Projections for Saudi Arabia's population growth predict it will reach 39.8 million by 2025, followed by 54.7 million by 2050 (Al-Hanawi, Khan & Al-Borie, 2019). In 2014, within the Kingdom, every 1000 population was served by 11 healthcare professionals; this is half the average rate of 22 healthcare professionals per 1000 population in G20 countries (Al-Hanawi, Khan & Al-Borie, 2019). The establishment of minimum safe staffing requirements has the potential to stabilize the health workforce to meet society's evolving healthcare demands and support the provision of safe patient care.
The assurance of minimum safe staffing requirements is a major strategic intervention to improve the safety of patients and the well-being of health workers. It is the only mechanism to safeguard adequate staffing levels, in all settings, at all times.
Currently, there is a vast variation in staffing levels at healthcare facilities throughout the Kingdom. Such variation in staffing levels negatively impacts the provision of care, resulting in missed care, medical errors, and adverse events leading to avoidable patient harm, including patient death. Variation in staffing levels also negatively impacts health workers at large, with increased levels of work-related injuries, job dissatisfaction, burnout, and turnover. Minimum safe staffing requirements that ensure adequate staffing across the private and public sectors is a required first step to guarantee both staff and patient safety.
Safe staffing is achieved when an appropriate number of health workers are always available across the continuum of care with the correct education, skills/competence, and experience to deliver safe patient care. The evidence is definitive. Healthcare facilities with adequate staffing standards have lower costs through decreased length of stay, prevention of hospital-acquired infections, reduced pressure injuries, fewer medication errors, lower staff turnover, and increased patient and staff satisfaction. Therefore, safe staffing standards are the most cost-effective approach to bringing about improvements in patient safety and the quality of care.
Countries with understaffed healthcare systems endanger their own citizens' health, becoming thereby more vulnerable to crises and their corresponding negative economic and social impact (UN High-Level Commission on Health Employment and Economic Growth, 2016).
Safe staffing levels ensures that the Saudi healthcare system achieves universal health coverage as well as the Kingdom's population health goals for Vision 2030 and national security goals. The implementation of minimum safe staffing requirements across the continuum of care leads to the highest standards of health service coverage and care to the Saudi population, whose rights to the attainment of the most optimal level of personal health is dependent on the availability, accessibility, acceptability, and quality of skilled healthcare professionals (Aba-Namay, 1993 & KSA MoH VRO, n.d.). Minimum safe staffing requirements enhance the safety of care provided to Saudi citizens and ensure the Saudi healthcare workers' protection and growth, thereby promoting the Kingdom's prosperity.
Objectives:
- To guarantee the minimum number of health workers to patient or bed ratio [Health Workers – Patient/Bed Ratios], assuring that the care provided within any given hospital meets patient safety, health worker safety, and quality of care standards.
- To have competent, adequate, motivated, and empowered health workers to carry out their roles and responsibilities at the highest level according to both the scope of practice and scope of service (IOM, 2010).
- To highlight the importance and impact of multidisciplinary health workers teams in improving the safety, efficiency, and effectiveness of the care provided.
- To emphasize the impact of health worker–patient ratios on health workers' well-being.
- To promote the application of best research-based evidence onto the health Worker–patient/bed ratios decision-making process.
- To align the health workers–patient/bed ratios with the overall goals of the Saudi Healthcare System Transformation and National Workforce Planning.
SSL.1. The hospital has a Multidisciplinary Clinical Team (MDCT) inclusive of care process and communication.
SSL.1.1. The hospital has a policy for the Multidisciplinary Clinical Team (MDCT).
SSL.1.2. Multidisciplinary Clinical Care Teams (MDCT) are comprised of the Most Responsible Physician (MRP), other physicians, in the critical care setting, the consultant of the primary service under which the patient was first admitted, pharmacists, clinical pharmacists, nurses, and allied healthcare providers.
SSL.1.3. Hospital leaders conduct multidisciplinary leadership safety walkrounds with MDCT members, engaging direct-care clinical, patients and families.
SSL.1.4. The MDCT practices effective communication amongst the MDCT members and with patients and families.
SSL.1.5. The hospital adopts team-based training to improve the performance of the MDCT.
SSL.1.6. The hospital has standardized patient handover and endorsement process of patients during change of shift, transition of care (to higher or lower levels of care), and for the transfer of patient responsibility.
