...Joint Commission Action Plan Accreditation Audit – AFT2 Task 1 Nightingale Community Hospital is a 180 bed hospital that prides itself in creating the most cost effective place to heal in the comfort of the most compassionate staff of excellence. Nightingale Community Hospital is thirteen months away from a visit from Joint Commission. The four identifying factors that we need to focus on are four areas: Information Management, Medication Management, Communication, and Infection Control to avoid falling out of compliance. I have chosen to provide an executive summary outlining the current compliance status of Nightingale in Information management. The world has been continuously transformed through various technological advances in various fields. One of those technological advances has been a great adaptation in healthcare, which is the use of EHRs (Electronic Health Records). Accurate and complete patient information is accessible to providers to improve their ability to make treatment decisions in a timely manner. All the administrative and all the clinical data are accessible in the EHR (Dimick, 2012). EHRs are more concise and accurate than paper charts because it allows for quick retrieval of various test results, allergies, problems, illnesses, infections, and procedures that the patient may have had in the present or past. Charts rarely go missing and the EHRs have been very cost effective. Nightingale has...
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...Accreditation Audit Task 1 AFT2 May 2015 Accreditation Audit Task 1 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 implementing a “time out” form to be completed by the surgeon, all assisting surgical staff and the patient, if possible, just prior to surgery. Both of these forms follow Joint Commission’s recommendations for best practice. According to the Joint Commission Handbook, National Patient Safety Goals (NPSGs) were established by the Joint Commission to help accredited organizations address specific areas of concern in regard to patient safety (2015). Nightingale Community Hospital obtained NPSGs data regarding their compliance with communications standards, with hopes of improving their effectiveness of communication. Data was collected over the span of one year. Hospital-wide compliance of reporting critical results within 60 minutes and evidenced...
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...Accreditation Audit 4 June 2015 Contents Executive Summary 3 Compliance Status 3 Plan For Compliance 3 Provider and staff education 4 Care team communication 4 Patient Discharge Education 4 Justification 5 Works Cited 6 Executive Summary 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 instructions and education with the patient and improved communication between the nurses, physicians and pharmacists to ensure the best possible outcomes. Compliance Status Source: (Nightingale Community Hospital, 2014) As the preceding graph shows, the adverse events related to anticoagulation therapy is trending downward. However, this leaves ample room for improvement of current processes to continue the downward movement to zero incidents. Continued progress in the area of medication management is required to maintain TJC standards compliance and is listed as a National Patient Safety Goal for the current term (The Joint Commission, 2015). During TJC audit two years ago, it was found that the hospital lacked documentation of appropriate...
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...Communication Regulations at Nightingale Hospital Western Governors University Communication Regulations at Nightingale Hospital 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 months during the year. This Joint Commission has this rule because it wants to protects the patients to be safe such the another event will not occur. The second NPSG is a Verbal Order/Read Back Audit by different department. The department with the lowest percentage is the Orthopedic. The nest NPSG is Unacceptable Abbreviations. The abbreviation which is not in compliant at the end of the year is Unit (U). The violation even increase to sixty-three percent from seventeen percent. The Joint Commission purpose is to conducted periodic audits of hospitals. This audits determine whether the hospital puts the patients in danger or not. The Joint Commission believes seventy percent of the sentinel events occur because of communication failure...
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...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...
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...Executive Summary A. While Nightingale Community Hospital may pride itself on their core values, as safety, community, teamwork and accountability, we understand that there is more that has to be done to provide a safer environment for our patients. Across the nation, hospitals are trying to find innovative ways to provide safer and cost effective healthcare for our patients. This is why it is important to establish and encourage standard practices within the infrastructure of the hospital, which in turn will reduce the chances for human error. Nightingale Community Hospital has the following universal policy in place to ensure that appropriate communication occurs prior to procedures. This policy consists of three specific parts, “pre-procedure verification, site marking, and a time out performed immediately prior to the procedure.” (Maureen Burger RN, 2011) In Joint Commission standard: UP.01.01.01 the hospital is to “implement a preprocedure process to verify the correct patient.” The standard goes on further to state that the hospital identify the items that need to be available for the procedure, (Commission, 2011) In response to this Nightingale has implemented a preprocedure hand-off check list that asks several questions that nursing has to answer prior to the patient procedure. The nurse then signs the sheet, and the receiving nurse also signs that all has been completed. Once the pre-procedure verification has been completed, standard UP.01.02.01 instructs...
