorum for the HSC is met as long as at least 60 percent (6/6) of committee members are present, with equal representation of voting direct care WSNA nursing and administration.
• A quorum is established before the committee takes a vote on all voting matters, including staffing plan approval or revision.
• A quorum is preferred for review of staffing complaints, though co-chairs may elect to move forward with presence of fewer than 60 percent of voting members for purposes of timely processing of complaints.
• Attendance is taken at the beginning of each HSC meeting.
• Members unable to attend a meeting notify co-chairs via email prior to the meeting to allow for adjustments to maintain the quorum.
• HSC voting members are identified at the beginning of each meeting so that voting is undertaken with an equal number of direct care nursing staff and hospital administration members.
• If an HSC member is unable to attend, notification to a co-chair 48 hours prior to meeting is required to allow time for alternative if required.
  – The number of voting members may be adjusted so that there is an equal number from direct care nursing staff and administration.

Attendance and Participation

• HSC members are expected to attend at least 75% or 9/12 meetings annually Jan-Dec each calendar year.
  – Attendance expectations may result in removal from the committee.
  – If a member is unable to attend a meeting, co-chairs are notified via email 48 hours in advance of the meeting.
• It is the expectation of the HSC that all members participate actively, including reading required materials in advance of the meeting as assigned and coming prepared to meetings.

Communication and Consensus

• The HSC strives to resolve issues through collaboration.
• Consensus is the primary decision-making model when a quorum is met and is used for approval of the annual staffing plan, changes to a staffing plan, classification of complaints, and other committee decisions.
• Should an issue need to be voted upon by the HSC, the action must be approved by a majority vote of a duly appointed HSC with an equal number of direct care nursing staff and administration present.

The following processes will be utilized when a HSC vote is needed:

1. Interested individuals present information relevant to the topic.
2. An opportunity is provided for discussion, questions, and clarification.
3. Co-chairs indicate that the committee will vote on the matter, restating the proposal that will be voted on.
4. Members submit their vote via role call verbal vote (Yea/Nay).

Consensus is reached if there is a 50 percent plus one vote of a duly constituted HSC (with an equal number of voting representatives from 50% WSNA direct patient care nursing staff and from administration).

Agenda

• Meeting agendas are developed and agreed upon by the HSC co-chairs prior to each meeting and disseminated to HSC members at least one week in advance of the upcoming HSC meeting.
• HSC members may request items to be added to the agenda either before or during the meeting.
  – Non-member employees may request that an HSC member include an item on the agenda.
  – Items added to the agenda during a meeting will be addressed as time allows and moved to the next meeting agenda if there is
  inadequate time.

HSC standing agenda items are as follows:

1. Call to order/attendance.
2. Approval of documentation from previous meeting.
3. Agenda review (opportunity for additions).
4. Charter approval (annually or more often as needed).
5. Committee member education (annually and as needed).
6. Old business (review prior assignments, unresolved discussions, and agenda items rolled over from previous meeting).
7. Budget review quarterly, January, April, July, October.
8. Quality data report (quarterly)/HR report (quarterly).
9. Proposed unit staffing plan changes (if any).
10. Hospital staffing plan review (including factors considered in development of the HSP – semi-annually).
11. Progress reports (corrective action plans in progress).
12. Staffing complaint trend data.
13. New staffing complaint review & classification.
14. Assignments and agenda items for next meeting.
15. Adjournment.

Documentation and Retention
Committee co-chairs designate a scribe to take notes during each HSC meeting. Meeting documentation (approved by co-chairs with input from HSC members) is distributed to HSC members for review at least one week prior to the next HSC meeting.

Meeting documentation includes:

• HSC meeting attendance and identification of voting members present.
• Approval of previous meeting documentation.
• Summary of member education provided during the meeting.
• The outcome of any votes taken during the meeting.
• Topics discussed during the meeting with action items and member assignment(s).
• Review/disposition/action taken on staffing complaints reviewed during each HSC meeting with tracking.
• Written documents containing confidential information are not removed from the meeting or shared with individuals who are not members of the HSC. All committee documentation, including meeting documentation and staffing complaint tracking logs are retained for a minimum of three years and consistent with the hospitals’ document retention policies.

