Aft2 Task 1

Nightingale Hospital complying with Joint Commission’s is not occurring. The Universal Protocols (UP) met on some months and not on others. The Time-Out Hospital Wide UP looks like hospital was increase in compliance over the year and reached the one hundred percent make until December. This protocol should be preform at every surgery or minor procedure (where necessary) according to hospital policy in which involves laterality. The National Patient Safety Goal Data (NPSG) for communication in Hospital Wide Compliance of Reporting Critical Results within sixty minutes met one hundred percent, zero

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

The Joint Commission (n.d.) states that, “Verbal orders are authenticated within the time frame specified by law and regulation”( Joint Commission, n.d., RC.02.03.07 - 4). With so many departments found to be in non-compliance during the process of just one audit this trend proves this issue is likely widespread throughout the entire hospital and that NCH is regularly non-compliant with this issue. The departments that did not show to have this non-complaint issue were: Cardiac Cath Lab, Endoscopy, ICU, OR, and Surgery Pre-op. To fix this issue, it is advisable to ascertain why and how some departments are meeting the standard while others are not. This issue may stem from improper procedures, training, a deficiency in staffing, or a lack of leadership in the non-compliant departments. Comparing and contrasting the departments should assist in resolving this non-compliant issue.

Nightingale Community Hospital identified a recent sentinel event involving the ambulatory surgical center. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). A three year old female presented to the hospital on September 14th for a planned outpatient procedure. The child was accompanied by her mother. The mother registered the patient with the registrar prior to the procedure. The patient and her mother went to the pre-operative area to complete the informed consent and the necessary physical assessment. The pre-operative nurse obtained the necessary contact

This sentinel event involves child abduction from the surgical unit of Nightingale Community Hospital on Thursday, September 14, 2014 at approximately 1230hrs. The patient, a three-year old female, arrived accompanied by her mother, for an outpatient surgical procedure at 0800hrs and proceeded to registration where all currently required documentation was completed and signed by the mother; this included the authorization forms for the surgery. After registration, the patient and her

* Personnel Issues: One of the key barriers to effective interaction for the pre-op nurses is that they are not getting any information from the registrar or the surgeon related to the patients unique circumstances. There is not a communication process in place for the pre-op nurse to actively communicate with the surgeon or his office regarding a patient’s care during their day of surgery. An additional factor in this situation was the pre-op nurse documented the mother’s contact information in her notepad, but not on the

The tracer was performed as part of a process improvement to assess compliance with The Joint Commission standards (The Joint Commission, 2015). In this process, a random patient chart was chosen and the process followed from admission to discharge including any directly related follow-up or readmission.

The verbal order read back initiated by the hospital has improved with all but one department exceeding a 90% ratio. This will be a focus area for the Ortho department, as they will have a goal to reach of exceed 90% within the remaining accreditation period. We will continue to quantify the results of all departments monthly as well as evaluate the Orhto department to determine if there are any roadblocks to attaining the improvement goal. The second lowest score is currently being achieved by the surgical unit although they are doing well we will target this department for ongoing training. All departments will continue to receive documentation and training in this area.

Nightingale Community Hospital is a 180-bed acute care hospital that is a not-for profit entity. The hospital is community based and provides leadership in quality health services in which they provide. Their vision is to be the hospital that people choose, the place employees, physicians and volunteers want to work and a hospital of choice for the community. They are committed to providing a healing environment to their patients with a compassionate commitment to healthcare excellence.

As our Joint Commission audit approaches, Nightingale Community Hospital has conducted a tracer patient survey to assess our compliance. The tracer methodology tracks a selected patient's care from admission to discharge, allowing us to evaluate our systems of providing care and to ensure that we are meeting the Joint Commissions standards of providing safe, quality healthcare.

Before the patients leave the clinic, the primary care nurse will give them a simple instruction such as doing the blood work, EKG and chest x-ray prior to pre-operative appointments. This is the end of primary care responsibility for the pre-operative process of patients undergoing surgical procedures. The accountability of making sure the patient is ready for the surgery is then handed over to the pre-operative management nurses. Cancellation of operations in hospitals is a significant problem with far reaching consequences (Kumar & Gandhi, 2012). One of the factors contributing to this cancelation is the pre-operative process itself.

‘Clear and complete communication between health care providers is a prerequisite for safe patient management. Which is a major priority of the Joint Commission's 2008 National Patient Safety Goals and long-term care (LCT). (Commission, 2008)

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).

Hai Resmy, good post, I like the portion you mention that Patient record plays an important role in the hospital’s ability to maintain JCAHO accreditation and are required for financial reimbursement. From a purely regulatory standpoint The Joint Commission requires the Standard of Staff are competent to perform their responsibilities. Staff competence is assessed and documented once every three years or more frequently as required by hospital policy or in accordance with law and regulation. There are numerous Joint Commission standards that require nursing documentation and can pose challenges to an organization. Nursing documentation is an overcomplicated process. Although many Joint Commission standards require documentation, hospitals

In this assignment I will throw light on my first clinical week that I had to observe the effective communication skills on the med surgical floor. As I started my day, the charge nurse was assigning patients to the dayshift. As the patients were assigned, the nurses started their shift report from the night shift in the break room. In this report, they discussed the patients diagnosis, previous medical history, labs and all pertinent information about each assigned patient. On the med surg floor, we get the opportunity to experience all areas of patient care with patients coming from surgery, emergency department, direct admit, and transferred from