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...------------------------------------------------- Task 1: Executive Summary Assessment Code: AFT2 Executive Summary: Nightingale Community Hospital Joint Commission Compliance Standards for Communication Focus Area Recently there has been much media focus on preventable medical errors. Any google search will produce a multitude of news articles that all report that preventable medical errors is now the third leading cause of death in the United States. Poor communication plays a role in most if not all of these errors. In fact the Joint Commission (2012) has published that an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients. While communication errors are not the sole cause, they certainly contribute to the problem and must be a consideration in every patient safety program. One particular area of preventable medical errors involving communication errors that has received widespread media attention is wrong site surgery. Chassin (2013) reported that wrong site or wrong person surgery occurs an estimated 50 times weekly in the United States. This number is hard to judge exactly as not all states mandate reporting, but the fact remains that wrong site surgery continues to occur despite concerted efforts to prevent it. All hospitals to include Nightingale must continue to place emphasis on preventing these errors. Nightingale has wisely chosen to focus on this area for the upcoming Joint Commission...
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...Jenny Windler Student ID: 000329547 Accreditation Audit (AFT2) Task 1 A. Compliance Status Nightingale Community Hospital is a complete and leading healthcare facility that believes in providing the best quality care to all of their patients. As part of Nightingale’s mission to put the patient first, the hospital must meet medication management standards set forth by the hospital and the Joint Commission. Medication management often involves the efforts of multiple services and disciplines. It is part of Nightingale’s policy that a patient’s information is accessible to a physician, pharmacist or nurse in the management of a patient’s medication. Nightingale Hospital has all the policies in place that the Joint Commission looks for to keep the hospital accredited. A1. Plan for Compliance In reviewing the safety of using medication associated with Anticoagulation Therapy, Nightingale Hospital needs some improvement. There was only one month out of the year that patients did not experience any adverse effects related to Anticoagulation Therapy. Numbers were high at the beginning of the year and tapered off by the end of the year, but Nightingale Hospital should be experiencing more months where there are no adverse events. In combination to the Joint Commission’s finding 2 years ago regarding the lack of documented evidence that the patient’s ability/readiness to learn, learning preference, or educational needs were assessed and documented in the file, we have much...
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...Executive Summary Nightingale Community Hospital (NCH) is currently preparing for its triennial Joint Commission survey which is expected in approximately 13 months. The Joint Commission primary focus areas for NCH are Information Management, Medication Management, Communication, and Infection Control. The primary focus area outlined in this summary is Communication. The Joint Commission has three standards in which NCH is evaluated. Currently, NCH is non-compliant with standards UP.01.01.01 and UP.01.02.01. They are: * UP.01.01.01 - Conduct a pre-procedure verification process. * UP.01.02.01 - Mark the procedure site. As stated in the policy "Site Identification and Verification (Universal Protocol)," the Preoperative / Preprocedure verification is a five step process. This process needs to be expanded to meet the minimum standard of care. The following corrective actions must be immediately implemented. The patient must be properly identified at the time of admission. The admissions staff will require the patient to provide proper identification while verbally verifying their name and date of birth. If the patient is unable to verify their identity, a family member or other legal representative must be able to identify the patient. Identification bands will be verified and placed on the patient as the patient is being admitted. Confirmation of the patient’s identity must be established and documented. Transferring responsibility for care of the...
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...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 01.01.01Conduct pre-procedure verification process UP 01.02.01Mark the procedure site UP 01.03.01Perform a Time-Out before the procedure. To determine NCH compliance, hospital documentation was used for comparison with the Joint Commission, Elements of Performance. The following chart specifies which documents were used to show areas in need of improvement. Nightingale Community Hospital Documentation| Compared with|(UP) Elements of Performance| Pre-Procedure Hand-Off check listSite Identification and Verification (UP) (Sub heading) Preoperative Verification Process||UP.01.01.01Description # 1Description # 2| Site Identification and Verification (UP) (Sub heading) Marking the Operative/Invasive Site||UP. 01.02.01Description # 5| Safety Report Time-Out Graph||UP. 01.03.01Description #1 | Compliance Status Executive Summary and Findings according to the Joint Commission, Elements of Performance...