Section 6 HSC Information/Data Review

• The HSC is responsible for the development and oversight of the staffing plan for provision of daily nurse staffing needs for the identified areas.
• The committee will review the effectiveness of each patient care unit nurse staffing plan semiannually. Department leaders should with any staffing changes or at a minimum semiannually report to the HSC all relevant information to be considered in the review and approval of the patient-care unit staffing plan.

Factors to be considered in the development of the staffing plan include, but are not limited to:

• Census, including total numbers of patients on the unit on each shift and activity such as patient discharges, admissions, and transfers.
• Patient acuity level, intensity of care needs, and the type of care to be delivered on each shift.
• Skill mix of staff and FTE mix of current staff, including full-time, part-time, per diem, travel/contract/local agency/float pool.
• Anticipated staff absences, (i.e., vacation, planned leave, sabbatical).
• Level of experience, specialty certification, and training of nursing and patient care staff providing care.
• The need for specialized or intensive equipment.
• Availability and ease of access of resources, equipment, and supplies.
• The architecture/geography of the patient-care unit, including but not limited to placement of patient rooms, treatment areas, nursing stations, medication preparation areas, and equipment.
• Staffing guidelines adopted or published by national nursing professional associations, specialty nursing organizations, and other health professional organizations.
• Availability of other personnel and patient-care staff supporting nursing services on the unit, (e.g., Respiratory Therapy, PT/OT, etc.).
• Measures to optimize available staff, (e.g., current/alternative staffing models of care, workflow optimization, etc.)
• Compliance with the terms of an applicable collective bargaining agreement, if any, and relevant state and federal laws and rules, including those regarding meal and rest breaks and use of overtime and on-call shifts.
• Semiannual review of the staffing plan against patient needs.
• Known evidence-based staffing information, including the quality indicators collected by the hospital.
• Review, assessment, and response to staffing variations or complaints presented to the committee.
• Hospital finances and resources as well as a defined budget cycle.

Section 7 HSC Information/Data Review

The HSC reviews relevant data outlined below to assess the effectiveness of unit-based staffing plans and financial performance.

Yearly: results from staff satisfaction and culture survey trends.

Monthly: staffing plan compliance reports.

Monthly: missed meal and rest break reports for nursing staff.

Monthly: overtime and mandatory on-call reports.

Quarterly (monthly reports reviewed quarterly): hospital and department specific budget reports

Quarterly: human resources report, including but not limited to:

• Turnover and vacancy rates by nursing staff job class and patient care unit.
• Nursing staff new hire turnover rates during the first year of employment.
• Aggregate anonymized exit interview trends.
• Hiring trends and hospital workforce development plans.
• Individual exit interview responses are not shared with the HSC due to confidentiality.

Quarterly: hospital-wide and department-specific quality indicators, including but not limited to:

• Patient complaints related to staffing.
• Patient satisfaction survey responses.
• Key quality indicators as identified by the committee:
  – During this hospital stay, how often did nurses treat you with courtesy and respect?
  – During this hospital stay, how often did nurses listen carefully to you?
  – During this hospital stay, how often did nurses explain things in a way you could understand?
  – Infection prevention, CAUTI, VAP, CENTRAL LINE INFECTION, HAPI

Data Validation

Staffing Plan Compliance Report
The HSC co-chairs conduct a monthly review of the staffing plan compliance report. The standard form includes a checkbox for either HSC co-chair to indicate their belief that the validity of the report should be investigated by the WA DOH. (start date July 2025).

