WGU Accreditation Audit: RAFT Task 1
Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013).
The Standards of Universal Protocols (UP) are: UP 01.01.01 Conduct pre-procedure verification process
UP 01.02.01 Mark the procedure site
UP 01.03.01 Perform a Time-Out before the procedure.
To
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Responsible Party: Surgery Leadership Committee. This is the committee who approved the Site Identification and Verification document.
Due Date: Document will be due at the committee’s second meeting from now. If the committee meets monthly, they will have the first month to assign the revision. The document will be due at the next meeting.
Results measured: Revised document will be provided for Surgery Leadership Committee to compare with recommendations.
UP.01.03.01 Recommendation:
1. Provide a Root Cause investigation.
2. Use examples from Joint Commission list of Quality Improvement Activities to
A. Design a new service: Provide education for the patient B. Experiment with new ways of carrying out a function: Incorporate Time-Out into Electronic Medical Records (EMR).
Responsible Party: Surgery Leadership Committee. This is the committee who approved the Site Identification and Verification document.
Due Date:
1. Root cause is provided below.
2-A. The committee will have 6 months to implement guidelines, specify who will do the teaching, how it will be done and set a start date.
2-B. The recommendation for Time-Out to be incorporated into the electronic medical records assumes the hospital is using an EMR. Even so, it will take co-operation with the medical records staff at the minimum and perhaps the IT department. 6 months may be too soon. At the minimum, a progress report will be due in 6 months and a new due date
Part A: The candidate with the approval of the school leadership will establish a professional learning community with a minimum of three peers to research areas of need in student learning and development in school.
Preparing for The Joint Commission, Nightingale Community Hospital reviews areas of compliance and non-compliance. A periodic performance review, which is a self-evaluation, is utilized by Nightingale Community Hospital, to prepare for The Joint Commission. The Joint Commission has eighteen accreditation requirements. (Commission, 2013) The periodic performance review found the hospital to be compliant and non- compliant in the following areas:
In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.
UP.01.03.01 requires a time-out before the start of the procedure. The Site Identification and Verification policy describes the time-out process however the policy falls short of fully meeting the intent of this standard. EP 2 describes which team members must participate in the timeout, EP 3 requires a time-out before each procedure when two or more procedures are being performed, and EP 5 requires documentation of the time-out. These 3 elements are missing from the hospital policy/process and therefore revisions to the process/policy are necessary to include these 3 elements. Nightingale’s Safety Report reveals increasing compliance (nearing 100%) with the time-out process, however as mentioned above, EP 5 requires documentation of the process. In addition to the policy revision, I recommend the development of a unique form which will be used to document
Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment that provides for proper care and emphasizes patient safety. NCH has shown to be 100% compliant with the majority of standards including: Infection Prevention and Control, Right and Responsibilities to Patients, Human Resources, Transplant
Based on the patient safety, patient satisfaction, data, and culture of the institution, it is possible to choose different methods of reducing risk in health care settings. Those methods include ancient methods such flow-sheets, Kardex, sticker reminders, checklists. The EMR is a new and convenient method to mitigate error in health care settings.
This service was provided during the postoperative period for a previous related procedure conducted by the same surgeon.
The Joint Commission defines the Periodic Performance Review as an assessment tool created to assist health organizations improve and monitor their performance throughout the year. This tool focuses on the processes that influence patient care and safety while providing the structure for unremitting standards fulfillment. Nightingale Community Hospital is compliant with most standards as set forth by the Joint Commission. However, upon inspection and in an effort to stay focused on compliance, our standards committee has located a few discrepancies that must be resolved to maintain our accreditation with the Joint Commission.
A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began
“Errors in communication give rise to substantial clinical morbidity and mortality (Riesenberg, Leitzsch, & Cunningham, 2010).” As a result, the Joint Commission has identified effective communication as one of its National Patient Safety Goals (Dunsford, 2009).
JCAHO (Joint Commission on Accreditation of Healthcare Organizations) Joint Commission Standards. 2000. Retrieved from www.jcaho.org/standard/jcstandards.html
a. Have all employees sign an acknowledgement form that they understand the new policy and corresponding procedures, and received training within 14 days of establishment of the new policy
Communication, this is the key focus area that is evaluated in this summary. Communication is a key focus area of the joint commission audit and is also a key area in which Nightingale Community can make enhancements. Communications must be a two way free flow of information. The information exchanges occur between providers, staff, and patients or clients. This was an area that needed improvement was noted in the previous accreditation audit. Some noted prior issues from 2 years ago included patient and family education and information not being properly disseminated to the nursing staff. These are areas where we have targeted and currently meet. Some areas that we continue to work on are as follows.
The four main areas of focus for the Joint Commission for Nightingale Hospital include Communication, Information Management, Medication Management and Infection
Besides the disadvantages of (EMR)’s the advantages pose great benefits to patient care and efficiency. The greater use of electronic medical records or health records can reduce wait times, of seeing doctors or waiting for test results. All staff would need to cohesively work out the technical challenges and software data. With sophisticated IT