Explanation:
The hospital has a policy and procedures with clear terms of references that highlight the overall details of the MDCT approach, including team members, frequency, communication, and documentation in the Medical Record. It is essential that for each patient, an MDCT is identified. Each team is led by the MRP (Consultant or Board-Certified Physician), in addition to the unit nurses, specialized nurses, other physicians from the team, pharmacists, and allied healthcare professionals (as needed).
To show their accountability to safety, the hospital leadership conducts regular Safety WalkRounds. Such practice helps bring safety concerns to leadership by staff from all levels during leadership safety rounds.
For the MDCT to be effective and safe, it must practice effective communication (in the preferred language of the patient/family). The communication is patient-centered and engages patients and families in the decision-making and treatment plan. The hospital strives to have team-based, simulated training especially in high-risk departments (Critical Care, OR, OB/L&D, and Emergency Department).
To guarantee the quality and safety of patients, there is an effective Patients' Handover process that assures all of the patients' pertinent information is shared between the outgoing and incoming clinical teams (physicians, nurses and allied health), as well as whenever there is a transition of care of patients from one unit to another.
SSL.2. The hospital supports staff well-being.
SSL.2.1. The hospital has an employee wellbeing program, inclusive of the management of a work-life balance and healthy lifestyle programs.
SSL.2.2. The hospital has policies and processes for the resolution of workplace issues, with measures to reduce workplace incivility, harassment and violence.
SSL.2.3. The hospital has clear policies and processes for performance management, corrective disciplinary action, including the management of underperformance and staff a grievance process.
SSL.2.4. The hospital has a policy and processes for Anti-retaliation protecting individuals who raise or report ethical violations, legal wrongdoings, and/or safety concerns within an organization from retaliation or mistreatment, loss of pay, demotion, slander, non-contracting, or termination.
Explanation:
The hospital has a Staff Wellbeing Policy/Program (WHO, 2020). The policy includes the following areas:
- Promoting civility and addressing incivility/abuse.
- Incentives to promote reporting staff safety-related adverse events, near misses, or other concerns
- Prevent/address burnout
- Counseling
- Dedicated coordinator/team
- Work/life balance programs and facilities including breakrooms
SSL.3. The hospital has qualified staff in clinical and non-clinical areas.
SSL.3.1. The multidisciplinary Human Resources (HR) committee addresses all strategic human resources decisions, inclusive of manpower needs assessments, staff ratios, and succession planning.
SSL.3.2. All clinical services are led by an accountable qualified consultant physician head of department (HOD) who provides direct leadership, overseeing all departmental aspects, including scope of services, policies, processes, morbidity and mortality review, and clinical and operational KPIs.
SSL.3.3. The chief nursing officer holds a baccalaureate degree in nursing and a SCFHS as a specialist or higher.
SSL.3.4. The deputy chief nursing officer holds a baccalaureate degree in nursing and SCFHS as a specialist or higher.
SSL.3.5. All clinical areas/units have an accountable qualified, manager/supervisor providing direct leadership, overseeing assigned non-physician staff and department aspects per their scope, and adherence to scope of service, policies, processes, and clinical and operational KPIs.
SSL.3.6. All senior nurse leaders/director level accountable for the ED, critical care (ICU, PICU & NICU), CCU, OR, PACU, oncology and hemodialysis hold a baccalaureate degree in nursing and SCFHS as a specialist or higher.
SSL.3.7. The nurse manager of the CCU holds a baccalaureate degree in nursing and SCFHS as a specialist or higher.
SSL.3.8. The nurse manager of hemodialysis holds a baccalaureate degree in nursing and SCFHS as a specialist or higher.
SSL.3.9. The nurse manager of oncology units or outpatient settings holds a baccalaureate degree in nursing and SCFHS as a specialist or higher.
SSL.3.10. There is s staffing plan which supports sufficient and agile staffing for all clinical and non-clinical areas.
SSL.3.11. Each defined area or service has staffing plan customized for its scope of service, staff skill-mix, staff competency, physical characteristics, volumes, and for clinical areas, specialties and patient acuity, as well as quality and safety requirements.
SSL.3.12. The hospital has policies and programs to float and cross-train employees between clinical areas.
Explanation:
The effective policy for staffing (WHO, 2020; SPSC, 2019) highlights the following:
· Linked to the budget and budget cycles.
· Agility- linked to professions' supply and demand.
· Adaptability /Adjustable to changing conditions (internal and external).