Section 8 HSC Staffing Plan Development, Review, and Approval

• Upon review of the proposed staffing plan and quality metrics, the HSC votes to adopt or re-work the proposed staffing plan.
• The HSC voting members approve the proposed staffing plan when a majority (50 percent plus one) vote of the HSC is in favor of the plan.
• The committee-approved staffing plan proposal is provided to the hospital Chief Executive Officer (CEO) for review.
• Due annually by July 1st for the following year and any time a staffing plan adjustment is requested and approved by the committee.
• Upon receiving a staffing plan proposal from the HSC, the CEO or designee reviews the proposal and provides written feedback to the committee. The written feedback must include, but is not limited to the following:
  – Elements of the proposed staffing plan the CEO requests to be changed.
  – Elements that could cause concern regarding financial feasibility, temporary or permanent closure of units, or patient care risk.
  – A status report on implementation of the staffing plan including nurse-sensitive quality indicators, patient surveys, recruitment/retention efforts, and success over past six months in filling open positions for employees covered by the staffing plan.
• The committee reviews and considers any feedback from the CEO, revises the staffing plan if applicable, and approves the new draft staffing plan by majority vote (50 percent plus one) before submitting the revised staffing plan to the CEO for approval.
• If the revised staffing plan proposal is not accepted by the CEO and adopted upon second review, the CEO documents rationale for this decision.
• If the HSC is unable to agree on a staffing plan proposal by majority vote or the CEO does not accept and adopt the proposed staffing plan, the most recent of the following staffing plans remains in effect: a) the staffing plan in effect January 1, 2023, or b) the staffing plan last approved by a 50 percent plus one vote of a duly constituted HSC and adopted by the hospital until a new proposal can be agreed upon.
• The CEO’s written report is retained with HSC documentation as outlined in Section 5 Documentation and Retention.

Section 9 HSC Complaint Review
Staffing concerns are addressed using the following process:

Step 1: Timely Communication
Staffing concerns are addressed (in real-time) with the immediate supervisor using chain of command.

Step 2: Immediate Intervention

• Staffing concerns are discussed with the leadership on duty in order of availability, nurse manager, nursing supervisor, administrative nursing supervisor, unit charge nurse.
• The staff member and on duty leadership work together to evaluate the immediate clinical situation, evaluate patient and staff conditions, and explore potential solutions.
• When a variance from the staffing plan is identified or clinical circumstances warrant additional staff to accommodate patient care needs, the shift lead or immediate supervisor determines the appropriate reasonable efforts to resolve the situation using available resources.
• Reasonable Efforts: the employer exhausts and documents all the following but is unable to obtain staffing coverage:
  – Seeks individuals to work additional time from all available qualified staff who are working.
  – Contacts qualified employees who have made themselves available to work additional time.
  – Seeks the use of per diem staff.
  – When practical, seek personnel from a contracted temporary agency when such staffing is permitted by law or an applicable collective bargaining agreement, and when the employer regularly uses a contracted temporary agency.
• When the shift lead has exhausted all available resources and determines that there is immediate risk to patient and/or staff safety, the shift lead contacts the next level supervisor as (outlined in the hospital chain of command policy) for assistance in resolving the concern.
• If the concern cannot be resolved after escalating to senior leadership, and the shift lead or supervisor determines that no immediate risk to patient and/or staff safety exists, the immediate shift lead or supervisor documents the following to aid in ongoing review of the concern:
  – Precipitating circumstances – such as an unforeseen emergent circumstance as defined below, unusually high number of sick calls or unexpected influx of patients.
  – All efforts to obtain additional staff.
  – Other measures taken to ensure patient and staff safety.
  – Rationale for shift-based staffing adjustments based on immediate circumstances.
• This documentation is sent via email to the Executive Director of Nursing and Unit Director/manager
• If the staffing concern is a result of an unforeseen emergent circumstance, the immediate shift lead or supervisor documents those circumstances for HSC review. Unforeseen emergent circumstances are defined as:
  – Any unforeseen declared national, state, or municipal emergency.
  – When a hospital disaster plan is activated.
  – Any unforeseen disaster or other catastrophic event that substantially affects or increases the need for health care services.
  – When a hospital is diverting patient to another hospital or hospitals for treatment.

