Standards of practice for hospital libraries and librarians, 2022: Medical Library Association Hospital Libraries Caucus Standards Task Force

The Hospital Library Caucus of the Medical Library Association (MLA) follows the practice established in 1953 of developing quality indicators and best practices in the newly developing and fast-changing world of hospital libraries. As these libraries increased in number and prominence, the Joint Commission on the Accreditation of Hospitals (JCAHO) included in 1978 a hospital library standard developed in collaboration with MLA. Subsequent changes in JCAHO, then The Joint Commission (TJC) knowledge management criteria as well as technological changes in the curation and delivery of evidence-based resources influenced standards changes over the years. The 2022 standards mark the most recent edition, replacing the 2007 standards.


BACKGROUND
The Medical Library Association's (MLA's) "Standards for Hospital Libraries" were developed in 2002 as a guide for hospital administrators, librarians, and accrediting bodies to ensure that hospitals have the resources and services to effectively meet their needs for knowledge-based information (KBI) [1]. In approving the original and subsequent revised versions of the standards, the MLA Board of Directors recommended that the Standards Committee of the Hospital Libraries Section continually evaluate the standards and revise them as necessary to reflect changes in the health care environment and MLA priorities. This document reflects the most recent update of these standards.

EXECUTIVE SUMMARY
MLA's "Standards of Practice for Hospital Libraries and Librarians, 2022" have been revised to reflect the technological, environmental, and budgetary changes so visible in hospitals today, with updates to meet the dynamic needs of 21 st century hospital libraries and the institutions they serve. The document serves a two-fold purpose: • as a guide for hospital senior and departmentlevel leaders, librarians, information technology (IT) teams, and accrediting bodies to ensure that libraries have the resources and services to effectively meet the hospital's KBI needs, to support evidence-based practices, quality and safety program development, and improved patient outcomes. • as an organizational benchmark to be used to meet the KBI needs for continuous access to point of care resources, to improve access to documented best practices that improve patient outcomes and contribute to quality and performance improvement initiatives, while being mindful of budget, space, and staffing constraints.
While many of the library practices remain constant over the years, the Committee updated or added content to • demonstrate the commitment to diversity, equity, and inclusion in all health care environments. • create consistency through the use of the broader term "hospital" or "health sciences library" in place of "medical library." • bring to light the increasing involvement of librarians with IT applications and teams, including KBI source links in electronic health records (EHR), mobile application support, and interactions with electronic resource products and vendors. Libraries 2007" and that the publication history be indicated [3].
In October 2019, a discussion ensued regarding a review and update of the existing "Standards for Hospital Libraries 2007." The Hospital Libraries Task Force was formed, with members volunteering to review specific standards for currency and application to modern practices and technologies. Despite COVID-19's impact and after numerous virtual meetings, a final draft was prepared for presentation to the Hospital Library Caucus in the Spring of 2022.

Standard 1:
The librarian serves as the primary department head responsible for managing resources and services to meet the KBI needs of the organization. The library has its own budget, and the library director/manager, as a department head, reports to the senior management of the organization [3,4].
Intent. Library as department. As reflected in Joint Commission resources, access to KBI is an information management requirement for a hospital or health system [5][6][7]. To enable the development of systems, resources, and services to meet this requirement, the needs, concerns, and contribution of the library must be communicated to decision makers at the highest levels in the organization. Departmental status with the librarian in a director/manager level leadership position facilitates this connection. Librarian interaction with other departmental leaders and administrators fosters a deeper understanding of the information needs of the organization. This interaction can also facilitate access to institutional resources and data necessary for providing information to satisfy the needs of hospital senior leaders, clinicians, patients, and family members [8].
In 2022, the MLA issued a statement adding additional support to the provision and maintenance of curated library services.
[Excerpt] "Hospital and health system executives must take concrete action to support clinical and administrative staff, patients and their families, and communities by funding hospital library services led by a professional librarian. Working together, hospitals, health care systems, and librarians are positioned to provide the resources, access, and support your health care teams can depend upon to provide evidence-based practice services that will support healthy patient outcomes." National associations and institutions have endorsed the full statement supporting hospital library departments [9].