· Linked to the hospital scope of service (current and future)
The health workers' staffing plan reflects the following influencing factors:
· Clinical Specialty, Scope of Service, Scope of Practice.
· Acuity of Care.
· Skill Mix – Experience, Qualification and Competencies the hospital workforce.
· Maximum allowed working hours per staff (day, week, and month).
· Volume.
· The clinical unit physical layout.
SSL.4. The hospital complies with the minimum nurse staffing standards in all clinical areas at all times.
SSL.4.1. Nurse staffing in the Emergency Department meets the minimum staffing requirements at all times.
SSL.4.2. Nurse staffing in the Adult Intensive Care Unit meets the minimum staffing requirements at all times.
SSL.4.3. Nurse staffing in the Adult and Pediatric Cardiovascular Intensive Care Unit(s) meets the minimum staffing requirements at all times.
SSL.4.4. Nurse staffing in the Cardiac Care Unit meets the minimum staffing requirements at all times.
SSL.4.5. Nurse staffing in the Pediatric Intensive Care Unit meets the minimum staffing requirements at all times.
SSL.4.6. Nurse staffing in the Neonatal Intensive Care Unit(s) meets the minimum staffing requirements at all times.
SSL.4.7. Nurse staffing in the Antenatal Ward (latent phase/induction area) meets the minimum staffing requirements at all times.
SSL.4.8. Midwives and nurse staffing in the Labor Room – Not in Active Labor and Active Labor meets the minimum staffing requirements at all times.
SSL.4.9. Nurse staffing in the Post-partum- “MOTHER-BABY SET" model of care meets the minimum staffing requirements at all times
SSL.4.10. Nurse staffing in the Post-partum- “MOTHER ONLY" model of care meets the minimum staffing requirements at all times.
SSL.4.11. Nurse staffing in the Well Baby Nursery meet the minimum staffing requirements at all times.
SSL.4.12. Nurse staffing in the Burn Unit meets the minimum staffing requirements at all times.
SSL.4.13. Nurse staffing in the Step-Down Unit/High-Dependency Unit/ Intermediate Care/ Chronic Ventilation Unit meets the minimum staffing requirements at all times.
SSL.4.14. Nurse staffing in the Operating Room (moderate and major cases) meets the minimum staffing requirements at all times.
SSL.4.15. Nurse staffing in the Recovery Room/PACU meets the minimum staffing requirements at all times.
SSL.4.16. Nurse staffing in the Cath. Lab meet the minimum staffing requirements at all times.
SSL.4.17. Nurse staffing in Endoscopy meet the minimum staffing requirements at all times.
SSL.4.18. Nurse staffing in the Radiology Department: Diagnostic/Interventional meets the minimum staffing requirements at all times.
SSL.4.19. Nurse staffing in Hemodialysis meets the minimum staffing requirements at all times.
SSL.4.20. Nurse staffing in the Telemetry Unit meets the minimum staffing requirements at all times.
SSL.4.21. Nurse staffing in the Oncology Unit and Clinics meets the minimum staffing requirements at all times.
SSL.4.22. Nurse staffing in the Adult and Pediatric Bone Marrow Transplant meets the minimum staffing requirements at all times.
SSL.4.23. Nurse staffing in the Medical Adult Unit meets the minimum staffing requirements at all times.
SSL.4.24. Nurse staffing in the Surgical Adult Unit meets the minimum staffing requirements at all times.
SSL.4.25. Nurse staffing in the Medical Pediatric Unit meets the minimum staffing requirements at all times.
SSL.4.26. Nurse staffing in the Surgical Pediatric Unit meets the minimum staffing requirements at all times.
SSL.4.27. Nurse staffing in Adult Psychiatric Unit meets the minimum staffing requirements at all times.
SSL.4.28. Nurse staffing in the Adolescent Psychiatric Unit meets the minimum staffing requirements at all times.
SSL.4.29. Nurse staffing in the Pediatric Psychiatric Unit meets the minimum staffing requirements at all times.
SSL.4.30. Nurse staffing in the Rehabilitation Unit meets the minimum staffing requirements at all times.
SSL.4.31. Nurse in Ambulatory Care/Out-Patient Department meets the minimum staffing requirements at all times.
Explanation:
To assure staffing processes and allocations promote safety and well-being for both employees and patients.
Table 1.: Safe Staffing Minimum Requirements.
SSL.5. The hospital complies with the minimum staffing standards for all physician and allied health staff in all clinical areas at all times.
