Goal 12 Nurse Staffing Compliance Checklist
Goal 12 – NPG.12.02.01: The nurse executive directs and implements a nurse staffing plan.
(Includes NPG.12.03.01 for psychiatric hospitals, if applicable.)
1. Governance & Leadership
Goal 12 Alignment: Supports EP1–EP2 – Nurse executive authority and oversight of staffing operations.
| ☐ | Nurse executive is assigned responsibility for staffing oversight and hospital decision-making |
| ☐ | Organizational chart shows reporting lines for staffing decisions |
| ☐ | Policies define accountability for unit leaders and charge nurses |
2. Staffing Plan
Goal 12 Alignment: Supports EP1, EP2, EP5 – Written staffing plan defining number and
types of nursing staff based on patient needs.
| ☐ | Written staffing plan exists for all units |
| ☐ | Plan includes baseline nurse-to-patient ratios |
| ☐ | Acuity-based staffing methodology is documented |
| ☐ | Skill mix aligns with patient acuity and unit needs |
| ☐ | RN supervises patient care 24/7 across all units |
3. Patient Acuity & Workload Monitoring
Goal 12 Alignment: Supports EP2, EP5 – Ongoing monitoring and adjustment of staffing to match patient acuity and workload.
| ☐ | Daily patient acuity assessments are performed and documented |
| ☐ | Staff assignments are adjusted based on real-time acuity data |
| ☐ | Non-nursing workload factors (procedures, transports, etc.) are considered |
| ☐ | Evidence of staff adjustments during census/acuity fluctuations is recorded |
4. Staff Competency & Readiness
Goal 12 Alignment: Supports EP5 – Verifies that nursing staff have appropriate qualifications and competencies.
| ☐ | Competency matrix exists for all nursing staff |
| ☐ | Training records show ongoing education in high-acuity care |
| ☐ | Orientation & mentorship programs evaluate new staff readiness |
5. Policies & Procedures
Goal 12 Alignment: Supports EP1, EP2, EP4, EP7 – Nursing policies define staffing standards, 24/7 RN coverage, and outpatient criteria.
| ☐ | Staffing policies include minimum standards and escalation procedures |
| ☐ | Escalation steps are documented when staffing cannot meet patient needs |
| ☐ | Policy review dates and revisions are current |
| ☐ | Outpatient department RN exemption policies exist |
6. Data Tracking & Reporting
Goal 12 Alignment: Supports EP1, EP2, EP5 – Documentation and reporting show staffing plan implementation and adequacy.
| ☐ | Daily staffing reports include nurse count, skill mix, and patient acuity |
| ☐ | Monthly/quarterly reports track trends, missed hours, overtime, and acuity mismatch |
| ☐ | Metrics link staffing to patient outcomes (falls, infections, readmissions) |
7. Continuous Improvement
Goal 12 Alignment: Supports EP1–EP2 – Nurse leadership reviews staffing data and drives improvement actions.
| ☐ | Nursing leadership reviews staffing data regularly |
| ☐ | Benchmarking against similar hospitals or units is conducted |
| ☐ | Action plans are in place to address gaps or trends in staffing adequacy |
| ☐ | Meeting minutes document review and follow-up actions |
8. Accreditation Preparation
Goal 12 Alignment: Supports EP1–EP7 and NPG.12.03.01 (if applicable) – Maintains readiness and documentation for survey review.
| ☐ | Policies, procedures, and staffing plans are ready for survey review |
| ☐ | Documentation of daily acuity assessments and corresponding staffing decisions is available |
| ☐ | Competency records, training logs, and orientation documentation are current |
| ☐ | Incident/escalation logs are maintained and accessible |
| ☐ | Continuous improvement evidence (reviews, action plans) is compiled |
Download this checklist as a PDF here, and read the associated blog, “How to Prepare for The Joint Commission Goal 12: Part A – Nurse Staffing, Patient Acuity, and Compliance Readiness.” Read the full blog here.
Would you like to learn more about AcuityPlus, and how it can support your preparation strategy for meeting Goal 12? Contact us for more information.
*This checklist has been created by AcuityPlus by Harris OnPoint for preparation purposes. It is not an official resource provided by The Joint Commission.