Standard 2:
A qualified librarian directs medical research and reference information systems and services. Academy of Health Information Professionals membership is preferred.
Intent. Librarian qualifications. Providing medical, nursing, and clinical information requires specific knowledge and skills related to understanding information management and technologies, meeting rapidly changing user needs in a health care setting and provision of information services and resources aligning with the organization's mission, vision, goals, and strategic plan. Reliance on a commercial electronic resource for clinical information cannot substitute for a qualified medical librarian.
A qualified librarian is a person who has earned a Master's degree from a: • program accredited by the American Library Association (ALA) or its successor accrediting organization [10] or • program in library and information studies accredited or recognized by the appropriate national body of another country As a health information professional, the health sciences librarian possesses unique knowledge, skills and abilities that have been identified as professional competencies. Evidence of continued advancement of these competencies is membership in MLA's Academy of Health Information Professionals (AHIP) [11]. The MLA has developed Competencies for Lifelong Learning and Professional Success outlining the essential professional skills and abilities that are expected of health sciences librarians. Competency areas include information services and management, instruction, leadership, evidence-based practice, research, and professionalism [12].
Provision of health information occurs in a variety of settings including hospitals and health care centers, research, and academic/medical, nursing, and allied health schools. Library and information services are developed that meet the strategic information needs of the individual or group being served. The role of the health sciences librarian may include but is not limited to [13][14]: MLA fosters excellence and is committed to diversity, equity, and inclusion in professional practice, leadership of health sciences libraries, and for information professionals, now and in the future [15].

Intent.
Staffing. An adequately staffed library is necessary to fully serve the KBI needs of the total institutional staff. Consideration for library staffing needs to include an understanding of the user community's information needs, new and potential users, and outreach endeavors that utilize/require library services. Library operations and workload are driven by the staff size, clinical research activities, and mission and complexity of the institution.
As stated in Standard 1, interaction of the librarian with other departmental leaders and administrators fosters a deeper understanding of the information needs of the organization. Working together, librarians, administrators, and stakeholders should decide upon the levels of library services when formulating a service level agreement.
We recommend that each hospital library utilize the grid in Table 1 [19].
The amount of staffing throughout the system should be at least at the level specified in the library staffing formula for minimum level of service (bronze or silver), taking all components and needs of the health care system into account. Whether each hospital or institution is treated separately in determining staffing levels, or the system is taken as a whole, is left to the judgment of the health information professional and administrators. It stands to reason that librarians providing services at the gold level, such as support for systematic reviews and other knowledge synthesis, or research data management, etc.
(or higher in the case of libraries providing services not listed in the HSICT document), will require additional staff. The important point is that staffing is sufficient to serve the number of users and is appropriate for the level of service required to meet the needs of the organization.
The grid in Table 1 may be used to determine appropriate staffing needed by level of service [16]. In establishing library staffing size, consideration must also be given to the service level, hours of operations, and expectations agreed upon by the hospital administrator/hospital leadership team, stakeholders, and library director or information professional. Just having a staffing formula is not enough to accurately determine how best to serve the organization.  [20,23,24]. •

Performance improvement and patient safety:
Active membership of the librarian on performance improvement committees and patient safety teams. Frequent provision of information on which performance improvement and patient safety decisions are based; routing current literature to appropriate individuals, committees, and teams relevant to the hospital's quality indicators, top chronic conditions/diagnoses, performance improvement projects, patient safety goals and/or identified problem areas [25].
• Patient education: Active membership of the librarian on patient education teams; consultation with team concerning selection, creation, and quality filtering of sources for patient education materials; provision of (or facilitation of access to) patient education materials for clinical staff that are diverse, culturally and age-appropriate and understandable; provision and marketing of library services directly to patients and families; and instruction in utilizing online resources for patient education [23]. other resources to support education and training; identification of print and electronic resources to support individualized learning and educational development; participate in continuing medical education (CME), graduate medical education (GME), clinical nursing education(CNE) [26,27].
• Clinical education (nursing) and resident/medical students; provision of specific literature to support grand rounds and related activities; and provision of access and instruction to virtual learning and other technology [28].

Standard 6:
The librarian provides evidence of an ongoing assessment of the information needs of the organization and the development and implementation of a plan to provide appropriate resources, services, and technology to meet those identified needs.

Intent.
Evaluations of KBI needs. The librarian uses a variety of tools and techniques, both formal and informal, direct and indirect, to assess the information needs of the hospital and medical staff. In response, resources and services are made available to meet those identified needs. Techniques may include, but are not limited to, focus groups, library committees, surveys, analysis of usage patterns, budget and strategic planning, inventory of collections, and one-on-one conversations with health care leaders regarding clinical and organizational information needs [29][30][31][32][33].
The librarian assures access to a current and authoritative collection of information that can be used for evidencebased practice, scholarly activity, and continuing education. Key resources, such as print, e-resources, multimedia, databases, etc., can be identified by review products such as Doody's Core Titles or by seeking recommendations from hospital staff or the national hospital library community. Resource-sharing agreements and membership in consortia should be utilized to enable efficient provision of additional resources.
Services should include expert literature searching, document delivery, and interlibrary loan. A recent benchmarking survey may be useful for determining what services other hospital libraries provide. Services should be ongoing and consider timeliness of delivery and user satisfaction [19].
Technology considerations include providing and maintaining a library catalog and/or discovery service to identify and locate library holdings; providing and maintaining a mechanism for remote access of library resources; and integration of library resources within EHR, intranet, and/or public website for easy access A strategic plan can help a librarian analyze trends and anticipate future needs. A plan for providing information needs to take into account the values of the broader organization.