SSL.5.1. Physician and allied health staffing in the Emergency Department meets the minimum staffing requirements at all times.
SSL.5.2. Physician and allied health staffing in the Adult Intensive Care Unit meets the minimum staffing requirements at all times.
SSL.5.3. Physician and allied health staffing in the Adult and Pediatric Cardiovascular Intensive Care Unit(s) meets the minimum staffing requirements at all times.
SSL.5.4. Physician and allied health staffing in the Cardiac Care Unit meets the minimum staffing requirements at all times.
SSL.5.5. Physician and allied health staffing in the Pediatric Intensive Care Unit meets the minimum staffing requirements at all times.
SSL.5.6. Physician and allied health staffing in the Neonatal Intensive Care Unit(s) meets the minimum staffing requirements at all times.
SSL.5.7. Physician and allied health staffing in the Antenatal Ward (latent phase/induction area) meets the minimum staffing requirements at all times.
SSL.5.8. Physician and allied health staffing in the Labor Room – Not in Active Labor and Active Labor meets the minimum staffing requirements at all times.
SSL.5.9. Physician and allied health staffing in the Post-partum- “MOTHER-BABY SET" model of care meets the minimum staffing requirements at all times
SSL.5.10. Physician and allied health staffing in the Post-partum- “MOTHER ONLY" model of care meets the minimum staffing requirements at all times.
SSL.5.11. Physician and allied health staffing in the Well Baby Nursery meet the minimum staffing requirements at all times.
SSL.5.12. Physician and allied health staffing in the Burn Unit meets the minimum staffing requirements at all times.
SSL.5.13. Physician and allied health staffing in the Step-Down Unit/High-Dependency Unit/ Intermediate Care/ Chronic Ventilation Unit meets the minimum staffing requirements at all times.
SSL.5.14. Physician and allied health staffing in the Operating Room (moderate and major cases) meets the minimum staffing requirements at all times.
SSL.5.15. Physician and allied health staffing in the Recovery Room/PACU meets the minimum staffing requirements at all times.
SSL.5.16. Physician and allied health staffing in the Cath. Lab meet the minimum staffing requirements at all times.
SSL.5.17. Physician and allied health staffing in Endoscopy meet the minimum staffing requirements at all times.
SSL.5.18. Physician and allied health staffing in the Radiology Department: Diagnostic/Interventional meets the minimum staffing requirements at all times.
SSL.5.19. Physician and allied health staffing in Hemodialysis meets the minimum staffing requirements at all times.
SSL.5.20. Physician and allied health staffing in the Telemetry Unit meets the minimum staffing requirements at all times.
SSL.5.21. Physician and allied health staffing in the Oncology Unit and Clinics meets the minimum staffing requirements at all times.
SSL.5.22. Physician and allied health staffing in the Adult and Pediatric Bone Marrow Transplant meets the minimum staffing requirements at all times.
SSL.5.23. Physician and allied health staffing in the Medical Adult Unit meets the minimum staffing requirements at all times.
SSL.5.24. Physician and allied health staffing in the Surgical Adult Unit meets the minimum staffing requirements at all times.
SSL.5.25. Physician and allied health staffing in the Medical Pediatric Unit meets the minimum staffing requirements at all times.
SSL.5.26. Physician and allied health staffing in the Surgical Pediatric Unit meets the minimum staffing requirements at all times.
SSL.5.27. Physician and allied health staffing in Adult Psychiatric Unit meets the minimum staffing requirements at all times.
SSL.5.28. Physician and allied health staffing in the Adolescent Psychiatric Unit meets the minimum staffing requirements at all times.
SSL.5.29. Physician and allied health staffing in the Pediatric Psychiatric Unit meets the minimum staffing requirements at all times.
SSL.5.30. Physician and allied health staffing in the Rehabilitation Unit meets the minimum staffing requirements at all times.
SSL.5.31. Physician and allied health staffing in Ambulatory Care/Out-Patient Department meets the minimum staffing requirements at all times.
Explanation:
To assure staffing processes and allocations promote safety and well-being for both employees and patients.
Table 1.: Safe Staffing Minimum Requirements.
SSL.6. The hospital complies with the minimum standards for service-based hospital staffing.
SSL.6.1. Pharmacist staffing meets the minimum staffing requirements at all times.
SSL.6.2. Pharmacy Technician staffing meets the minimum staffing requirements at all times.
