A. Compliance Status
The following executive summary focuses not only on the identified gaps in the current process, but also the corrective action plan to support compliance in the noted areas of the Communications Standards as provided by The Joint Commission, (National Patient Safety Goals, 2013). The high risk associated with surgical procedures performed on the wrong site has driven a risk mitigating approach to the processes involved for these procedures. The goal is to prevent harm to patients having a surgical procedure.
The following summary is the current compliance status if the Priority Focus Area of Communication for Nightingale Community Hospital. After review of the specific areas identified in the Priority Focus Area, the following have been identified as requiring further attention: time-outs are routinely performed prior to every procedure (UP 01.03.01) and procedure site is marked (UP 01.02.01). Based on the evaluation of the Nightingale Community Hospital National Patient Safety Goals for Communications the current compliance rate related to the Universal Protocol Time-Out processes performed hospital wide indicate a 95% to 100% compliance rate for the year. The graph provided in the Nightingale Community Hospital National Patient Safety Goals Communication assessment provides limited information as these are hospital wide percentages. No unit specific evaluations of performance have been provided in the report.
Upon review of the Site Identification and Verification used by Nightingale Community Hospital for the Priority Focus Area of Communication there are indications for specific areas of opportunity (The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery). The Joint Commission Standard UP.01.02.01, Element of Performance #3, indicates the requirement of a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed is to mark the procedure site as appropriate (Joint Commission Resources, 2013). The Universal Protocol does not indicate the independent practitioner marks the site but states the patient or family member will do so and if patient or guardian is unable, the physician will be notified. Element of Performance #5 for the UP.01.02.01 also indicates a written, alternative process is in place for patients who refuse site marking (Joint Commission Resources, 2013). The Universal Protocol currently being utilized does address anatomically impossible or impractical sites for marking however it does not address a patient’s refusal of marking of the surgical site altogether. Lastly, UP.01.03.01 rationale indicates a designated member of the team initiates the time-out as well as including active communication among all relevant members of the procedure team (Joint Commission Resources, 2013). The Universal Protocol indicates the nurse or technologist is responsible but does not indicate a staff member will be designated to call the time-outs.
Element of Performance #3 indicates when two or more procedures are being performed on the same patient, and the person performing the procedure changes, another time-out must be performed prior to the initiation of each procedure (Joint Commission Resources, 2013). This element of performance is not identified within the current Universal Protocol utilized by Nightingale Community Hospital.
A1. Plan for Compliance
The performance plan related to the Priority Focus Area of Communication recommends the data collection be obtained from each area of Nightingale Community Hospital that performs procedures including those procedures performed at the bedside. This will enable both the quality analysts and the performance improvement team a method to focus on specific areas that continue to demonstrate opportunities for improvement. This information may also provide information regarding trends related to specific procedures, staff, or physician that will allow the organization an opportunity to focus as necessary on behaviors as well as potential corrective action plans. The results will determine the frequency of which data should be collected. If a specific area is noted to have a higher rate of non-compliance, this may indicate a need to analyze date more frequently than those areas that are meeting the required 100% goal who may be reporting the results of these audits on a quarterly basis.
The Joint Commission Standard UP.01.02.01, Element of Performance #3 indicates a licensed independent practitioner, who is ultimately accountable for the procedure and is present when the procedure is performed, is to mark the surgical site as appropriate (Joint Commission Resources, 2013). It is recommended that the Universal Protocol currently being utilized by Nightingale Community Hospital be updated to reflect this requirement. It is also recommended to develop a policy to support not only the Universal Protocol, but also the required tasks associated with the Element of Performances for Site Identification and Verification process. An administrative policy to support this process will immediately be developed by the CNO in partnership with the Chief of Surgery as well as the Surgical Department manager. All surgical cases will initially be audited (100%) by the compliance department in order to assure compliance. Feedback will be provided by the department manager and/or delegated appropriately to team leader as necessary. The CNO is ultimately responsible for assuring compliance in this area.