Standard 7:
The library actively promotes KBI services and resources to all user groups and provides documented evidence thereof.
Intent. Service promotion. Promotion increases user awareness and efficient use of the services and resources available [34]. The library serves not only clinical staff, but may serve others, including: • administrative and managerial staff,  [35,36].
Intent. Regulatory compliance. Interlibrary loan, document delivery, and onsite and remote access to subscription resources, as well as copying, faxing and printing of biomedical literature must adhere to vendor license agreements, publishing contracts, and federal and/or international copyright legislation. In addition, the hospital library adheres to the Health Information Portability and Accountability Act (HIPAA) and patient confidentiality when assisting patients, families, health care providers and others who may use the library or any of its services or resources [34,35].  [5,7]. The Accreditation Council for Graduate Medical Education also requires that "Residents must have ready access to specialty-specific and other appropriate reference material in print or electronic format" (I.D.3.) [26].
Continuous access to resources may take multiple forms, depending on the size and structure of the institution. A broad selection of resources should be made available in a physical library and/or through electronic means. Physical resources should be made continually accessible to clinical staff, and the library should provide onsite and remote access to electronic resources.

Standard 10:
The term library refers to the departmentphysical, virtual or a combination thereof-and includes a qualified librarian and support professionals, services, and resources that when put together, best meet the information needs of the health care organization.
Intent. Library as space. The term library has evolved and should reflect the dynamics of the health information world. Given the ever-changing needs of a health care organization, a library must be nimble and flex to meet the needs of users. Traditionally, the library was a physical space located onsite with a print collection. Today a library can be a single physical location that provides resources, staff, and services to one or more facilities, or it could be a completely virtual presence, or any combination of the two. A library that meets the needs of the organization it serves, whether physical, virtual, or a combination of the two is a library that is likely to be wellutilized.
In the case of a physical library, the space should be large enough to accommodate walk-in users and the library staff, any in-house collection(s), and an appropriate number of computer or other IT hardware workstations. Space should permit demonstration of and access to resources and ample seating for users. A separate office for staff ensures privacy of communication among library staff and confidentiality for persons requesting information [37].

Standard 11:
IT resources are available to support the library's mission of providing KBI resources and services.
Intent. IT resources. Adequate IT resources are essential in the provision of up-to-date KBI resources and services. The library must have hardware and library-specific software applications to perform basic functions related to acquiring, organizing, retrieving, and delivering KBI resources to support the institution's mission. The library also must have internet connections with sufficient speed, performance, and bandwidth to access the many webbased resources now available [6,7,[11][12][13]21].
Hospitals have specific security and privacy issues. Therefore, the library director/manager should work in concert with the institution's IT department to assure that users' needs to access essential web-based KBI resources from the point of need are balanced with the network security needs and firewall policies of the institution. Examples of essential information technology resources include: • access to the internet sufficient to use email, DOCLINE, OCLC, PubMed, and any commercial databases and full-text resources to which the library may subscribe, • access should be convenient for all users in the library's institutions twenty-four hours, seven days a week; remote access should be available as licenses permit, • specialized library software that can describe and track library resources and their use (e.g., catalog, circulation, serials control, and/or an integrated library system) appropriate to the library's collection and services; this software can be hosted locally or remotely, and • access to high-bandwidth communication technologies (e.g., full-motion video, video streaming, and webcasting) appropriate to the library's services and its institution's educational programs.

CONCLUSION
As the team worked, we acknowledged that we stood in the shadow of those who went before us. The original Hospital Libraries Section of MLA saw the need for cohesiveness in setting out a philosophy of services unique to those serving the medical profession. Standards established in response to those set forth by the medical associations forged a bond assuring physicians of easy access to authoritative literature. As the fields of medical sciences progressed, so did the need for updated hospital library standards.
The team also stood on the shoulders of our contemporaries. As we looked back and around, we recognized with professional pride how the term "health sciences librarians" easily expanded from serving physicians to including nurses, pharmacists, physical and allied health therapists, technicians, and ultimately administrators. As colleagues, we generously shared our time, wisdom, and experience with each other in revising the 2007 standards. We also accept that new research and knowledge will ultimately require continued and timely revisions.
The Task Force includes representatives from diverse fields with varying levels of experience. Our passion for using our talents to make the best and the latest knowledge available to our health care teams knows no bounds and aims for inclusivity. We offer the 2022 Standards as evidence of our commitment to patient care and safety and clinical education for all staff and patients.