Aft2 Task 3

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

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

Trinity Hospitals five year plan includes development of an orthopedic center, cardiovascular center and a cancer center. Task four asks for an assessment of the viability of one of these service lines. By assuming the role of the hospital CEO, I will evaluate the orthopedic center service line and present the findings to the board of directors for their approval.

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

For example, a hospital-wide policy can be made making it mandatory for all critical results to be documented and reported within the hour. Attestations can be put in place for all hospital staff to sign, holding them responsible if policies are not followed. Another suggestion would be to have all critical results reported to two sources, for example the patient’s nurse and charge nurse, to increase the likelihood of rapid documentation. The point of the corrective actions is to ensure that each staff member knows what they are responsible for. For example, laboratory staff knows to document the critical values and alert the appropriate nurse or charge nurse, the nurse or charge nurse knows to document the critical lab values or test result and to alert the ordering physician, the ordering physician knows to discuss a treatment plan with the patient and to document appropriately in the chart, etc. The point is, every staff member has a role to play in assisting the hospital in becoming one hundred percent compliant. This corrective action plan holds each staff member accountable. Those who do not comply can easily be tracked and disciplined by their supervisor.

* 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 purpose of this report is to summarize, analyze and evaluate the compliance status of Nightingale Hospital to Joint Commission requirements. This report will focus on medication management, specifically anticoagulation therapy and the patient and staff education associated with it. In an effort to maintain the highest quality of care for our patients, we must continue to work towards a reduction in adverse anticoagulation related events. This will involve proper pre-discharge

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.

In preparation of a review from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Nightingale Community Hospital will focus on improving its communication process in the operating room. The purpose of communication in the healthcare setting is to disseminate information in such a way as to create shared understanding about the patient and about what needs to be done for a positive outcome. (synergia.com) A patient is at his most vulnerable state during procedures that require sedation or anesthesia. The patient is releasing his decision making ability and safety into the control and care of the healthcare team. Therefore, effective communication on behalf of the patient is

The upcoming inspection will involve surveyors from the Commission who select patients to randomly ascertain these patients' medical records to serve as a blueprint for evaluating standards compliance within our organization. The surveyors use these medical records to trace patients' experiences within our facility as well as discussing these patients experiences with doctors, nurses, and other staff at our organization that have interacted with patients randomly selected by the Commission.

Facility Admission History and Physical (H&P): This report is usually dictated by the admitting physician or resident when a patient is admitted to the hospital. It usually begins with a chief complaint. The “history” includes a history of the present illness, past medical history, social history, and family medical history. There is usually a review of systems and a complete physical examination from head to toe. The report usually ends with an admission diagnosis and a plan for the patient’s treatment

The medical director is the oversight for the medical portion of the program. Their responsibility in a nut shell is to make sure the medical education distributed is accurate, up-to-date and meets the criteria. They are active in review of the curriculum, approving and evaluating written exams, and monitoring practical skills whether in a testing environment or in the classroom. The medical director also evaluates the quality of the instruction delivered by the

CQC Report For North Middlesex Hospital Date of inspection visit: 3-6 June 2014 & 23 June 2014

The stickers will capture the critical value being called, time and date called, and by whom the information was called to and received from, along with the date and time, and that the information was read back for accuracy. To document the read back process, there will be a box to check to verify that the read back process was completed at each point of the communication process for communicating critical values. It will also contain the same information for documentation of calling the critical value information to the patient 's primary care practitioners. The task force team was able to identify the issue, improve the process and choose a reasonable timeline to roll out the improved communication process. It has been communicated to all hospital leaders that the updated communication of critical values will be rolled out in four weeks with all clinical areas of the hospital responsible for educating their department staff through in-services and staff meetings prior to the roll out. To ensure compliance with the revised process and the read back process, the method of collecting data will be a random review of 10 critical value reports in the EMR each month in each clinical area with the scores of each area being provided to the performance improvement department for review and feedback. To ensure the best patient safety, the compliance goal will be 100% of all