UP.01.02.01, Element of Performance #5 requires an alternative process, when appropriate, be available in writing for patients who refuse to have their surgical site marked as required by The Joint Commission (Joint Commission Resources, 2013). It is recommended that the facility adopt an administrative policy that supports the use of an alternative site marking process. The areas mentioned within Element of Performance # 5 are the following: mucosal surfaces or perineum; minimal access procedures treating a lateralized internal organ, whether percutaneous or through a natural orifice; and interventional procedure cases for which the catheter or instrument insertion site is not predetermined such as cardiac catheterization or pacemaker insertion, teeth, premature infants for whom the mark has potential to cause a permanent tattoo (Joint Commission Resources, 2013). It is recommended to initiate a second time-out immediately prior to incision for those situations where an alternative to site marking is necessary. When marking is refused, impractical, or impossible it is recommended that clearly labeled body diagrams be used that would allow for identification of the appropriate surgical site (Surgical Safety Admission Ticket, 2011). This diagram could be referenced during the time-out(s) both preoperatively as well as the second time-out immediately prior to time of incision (Surgical Safety Admission Ticket, 2011). The process of utilizing the diagram as an alternative site marking process will be initiated immediately by the development of an administrative policy by the CNO. The auditing process by the compliance team will include 100% audit of surgical case. The CNO is ultimately responsible for assuring compliance in this area.
UP.01.03.01 rationale indicates a designated member of the team initiates the time-out and includes active communication among all relevant members of the procedure team. It is recommended that the surgical team designate specific staff members to be designated as the time-out leader on each surgical teams and each shift (Joint Commission Resources, 2013). By rotating this responsibility to each member of the surgical team, the staff will be more actively involved in the process and become very familiar with the importance of this verification process. This process should also be included in the protocol and the administrative policy should reflect the requirements as listed in the standard in order to provide direction regarding the protocol. UP.01.03.01, Element of Performance #3 requires that when two or more procedures are being performed on the same patient, and the person performing the procedure changes, another time-out must be performed prior to the initiation of each procedure (Joint Commission Resources, 2013). It is recommended that this information also be included in an administrative policy as well as updating the Universal protocol to include this process. The CNO will have responsibility to ensure the Surgical Department Manager has implemented the process/policy developed by the CNO in partnership with the Surgical Section Chief and the department manager. The designated staff member who is responsible for the time-out will immediately report any non-compliance by those participating to the CNO and compliance team. All surgical cases will be audited at 100% to ensure compliance with the process.
The performance improvement plan would require some specific strategies be in place to support the effort of the organization and the individuals involved in the process. Education would be provided in a variety of formats including examples of events and near misses from other organizations to improve awareness. The physician champion in the surgical area would be helpful in encouraging other surgeons and anesthesia staff to participate in the clinical process improvement efforts generated from the surgical department. Senior leaders should include the surgical team, which also includes surgeons and anesthesia, in the senior leadership rounding process and reinforce the expectations of the physicians’ requirement to complete surgical site markings prior to the procedure. Senior leadership should strive to build a culture of no exceptions for any physicians when the consent is involved, provide tools that may be helpful to staff to support the time-out process, and empower surgical team members to speak up when identifying non-compliant behaviors and rewarding those who identify near misses. Goal | Objectives | Surgery Scheduling Verify * Proposed procedure * Surgical site * Laterality | Process implementation to designate scheduling staff to verify surgical information at time of procedure scheduling. Designated staff to perform verification process to include read back as part of the validation process.Responsibility of: CNODate of Policy Implementation: Immediately | Data CollectionUP 01.02.01 EP #3: Develop process for department specific data collection for risk analysisVerificationUP.01.02.01 EP #5: Incorporate an alternative process in writing addressing site marking refusalsUP.01.03.01 EP #3: Multiple procedures with multiple physiciansDocumentationPolicy Development that supports the institutions vision related to the Communications Standards of Compliance as documented by The Joint Commission.Universal Protocol Revision | Evaluation of data regarding unit specific error rate regarding preoperative verification, site marking, and time-out process compliance including: * Preoperative verification agrees with the prior to patient arrival verification form * Confirmation of licensed practitioner involved in the procedure completing the marking of the surgical site * Monthly data submission and review of process compliance initiallyResponsibility of: CNOPolicy Development: CNO, ImmediatelyDate of 100% Audit of Surgical Cases: Immediately * Implementation of a second time-out initiated immediately prior to incision, as an additional safety measure, when patients have refused site marking or it is impossible or impractical to mark site * Include the use of clearly labeled body diagrams used in refusal, impossible, or impractical site marking surgical cases that would allow for identification of the appropriate surgical site. This diagram could be referenced during the time-out(s) both preoperatively as well as the second time-out immediately prior to time of incisionResponsibility of: CNODocumented Process Development: CNO/Surgery Mgr.Date of 100% Audit of Surgical Cases: Immediately * Implementation of an additional time-out performed prior to the initiation of each procedure * Development of policy that supports this process as part of the time out procedure for all surgical cases involving multiple procedures and/or multiple physiciansResponsibility of: CNOPolicy/Process Development: CNO/Surgical Chief/Mgr, ImmediatelyDate of 100% Audits of Surgical Cases: ImmediatelyDevelopment of a policy supporting the organizations goal of ensuring no surgical procedures performed on wrong site, which supports the Priority Focus Areas of The Joint Commission Communication Standards. * Protocol revision includes the addition of verification process to begin at time of scheduling of procedure and read back process when applicable * Protocol revision to include alternative process when patient refuses site marking or site marking is impossible or impractical and includes the additional time-out to be performed immediately prior to incision * Inclusion of additional time-out for each procedure immediately prior to incisions for procedures where multiple sites and/or physicians are involved in the procedure * Confirmation of licensed practitioner is completing the surgical site marking as appropriateResponsibility: CNODate of Implementation: ImmediatelyMeasurement: Compliance via Chart Audits at 100%Expectation: 100% compliance |

A2. Justification
In support of the National Patient Safety Goals, as it applies to communication within the various units of a health care facility, Communications area of the Priority Focus Areas was selected as a way to learn best practices and approaches to support a process improvement plan related to communications, (National Patient Safety Goals, 2013). This review has allowed for the opportunity to analyze the statistical information available for this project and apply the skills required and utilize them in my current role at a large health care organization, in which duties include that of a Quality Officer. Given my professional experience and background in a variety of areas within several different health care organizations as a registered nurse, I feel it is imperative that a culture in which communication is promoted is vital to the success of the organization. A recent article from “Becker’s Hospital Review,” includes information regarding ten interventions that could mitigate risk and create a culture of safety in the operating room. It was interesting to see that this article included item number ten, Instilling a “Just Culture” at the end of the list (Buchler, 2013). As shared in the plan for compliance section of this task, it is imperative that organizations support a culture of empowerment allowing staff members the opportunity to participate in the process of mitigating risk and promoting safety by speaking up and not having fear when addressing a question or potentially preventing an error by speaking up. This is a behavior that should be promoted and not be considered taboo.
In a recent situation within the facility where I am employed, it was brought to my attention that a surgeon was not having consents signed prior to the procedure on multiple occasions but was having this done after the procedure and often demanding others to “cover” for him. Out of fear of retaliation, the staff was initially afraid to speak up and share this experience with the leadership. Once the staff members decided to share this information appropriately, and the situation was addressed without implications to the associate, a meeting with the senior leadership occurred. This meeting with the senior leadership and the chief of surgery focused on facilitating the development of a process improvement plan for improved communications in the operating room. The initial process improvement plan is in process; however, the initial steps include educating the operating rooms staff, including the physicians, by sharing experiences from one of our affiliates which were video-taped and demonstrated the importance of a non-punitive environment when professional communications were encouraged from all. Specifically within the surgical department, within 25 days after initiating this process, the raw data indicates a decrease in adverse events and near misses since initiation of this process improvement initiative as compared with prior data. Interestingly, the number one item in Becker’s Hospital Review article is related to establishing a shared governance model for the surgical staff which would allow for a more collaborative oversight of the surgical area policies and protocols as well as promoting a more engaged group of stakeholders (Buchler, 2013).
Interestingly, communication is key to a successful outcome in all process improvement efforts, and is a key ingredient to the success of any initiative involving a group of people; however, this is often the last element to be considered when developing a process improvement. In my experience, when faced with an opportunity to improve a process, I have learned to program myself to consider first, how best to communicate the educational opportunity to others. I feel this promotes acceptance of new ideas, allows for discussion of additional ideas, and allows the staff an opportunity to be a participant in the planning of processes that affect them. This leads to improved employee satisfaction, while also improving patient outcomes. In the review results of the information presented in this case study, the implementation of a shared governance surgical committee would be beneficial in the development of improved processes as indicated in the objectives column of the table above.

B. Sources
References
Buchler, R. (2013, February 28). Clinical Quality & Infection Control. Retrieved from Becker's: how-hospitals-can-improve-the-culture-of-safety-in-the-surgical-suite-10-interventions-to-mitigate-risk-and-create-a-culture-of-safety-in-the-or
Joint Commission Resources. (2013). 2013 Hospital Accreditation Standards. Oakbrook Terrace: The Joint Commission Department of Publicatons and Education.
National Patient Safety Goals. (2013). Retrieved from The Joint Commission: http://www.jointcommission.org/standards_information/npsgs.aspx
Surgical Safety Admission Ticket. (2011, April). Retrieved from University of Virginia Health System: http://www.virginia.edu/uvaprint/HSC/pdf/081267.pdf
The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. (n.d.). Retrieved from The Joint Commission: http://www.jointcommission.org/assets/1/18/UP_Poster.pdf