Step 3: Staffing Concern/Assignment Despite Objection (ADO) – by WSNA Nursing staff only
When a staff member has discussed their staffing concern with the shift lead/immediate supervisor and is not satisfied with the outcome or solution, the staff member initiates an Assignment Despite Objection (ADO).

Other shop unions have not provided how they prefer to address their staffing concerns as of the date of this charter and amendment will be made when provided.

PHI is not included in the staffing concern report.

• The purpose of reporting a staffing concern is to escalate unresolved concerns to the manager and HSC for review. Ideally, the reporting staff member completes the report prior to the end of the shift in which the concern occurred. The HSC aims to resolve complaints within 90 days of receipt by the co-chairs, or longer with majority approval of the HSC.
• If a concern is resolved during the shift by activating the standard chain of command, an ADO may or may not be completed at the discretion of the staff member. Concerns resolved during the shift are classified as resolved and closed upon staffing committee review.
• A staffing concern report may be submitted to the committee if there is a recurring pattern, even if the immediate concern is resolved.
• Multiple reports submitted for the same occurrence will be reviewed for context and to ensure all information is considered but will be counted as a single occurrence for documentation purposes.

Step 4: Routing of Staffing Concerns

• The staffing committee co-chairs, and the department manager are notified immediately that a report has been filed online via the union website using the ADO template.
  – The union then forwards the submitted ADO form to the Executive Director of Nursing and Unit Manager
  – The Executive Director of Nursing will then forward the completed form to the co-chairs and parties involved for review.
• Delayed or incomplete reports that are missing pertinent information may delay the review process. Efforts to obtain necessary information include, but not be limited to:
  – Contacting the staff member who submitted the report if known.
  – Contacting the shift lead/immediate supervisor on the shift in which the concern occurred.
  – Contacting other staff members working the shift in which the concern occurred.
  – A report may be dismissed by the committee due to insufficient information to investigate the concern.
• The HSC reviews all written reports submitted to the committee regardless of the format used to submit the report.
• The use of a reporting method other than the process outlined above may cause a delay in HSC co-chairs receiving the report.
• The Executive Director of Nursing (or designee) will log the date each report is received and will proceed with the standard review process.

Step 5: Department/Unit Level Review and Action Plan

• Upon receiving a staffing concern, the department manager initiates a department level review. Within 3 days of receiving a concern, the Executive Director of Nursing/designee will notify the staff member in writing via their work email that their concern has been received and will be reviewed by the department manager and HSC.
• The department manager identifies trends and factors that contributed to staffing variances, facilitates problem solving at the department level, and implements and evaluates corrective interventions, as appropriate.
  – The department manager evaluates the effectiveness of interventions with input from staff and makes a recommendation to the HSC regarding classification and future corrective actions.

Step 6: Presentation to the Hospital Staffing Committee

• Prior to a concern being presented to HSC for review, the Executive Director of Nursing/designee will notify the staff member who submitted the concern that their concern is scheduled for HSC review to allow the staff member to arrange for themselves and their labor representative (if desired) to attend the meeting if the staff member wishes to do so.
  – If a staff member is unable to attend the scheduled meeting but still wants to present their concern to HSC directly, they may request that HSC postpone the review of their concern until the next scheduled meeting. If the postponement exceeds the 90-day review period, HSC members will vote on whether to review the concern or extend the review period to allow the staff member to present their concern.
  – Any request to postpone a review and the committee decision will be documented on the complaint tracking log.
• Whenever possible, the staff member and department manager present the concern to the HSC together, along with any corrective action plans, and further recommendations.
  – If the staff member declines to attend the meeting, the department manager/designee presents their recommendations to the
  committee.
• ONLY WSNA HSC members and equal administration will vote on ADOs presented.