SSL.6.3. Medical Laboratory Technician staffing meets the minimum staffing requirements at all times.
SSL.6.4. Radiology Technician staffing meets the minimum staffing requirements at all times.
SSL.6.5. Physiotherapy staffing meets the minimum staffing requirements at all times.
SSL.6.6. Occupational Therapy meets the minimum staffing requirements at all times.
SSL.6.7. Social Services staffing meets the minimum staffing requirements at all times.
SSL.6.8. Palliative Care staffing meets the minimum staffing requirements at all times.
SSL.6.9. Dietary Services staffing meets the minimum staffing requirements at all times.
SSL.6.10. Quality & Patient Safety Specialists staffing meets the minimum staffing requirements at all times.
SSL.6.11. Infection Prevention & Control Specialist staffing meets the minimum staffing requirements at all times.
SSL.6.12. CSSD staffing in hospitals with bed capacity 100 beds meets the minimum staffing requirements at all times.
SSL.6.13. CSSD staffing in hospitals with bed capacity > 100 meets the minimum staffing requirements at all times.
SSL.6.14. Diabetic Educator staffing meets the minimum staffing requirements at all times.
SSL.6.15. Environmental Services staffing meets the minimum staffing requirements at all times.
SSL.6.16. Unit Clerks /Ward Clerks staffing meets the minimum staffing requirements at all times.
SSL.6.17. Porter staffing meets the minimum staffing requirements at all times.
SSL.6.18. Clinical Coder staffing meets the minimum staffing requirements at all times.
SSL.6.19. Emergency Medical Services staffing meets the minimum staffing requirements at all times.
SSL.6.20. Dental Services staffing meets the minimum staffing requirements at all times.
Explanation:
To assure staffing processes and allocations promote safety and well-being for both employees and patients.
Table 1.: Safe Staffing Minimum Requirements.
SSL.7. There is an effective Business Continuity Plan (BCP) for dealing with disasters and emergencies.
SSL.7.1. The Business Continuity Plan (BCP) is activated by clear criteria during disasters and emergencies.
SSL.7.2. The hospital establishes a multidisciplinary team led by the CEO (or senior executive) to ensure effective implementation of the BCP.
SSL.7.3. The BCP focuses on the continuity of critical processes, functions, and mission-essential services of the hospital.
SSL.7.4. The BCP has a robust staffing component to plan and re-assign hospital staff according to the need to maintain patient safety, staff safety, and continuity of essential services.
Explanation:
To develop a BCP for the hospital to continue delivering healthcare services at an acceptable predefined threshold following any disruptive incidence/disaster or crisis (man-made and/or natural).
BCP is activated using a pre-defined criterion. The hospital establishes a multidisciplinary BCP team (taskforce), to ensure that the BCP is implemented effectively. The multidisciplinary BCP team (taskforce) is empowered and accountable to provide prompt action. The CEO (or a senior executive) chairs the BCP task force to assure its effectiveness.
The objective of the BCP is to minimize the impact of disasters/emergencies on the safety of patients and healthcare workers while maintaining essential operations during the response and recovery period. Disasters/emergencies can negatively disrupt daily operations and clinical services.
The hospital's BCP has a core component that addresses the healthcare staffing of clinical units/services to guarantee the agility of the response and the safety of patients and healthcare workers.
Table 1. Safe Staffing Minimum Requirements The following are the minimum safe staffing requirements for health workers ratio per patient, per bed or as listed.
