Executive Summary The Joint Commission is scheduled to visit Nightingale Community Hospital for its triennial accreditation survey within the next 13 months. The purpose of this document is to provide senior leadership with an outline of the hospital’s current compliance status in the Priority Focus Area of Communication. Recommendations for corrective action are included in this document which are designed to bring the organization into full compliance in the areas where deficits have been identified.
The Priority Focus Area of Communication includes 3 Joint Commission (JC) standards relative to Universal Protocol. These 3 standards, which are components of the National Patient Safety Goals, are aimed at ensuring the correct
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EP 5 requires a written process for patients who refuse site marking or when it is impossible or impractical to mark the site. This written process is absent in the hospital’s policy. Nightingale’s policy and process must be revised immediately to reflect all the required elements of the standard. Hospital physicians and staff must be educated on the necessary changes and the revised process must be put into action. Once these changes have occurred, I recommend a focused audit to ensure full compliance with the revised policy/process.
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
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.
The ongoing survey readiness audits that are conducted in the hospital on a daily basis have identified areas we will focus on to ensure that our accreditation survey results are exceptional. Audits are performed on an ongoing basis with a focus on trends that are most commonly cited by the Joint Commission. Nightingale hospital has proven to have made great improvements over prior survey findings in Emergency Management, Human Resources, Leadership, Medical Staff, Nursing Care, Provision of Care, Treatment and Services, Information Management, Handoff Communication and critical value reporting. We have placed an abundance of resources and efforts into improvement in these
2. ensure the agreed care plan has been checked prior to undertaking the pressure area care
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.
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
An accreditation organization of United States is going to conduct inspection by the Joint Commission (JCAHO) for which Nightingale Community Hospital is doing preparation. For safeguarding the safety of patient, used recommended medical symbols is a very important factor for healthcare delivery. The correct policies are properly identified, prevented, reported and measured at the time of execution is reviewed along with current compliances in system will be covered in the summary.
I prepared and reviewed an accreditation audit for Nightingale Community Hospital to organize and ensure compliance with Joint Commission standards for our hospital. We are preparing for a site visit that should occur within the next 13 months. I have reviewed the current compliance status of our hospital and will explain our corrective action plan that will ensure compliance with the Joint Commission standards for the focus area of communication.
Procedure to indicate “a time-out must occur when two or more procedures are performed on the same patient and the individual performing the next procedure changes”
Under HIPAA, the DHHS established a set of codes for identifying diseases and procedures when healthcare transactions are submitted electronically (Ong, 2011). According to AMA (2015), the appropriate International Classification of Diseases (ICD) code and Current Procedural Terminology (CPT) code must be accurately documented to comply with HIPAA, which begins with scheduling the patient’s appointment. For example, to schedule an office visit for a patient diagnosed with a mental disorder referred for neuropsychological testing, the following codes must be documented when scheduled: Dx: 294 [CPT 96116 (2 hrs)] & [CPT 96119; Tech 183732 (3 hrs)].
In both plans a physician advisor reviews cases but within HH the case manager compiles all the clinical data and reviews, seeking the advice of physician advisor if necessary. Equally, the plans provide for utilization review to be initiated within the first twenty-four hours of the patient’s admission, if not prior to admission. In addition, both plans provide opportunities for the admitting physician to provide proof or argument for discrepancies in treatments or length of stays. Although the UK HealthCare UR plan provides a single physician review of inadequate treatment or length of stay, HH UR plan stipulates a minimum of two physician members review additional information submitted via the admitting physician. Specifically, in the HH UR plan exists a component of a continuous medical care evaluation studies to provide provisions for the Continuous Quality Improvement Committee. In addition, physicians continually need to be educated on detail specific care in HH, as physicians occasionally do not want the prescribed orders challenged. Pre-printed patient progress notes with check boxes assist some of HH’s physicians in considering necessary or unnecessary treatments
Case management in the emergency department, constantly works to find the right data in a patient’s record to ensure that they have the correct insurance coverage and can be admitted or discharged at the appropriate time and place. Even when the smallest amount of essential information is not documented, this otherwise straight forward process turns into a scavenger hunt for who has seen the patient, interventions that were done and for what reasons, and at what time all of these things took place. ED case manager Veronica Kountz (personal communication, March 20, 2015) states that the inadequacy of documentation can lead to insurance companies not covering patient costs, which the hospital then has to absorb. Before a patient can be admitted or discharged, the right
Hughes, R. (2008). Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Dept. of Health and Human Services.
By implementing these recommendations the policy will be up to date. The safety, quality, and outcomes of patient care will improve. Recommendations for evidence based practice