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...WGU AFT2 RAFT2 (Accreditation Audit) MBA Graduate Programe - Complete Course All 4 Tasks http://www.homeworkminutes.com/question/view/41054/AFT2-RAFT2-Accreditation-Audit-WGU-MBA-Graduate-Program-Complete-Course AFT2 Accreditation Audit Task 1 1. The purpose of this executive summary is to outline the current status of compliance of the organization for the priority focus area of communication, namely the standard UP.01.01.01 which is named the “Conduct a Pre-procedure Verification Process” as noted by the Joint Commission standards. A.2. The primary area of focus I chose to review was the communication aspect. I feel that communication is vital in any business, especially health care. Clear communication improves patient care and the quality of care. This is evident when time is taken to verify a patient or a procedure. When things go wrong due to misidentification of a patient, not only does that cost time and money for the patient as well as the extra burden of having that wrong fixed, but it also costs the hospitals too. Their costs are increased by trying to fix the issue and then legal issues to follow. The best way to avoid any mistake and/or injury is to adopt a more vigorous verification system. AFT2 Accreditation Audit Task 2 A.1. An unexpected occurrence that involves serious bodily or psychological harm including death or the risk leading to these is known as a sentinel event. (Sentinel event, 2013) A.2. Several people were...
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...Accreditation Audit: AFT2 task 2 1 Accreditation Audit: AFT2 Task 2 Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process. Accreditation Audit: AFT2 task 2 2 Analysis of Key Components RCA: Child Abduction Please note that the root cause analysis and action plan must show evidence of an analysis within the key components as outlined on the root cause analysis matrix for the specific type of event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated. Brief description of event Briefly summarize the circumstances surrounding the occurrence including the patient outcome (e.g., death, loss of function). A 3-‐year-‐old female pediatric patient...
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...AFT2 Task 1 Christian Fisher Western Governors University AFT2 Task 1 A. Compliance Status During the last Joint Commission survey two years ago, there were several areas of deficiency surrounding the use of moderate or deep sedation or anesthesia. These noted deficiencies gave Nightingale Community Hospital the opportunity to revamp and strengthen our procedures in all areas of peri-operative services. These include the Main OR, CVOR (Cardiovascular OR), Interventional Labs (Cardiac Catheterization and Interventional Radiology), and Endoscopy Suites. Significant process has been made especially in the area of the Time Out. A Time Out is the step by which all work in the particular surgical area halts and everyone in the suite actively participates in ensuring that for the current surgery we have: 1. Correct patient. 2. Correct side and site. 3. Correct procedure to be done. 4. Correct patient position. 5. Correct implants and equipment. All of the Peri-Op services procedural areas brought members of their teams to participate in brainstorming and development sessions in the area of the Time Out to ensure that it was robust and all encompassing. As well, some of these components and other important details should actually be completed prior to the patient’s arrival in the surgical suite. While the Time Out is an effective last act before a surgery proceeds, many other details should and must be completed long before that. This ensures the safety of the...
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...Accreditation Audit AFT2 Task 1 Executive Summary Current Compliance Status A. Compliance Status – Executive Summary Nightingale Community Hospital’s is a healthcare facility with a vision to” be the hospital of choice for patients, employees, physicians, volunteers, and the community.” We also state our mission is to create a healing environment, with a passionate commitment to healthcare excellence. Creating this vision and staying true to the stated mission requires that we adhere to the requirements set forth by the Joint Commission. In preparing for the Joint Commission visit there are focus priority areas that will need to be addressed if Nightingale is going to be compliant. The specific focus area addressed in this summary is medication management. There are three standards that come under the medication management area. The standards are listed in the table below along with their descriptions and summary of whether Nightingale Hospital has the documentation/data to be Joint Commission compliant for the given standard. Standard | Description | Joint Commission Compliance | MM.01.01.01 | The hospital plans its medication management processes. | MetNightingale PoliciesPatient Care Polices: 1. Medication Management, Patient Specific Information 2. Medication Administration | NPSG.03.04.01 | Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field. | MetNightingale Hospital...
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...Accreditation Audit (AFT2) Task 2 Executive Summary: Root Cause Analysis Accreditation Audit (AFT2) Task 2 Executive Summary: Root Cause Analysis A. Aspects of Root Cause Analysis 1. Description of Sentinel Event Nightingale Community Hospital is conducting a root cause analysis of a pediatric abduction which occurred during a post-operative discharge process. “A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. Such events are called "sentinel" because they signal the need for immediate investigation and response.” (The Joint Commission, n.d.) In this event, a three year old child was admitted to Nightingale Community Hospital for a bilateral myringotomy. The mother of the child stepped out during the surgery in order to run an errand involving her other child. The mother was told the surgery would take about 45 minutes. The mother relayed that she should be back after the surgery to pick up her child. The mother did not respond after the recovery, even though the recovery nurse called out to the waiting area and paged for the mother. The patient was then transferred to the discharge nurse. The child was agitated waiting for her mother to return. Coincidentally, the father was at the desk and the nurse invited him to see his child. The nurse was relieved as the child changed her affect to one of excitement and called him daddy...
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