Presentations to the HSC use the SBAR format to facilitate clear communication.
Situation – explain the staffing concern or variation.
Background – explain contributing factors, and any identified root cause(s).
Action & Assessment – corrective action taken at the department level and evaluation of effectiveness of attempted solutions.
Recommendations – provide other potential solutions and the recommended classification of the complaint.

Step 7: HSC Complaint Classification
After receiving the department report, the HSC determines classification of each staffing concern and whether additional action is needed to resolve the concern. The following standard definitions are used to classify each concern:

DISMISSED (unsubstantiated data)
Not enough information/detail was provided to investigate.

Unresolved/non-violation
HSC acknowledges that there was a variation from the staffing plan which could not be resolved due to the following circumstances:

• The hospital documented that it made reasonable efforts (RCW 70.41.410) to obtain staffing but was unable to do so.
• The incident causing the complaint occurred during an unforeseeable emergent circumstance (RCW 70.41.410).

RESOLVED
HSC agrees that the complaint has been resolved and designates a resolution level.

• Level 1 – Resolved by immediate supervisor during shift in which concern occurred.
• Level 2 – Resolved at department/unit level with final review by HSC.
• Level 3 – Resolved after HSC action.

IN PROGRESS (awaiting resolution)

• A potential solution or corrective action plan has been identified and initiated.
• Intermediate or contingent designation. May not be the final disposition of a complaint.
• HSC to follow up on the concern to evaluate the effectiveness of the corrective action plan and determine the final disposition of the concern.

ESCALATED (awaiting resolution)

• HSC needs additional assistance and/or resources from senior leadership to address the concern.
• Intermediate or contingent designation. May not be the final disposition of a complaint.
• HSC revisits this concern for further discussion until it can be resolved.

UNRESOLVED

• HSC agrees that the complaint is not resolved or is unable to reach consensus on resolution.
• If a complaint is not classified as dismissed or resolved when presented to the HSC, the committee identifies potential solutions and develops an action plan.
• The committee makes every effort to resolve concerns within 90 days of HSC co-chairs receiving a concern.
  – The HSC extends the review period longer than 90 days with approval from the majority (50 percent plus one) of the committee.
  – Any decision to extend the review period will be recorded by the committee co-chairs on the complaint tracking log.

Step 8: Implementation or Escalation
During this step solution(s) identified by the HSC are implemented as agreed upon in Step 7. If a solution cannot be identified or the committee recognizes that additional resources are needed to implement the plan, the committee may invite other senior leaders or stakeholders to assist in addressing the concern. The committee may repeat Step 7 with additional senior leaders or stakeholders and return to Step 8 when a solution has been identified.

Step 9: Evaluation
After a time agreed upon by HSC members, the HSC reviews and evaluates the effectiveness of the corrective action plan. The committee will reclassify the concern at this time and record the new classification in the complaint tracking log. If the concern is not adequately resolved, the committee may choose to repeat Steps 6 through 9 as many times as necessary to resolve the problem. If this process exceeds 90 days from the date the report was received, the committee will vote on whether to extend the review period.

Step 10: Documentation
Protected health information (PHI) is not included in HSC documentation.

The following information for each staffing concern report is logged on the Staffing Concern Tracker:

• Date the concern was received by the committee.
• Information from the immediate supervisor and/or department manager review including:
  – Precipitating circumstances including unforeseen emergent circumstances if applicable.
  – All efforts to obtain staff, including exhausting reasonable efforts as defined.
  – Other measures taken to ensure patient and staff safety.
  – Rationale for shift-based staffing adjustments based on immediate circumstances
• Initial, contingent, and final deposition.
• Corrective action taken, if necessary.
• Date resolved (within 90 days of receipt or longer with majority approval).
• Attendance by employee involved in complaint and labor representative if requested by the employee.
• Closed-loop written communication to the complainant stating the outcome of the complaint.

Step 11: Closed-Loop Communication
The outcome of each complaint review will be communicated to the staff member who initiated the concern in writing via the staff member’s work email.