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Safe staffing requirements can be influenced by the following factors (when applicable), which include but are not limited to the following: - Designated hospital level, as per MOH definition. - Status of open or closed Intensive Care Unit (ICU). - Patient acuity or dependency, regardless of patient location. - Occupancy rates (average daily census). - Health workers' experience and competence (i.e., skill-mix). - Patient volume/turnover: it includes planned and unplanned admissions, discharges, and transfers per 24-hour period. - Unit physical layout: consider the safety of patients who may need closer observation, the distance that staff must travel to access resources within the unit. - Availability of or proximity to technological support, automation and/ or other resources including, but not limited to electronic medical record (EMR), Pyxis systems, pneumatic tubes systems and pharmacy staff to prepare medications. - Other patient/family-specific factors. NOTE1: These numbers and ratios do not allow for replacement or substitution: [i.e., Pharmacy Technicians do not replace Pharmacists or non-nurse licensed ancillary staff do not replace licensed nurses]. NOTE2: All professional categories are defined and licensed as per the Saudi Commission for Health Specialties (SCFHS). |
| | Clinical units | Physicians |
Nurses/Midwives (when applicable) | Respiratory Therapists & Ancillary Staff (when applicable) |
| | Emergency Room | 1:2.5 patients or fewer per hour [Augustine, 2016] | 1:3 patients or fewer [SPSC 2019 & NNEP, 2020] 1 supernumery charge nurse at all times | Per hospital inpatient bed coverage. |
| | Adult Intensive Care Unit/Cardiovascular Intensive Care Unit | ICU Consultant 1:20 patients or fewer ICU Specialist 1:10 patients or fewer ICU Resident 1:5 patients or fewer [MOH, 2018]
| 1:2 patients or fewer (Ratios can be either 1:2, 1:1 or 2:1 or more if needed) [SPSC 2019 & NEEP,2020] 1 supernumery charge nurse at all times
| RTs 1:5 patients or fewer [MOH, 2018] Clinical Pharmacist 1:20patients Clinical Dietician 1:20patients 1 Physiotherapist |
| | Cardiac Coronary Unit | ICU Consultant 1:20 patients or fewer ICU Specialist 1:10 patients or fewer ICU Resident 1:5 patients or fewer [MOH, 2018] |
1:3 patients or fewer [SPSC 2019 & NEEP 2020] 1 supernumery charge nurse at all times | RTs 1:5 patients or fewer [MOH, 2018] |
| | Pediatric Intensive Care Unit | ICU Consultant 1:20 patients or fewer ICU Specialist 1:10 patients or fewer ICU Resident 1:5 patients or fewer [MOH, 2018] | 1:2 patients or fewer (Ratios can be either 1:2, 1:1 or 2:1 or more if needed) [SPSC 2019 & NEEP,2020] 1 supernumery charge nurse at all times | RTs 1:5 patients or fewer [MOH, 2018] |
| | Neonatal Intensive Care Unit | ICU Consultant 1:20 patients or fewer ICU Specialist 1:10 patients or fewer ICU Resident 1:5 patients or fewer [MOH, 2018] | LEVEL 3 - 1:1 patient (Ratios can be either 1:1 or 2:1 or more if needed) LEVEL 2 - 1:3 patients or fewer [SPSC 2019, NNEP, 2020] 1 supernumery charge nurse at all times, per unit level of neonatal care/unit | RTs 1:5 patients or fewer [MOH, 2018] |
| | Antenatal Ward: latent phase/induction area) | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:6 patients or fewer [Stones et al, 2019] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Labor Room | | | | |
| | Not In active labor | Enough OB/Gyn specialists or midwives to meet the active labor requirements (3.1.7.2.) and as per CBAHI Safe Labor and Birth Standards. | 1:2 patients or fewer. Staff is either a licensed and privileged midwife or a competent/experienced Labor & Delivery (L&D) nurse as per the International Confederation of Midwives, with NRP. [CBAHI Safe Labor & Birth, 2021, SPSC, 2019, NNEP, 2020, & Stones et al. 2019] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Active labor | 2 or more:1 – of which at a minimum 1 of the clinicians (physician or midwife) is privileged to deliver and the others are "skilled" (i.e., competent per the International Confederation of Midwives, with NRP and experienced in L&D) [CBAHI Safe Labor & Birth, 2021, SPSC, 2019 & SPSC, 2020, Stones et al. 2019] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Post-partum | | | | |
| | “MOTHER-BABY SET" model of care | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:4 patients or fewer [SPSC, 2019 & NEEP, 2020] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | “MOTHER ONLY" model of care | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:6 patients or fewer [SPSC, 2019 & NEEP, 2020] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Well Baby Nursery | Covered by NICU medical staff. | 1:8 patients or fewer [SPSC, 2019 & NEEP, 2020] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Burn Unit | Consultant 1:20 patients or fewer Specialist 1:10 patients or fewer Resident 1:5 patients or fewer [MOH, 2018] | 1:2 patients or fewer (Ratios can be either 1:2, 1:1 or 2:1 or more if needed) [SPSC 2019 & NEEP,2020] 1 supernumery charge nurse at all times | RTs 1:5 patients or fewer [MOH, 2018] |
