Improvizations, LLC (Improv), a strategic advisory, implementation, and managed support firm for Human Capital Management and Workforce Management initiatives, has launched the Inman Healthcare STAR Framework, a diagnostic and implementation engagement designed to help hospitals and health systems build the staffing governance infrastructure required to achieve and sustain Joint Commission accreditation.
The proprietary framework – developed by Dr. Sarah Inman, DHA, SHRM-CP and SVP Healthcare at Improv – was developed in direct response to the Joint Commission’s NPG 12 standard, which requires healthcare organizations to demonstrate that staffing decisions are based on patient need, documented at the point of decision, and overseen by accountable executive leadership at every level of the organization.
The STAR Framework scores healthcare organizations across five domains of staffing governance: Staffing Decision Process, Quality and Safety Alignment, Executive Accountability, Documentation and Audit Readiness, and Competency Integration. Each domain is scored on a validated 1.0 to 5.0 scale, producing an overall STAR level that tells leadership where the organization stands, what its current accreditation risk posture is, and what specific work is required to reach a defensible Level 4 or Level 5 designation.
The framework is designed to close the gap between what organizations believe their governance looks like and what a surveyor actually observes when they walk through the door.
The full STAR framework engagement from Improv is structured in four phases.
- Phase one conducts the scored governance assessment.
- Phase two addresses governance and policy alignment, ensuring that named leaders at every level have formally defined, actively exercised roles.
- Phase three focuses on operational standardization and adoption, translating governance structures into unit-level standard operating procedures that function in daily operations rather than on paper alone.
- Phase four delivers a mock survey and readiness validation, giving leadership teams direct experience with the questions and evidence standards they will face on survey day.
Organizations that complete the engagement receive a confirmed STAR level designation with full supporting documentation, NPG 12-aligned policies, unit-level standard operating procedures, a trained leadership culture from charge nurse to board, a documented escalation framework, an adoption metrics dashboard, and a board reporting template that frames staffing as a patient safety matter. The framework is built to leave governance infrastructure that sustains itself after the engagement ends.
The assessment is designed for hospitals and health systems preparing for Joint Commission survey, organizations implementing or optimizing centralized staffing, and leaders seeking to get ahead of NPG 12 requirements before survey day.
It carries particular urgency for organizations that received staffing-related findings in a prior survey, systems where the CNO and CFO describe staffing governance differently, and hospitals relying on agency labor or float pool without documented competency verification.
“Most organizations believe their staffing governance is stronger than it is. The gap between what leadership thinks is in place and what a surveyor actually observes is where accreditation risk lives. The Inman STAR Framework was built to close that gap honestly, before survey day, not after,” said Dr. Sarah Inman, MHA, DHA, SHRM-CP, SVP Healthcare Strategy and Partner at Improv.
Healthcare leaders ready to assess their current readiness posture can request a discovery assessment through the Improv STAR Framework page. The discovery assessment takes less than a day and delivers a clear, actionable baseline. Organizations can also learn more about Improv’s broader healthcare workforce management solutions.
About Improv
Improvizations, LLC (Improv) offers strategic advisory, implementation and managed support for Human Capital Management (HCM) and Workforce Management (WFM) initiatives. With decades of proven success, Improv helps companies simplify their transformations and evolve with clarity. Their Elevated Suite of services supports every stage of the WFM/HCM journey. From igniting strategy to forging solutions and evolving performance, they provide the flexibility to start anywhere and deliver measurable results that last. Their industry-specific expertise, adaptable solutions, and technology independence drive measurable outcomes for the businesses and industries they serve. Connect with them at www.improvizations.com.