| | Step-Down Unit/High-Dependency Unit/Intermediate Care/Chronic Ventilation Unit or Patient | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:3 patients or fewer [NNEP, 2020, MOH 2018] 1 supernumery charge nurse at all times | RTs 1:5 patients or fewer [MOH, 2018] |
| | Operating Room (moderate and major cases) | 1 Primary Surgeon and 1 Assistant (scrub-in):1 case, as per case classification (Expert Opinion, 2021). 1 Anesthesiologist assigned to each operating room/ongoing case. May increase to 2:1 based on case classification. (CBAHI Standards Peri-Op 4th edition, 2021 & Expert Opinion, 2021). | 3 or more:1 For moderate or major cases. Fewer nurses for minor cases. [NEEP, 2020] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Recovery Room | 1 Anesthesiologist assigned per Recovery Room. (CBAHI Standards Peri-Op 4th edition, 2021 & Expert Opinion, 2021). | 1:2 patients or fewer (Ratios can be either 1:2, 1:1 or 2:1 or more if needed) [SPSC 2019 & NEEP, 2020] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Cath Lab | 1 Attending Consultant and an additional board-certified physician as needed per case definition (diagnostics vs. interventional (Expert Opinion, 2021). | 2 or more:1 patient [NEEP, 2020] & 1 Radiology/Cath Lab Technician. 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Endoscopy Unit | 1 Attending Consultant and an additional board-certified physician as needed per case definition (diagnostics vs. interventional (Expert Opinion, 2021). | 2 or more:1 patient [NEEP, 2020] & 1 Radiology/Endoscopy Technician (as required). 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Radiology Department: Diagnostic/Interventional | 1 Radiologist per hospital or 1:100 beds or fewer (MOH, 2018] and 1 Medical Physicist per hospital | 2 or more:1 patient [NEEP, 2020] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Oncology | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer | 1:3 patients or fewer [SPSC, 2019 & NEEP, 2020] 1 supernumery charge nurse at all times
| RTs Per hospital inpatient bed coverage. Clinical Pharmacist 1:20 |
| | Bone Marrow Transplant (Adult and Pediatric) | BMT Consultant 1:20 patients or fewer BMT Specialist 1:10 patients or fewer BMT Resident 1:5 patients or fewer | 1:2 patients or fewer [SPSC, 2019 & NEEP, 2020] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. Clinical Pharmacist 1:20 |
| | Hemodialysis Unit | 1 Nephrologist per hospital then 1: 200 patients or fewer at any given time (Harley et al, 2013). 1 Consultant Nephrologist:15 or fewer HD stations 1 specialist:10 or fewer HD stations 1 Resident 1:15 or fewer HD stations (MOH, n.d.) | 1:3 HD stations or fewer [NEEP, 2020] 1 Dialysis Technicians:3 machines 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Telemetry | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:4 patients or fewer [SPSC, 2019 & NEEP, 2020] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Medical Adult | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:5 patients or fewer [SPSC 2019 & NNEP,2020] 1 supernumery charge nurse at all times | RTs 1:15 beds or fewer [MOH, 2018] |
| | Medical Pediatrics | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:4 patients or fewer [SPSC 2019 & NNEP,2020] 1 supernumery charge nurse at all times | RTs 1:15 beds or fewer [MOH, 2018] |
| | Surgical Adult | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:4 patients or fewer [SPSC 2019 & NNEP,2020] 1 supernumery charge nurse at all times | RTs 1:15 beds or fewer [MOH, 2018] |
| | Surgical Pediatrics | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:4 patients or fewer [SPSC 2019 & NNEP,2020] 1 supernumery charge nurse at all times | RTs 1:15 beds or fewer [MOH, 2018] |
| | Adult Psychiatric | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:3 patients or fewer & Suicidal patients 1:1 [NEEP, 2020] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Adolescent Psychiatric | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:2 or fewer & Suicidal patients 1:1 [NEEP, 2020] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Pediatrics Psychiatric | Consultant: 1:140 patients or fewer Specialist: 1:70 patients or fewer Resident 1:21 patients or fewer [MOH, 2018] | 1:1 patient & Suicidal patients 1:1 [NEEP, 2020] 1 supernumery charge nurse at all times | RTs Per hospital inpatient bed coverage. |
| | Rehabilitation | Consultant and Specialist 1:140 patients or fewer Psychiatric Consultant and Specialists: 1:30 patients or fewer Resident 1:50 or fewer [MOH, 2018]
| 1:7 patients or fewer [MOH,2018; SPSC 2019] 1 supernumery charge nurse at all times
| RTs 1:30 patients or fewer [MOH, 2018] |
| | Ambulatory Care/Out-Patient Department | 1 Board Certified physician per designated clinic. [Expert Opinion, 2021]. | A licensed nurse is required only for procedural areas or highly specialized/expert nursing care, as per the scope of nurse practice. Non-nurse licensed ancillary staff to cover activities and assist the physician, as per documented competency (i.e., vital signs, glucose monitoring, etc.). The non-licensed ancillary staff as patient chaperone duties and administrative assistance to the physician. [Expert Opinion, 2021] [NEEP, 2020].
| RTs Per hospital inpatient bed coverage. |
| | | | | | |
| Pharmacists | 1:5 inpatient beds [Schneider et al, 2019]. In the outpatient setting 1:80-120 prescribed items per 8-hour shift [Expert Opinion, 2021] |
| Pharmacy Technicians | 1:10 inpatients beds [Schneider et al, 2019] In the outpatient setting 1:80-120 prescribed items per 8-hour shift [Expert Opinion, 2021] |
| Medical Laboratory Technicians | 1:70 beds or fewer [MOH, 2018] Note: 1:50 or fewer for ICU and Chronic Ventilator Beds/patients (MOH, 2018) |
| Radiology Technicians | 1:50 beds or fewer [MOH, 2018] Note: 1:30 or fewer for ICU and Chronic Ventilator Beds/patients [MOH, 2018]. Each Radiology Department to have at a minimum 1 technician per shift per department |
| Physiotherapy | 1:50 beds or fewer [MOH, 2018] |
| Occupational Therapy | 1:30 beds or fewer [MOH, 2018] |
| Social Services | 1:70 beds or fewer [MOH, 2018] |
| Palliative Care | Nurse 1:4 patients or fewer [NNEP, 2020] |
| Dietary Services | 1:25 to 50 beds [MOH, 2018; Cartmill et al, 2013] |
| Quality & Patient Safety Specialists | 1:100 beds [MOH, 2018] |
Infection Prevention & Control Specialist | 1:50 beds [CBAHI, 3rd version] |
| CSSD [hospitals with bed capacity 100 beds or less] | 1 CSSD worker:20 beds or fewer & 1 additional CSSD worker per 100 surgical procedures done per month but with a minimum of 3 CSSD workers. Note: Facilities without OR and no surgical procedures done on-site a minimum of 3 CSSD workers is required [MOH, 2021] |
| CSSD [hospitals with bed capacity > 100 beds] | 1 CSSD worker:50 beds or fewer & 1 additional CSSD worker per 100 surgical procedures done per month but with a minimum of 5 CSSD workers. Note: Facilities without OR and no surgical procedures done on-site a minimum of 3 CSSD workers is required [MOH, 2021] |
| Diabetic Education | 1:50 beds or fewer (Expert Opinion, 2021) |
| Environmental Services | 1:2 hospital beds [Ministry 0f Health and Family Welfare Government of India, 2015] |
| Unit Clerks /Ward Clerks | 1 clerk per inpatient unit 24/7. On nights and weekends, 1 clerk may cover 2 units based on occupancy rates, training/competency, and geographic proximity. |
| Porters | Enough porters are, available based on occupancy/volume, to ensure nurses do not leave the unit for routine, stable patient transport (i.e., not requiring primary assigned nurse, RT or physician to accompany the patient). ED, ICU and OR require porters designated/assigned to their unit/area. Other units may either have a porter pool/assigned porter to their unit. |
| Clinical Coders | Inpatients - 1 Clinical Coder:20 episodes' reviews per/day Day Medical and Surgical - 1 Clinical Coder:40 patient files' reviews per/day [Case mix Center of Excellence, Saudi Arabia, 2021; AHIMA, McKenzie K., et al., 2004]
|
| Emergency Medical Services | Three (3) EMS (Paramedic and EMTs) staff per ambulance transport (inclusive that one of the three professionals is performing the driving skills). EMS transport includes 1 paramedic or higher HW. [Expert Opinion, 2021] |
| Dental Services | 1 Dentist:1 patient Licensed dental technician or equivalent required only for procedural areas or highly specialized/expert dental care, as per the scope of practice. Non-technician licensed ancillary staff to cover activities and assist the dentist, as per documented competency. The non-licensed ancillary staff as patient chaperone duties and administrative assistance to the dentist. [Expert Opinion, 2021]. |
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