...Discuss the current compliance status of the healthcare facility. Nightingale Community Hospital is compliant with The Joint Commission standards except the following areas: Accreditation function of environment of care and life safety, it was documented that more than 3 smoke wall penetrations were found on the 1st floor and one on the 4th floor. The hospital is to minimize the potential for harm from fire, and smoke (TJC, 2013). A review of documentation showed appropriate ILSM was not initiated during 3 construction projects this put employees and patients at risk. Education of fire safety equipment should have been completed before the project. The gift shop did not have the required 18 inch clearance from the sprinklers. All sprinklers must have at least 18 inches below and around of clearance for The Joint Commission standards. Review of department documentation shows that the master alarm panel for medical gasses was not tested annually per policy. This is a policy written by the hospital that is not being met. They are to follow the policies that they set for themselves. The Fire Drill History Report showed that the fire drill process is not adequate and does not meet standards. Quarterly fire drills are to be conducted as regulated by the Life Safety Code (TJC, 2013). Clutter was found in the hallways of 3E, 4E, OR and telemetry this could restrict people from leaving the floor safely in case of fire or smoke. Accreditations function of Nursing Leadership it was...
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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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...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 (AFT2) Task 2 Sentinel Event Western Governors University Accreditation Audit (AFT2) Task 2 Sentinel Event A1. Sentinel Event Summary This sentinel event is directly associated with a child abduction at Nightingale Community Hospital. A 3 year old patient was having surgery at Nightingale Community Hospital on Thursday, September 14. The patient’s mother accompanied the patient before surgery and completed all consent form. An estimated time of 1 hour 45 minutes was given as the time to complete surgery and recovery. The mother informed the pre-op nurse that she would be off campus during the surgery and would return to pick up the patient in the time frame given. She also provided a phone number to contact her if the procedure was finished earlier than planned. Upon completion of surgery and recovery, the patient’s mother was paged from the waiting area by the recovery nurse. The mother was had not returned to the hospital at this time. The patient care was then transferred to the discharge nurse while waiting for the mother to return. During this time the patient was very upset and crying for her mother. The discharge nurse was notified that the father was in the waiting area and approved for the father to see the patient. The father was with the patient for about 30 minutes and the mother had still not arrived. At that time, with no specific information about the patient’s custody arrangement, the discharge nurse provided the father...
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...AFT2 – Task 1 2/4/2014 Nightingale Community Hospital (NCH) is a 180-bed hospital, acute care, not-for-profit hospital that prides itself in quality healthcare. In thirteen months, NCH will face their next Joint Commission audit, and based on current findings and statistics they will need to make some adjustments to be compliant. While Joint Commission will address all the Priority Focus Areas: Infection Control, Communication, Medication Management, and Information Management, this summary will concentrate on areas in the Communication area that are lacking. A. Compliance Status UP.01.01.01: Conduct a preprocedure verification process – This Element of Performance is in place to ensure that a hospital is always performing procedures on the right patient. 1. Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site. Nightingale Community Hospital currently has a written policy to conduct a preprocedure verification and a Preprocedure Hand-Off form to ensure information is communicated; however, there are areas lacking in the hand-off form. Although the current hand-off form has an area to verify the patient identification/armband and if the site has been marked, there is no area to verify the patient procedure and the procedure site thus leaving the hospital not in compliance with the standard. 2. Identify the items that must be available for the procedure and use a standardized list to verify their availability...
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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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...Compliance Status “Effective communication is a cornerstone of patient safety” (The Joint Commission, 2007). Nightingale Community Hospital has areas of improvement needed in the area of communication. The following are the results of an audit for National Patient Safety Goal (NPSG) compliance. * Hospital –wide compliance of reporting critical results within 60 minutes with supporting documentation present is 82% at its highest. * Verbal Order/Read Back – 7 departments are not at 100% with the Orthopedic department the lowest at 62% compliance * Unacceptable Abbreviations used included “qd” used 9 times in January, “x3d” was used 3 times in January, “sc” was used 10 times in January and “u” was used 17 times in January and 63 times in December. * Time-Out was only at 100% in December. These are all communication issues that failed the processes that are currently in place. Plan for Compliance To become compliant with reporting of critical lab results, the lab technician will notify the charge nurse of the critical lab result as soon as the result is noted. The lab technician will then enter in the comment section of the lab report which nurse the results were verbally provided to, the time they were provided and the reporting technician’s name. The report will then be released for printing to the appropriate department. The charge nurse will be responsible for notifying the physician when the report is received from the lab. Each department will be issued...
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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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...Accreditation Audit 4 June 2015 Contents A. Sentinel Event 3 A2. Personnel Involved 4 A3. Personnel Issues 6 Interactions improvement 6 A4. Quality Improvement 7 B1. Risk Management Program 8 Resources 9 Works Cited 10 A. Sentinel Event 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 mother were taken to the pre-op area for the preparation for the surgery. After completion of pre-op screening but prior to the patient entering the operating area, the mother stated that she was leaving campus to address a personal matter involving her other child while the patient was in surgery. Contact information was obtained from the mother prior to her leaving the hospital grounds. After this discussion, the patient proceeded to the operating room. After a successful and uneventful surgery, the patient was taken to the Post Anesthesia Care Unit (PACU) for recovery. At this time, the mother was paged overhead to the PACU, but was found to have not yet returned to the hospital. The recovery process was completed and the patient was...
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...AFT2 Task 3 / Tracer Patient A.1. Evaluation In reviewing the Surgical Patient Tracer Worksheet (SPTW), it was found that a deficiency was noted that stated “History and physical not done within 24 hours of admission (> 72 hours).” This meant that the laparoscopic hysterectomy related History and Physical (H&P) the patient received was used for the abdominal hysterectomy. Plus, it was more than seventy-two hours after being admitted to NCH for surgery that the patient received the H&P for the abdominal hysterectomy. In reviewing the Tracer document and other information, it became clear that there were three violations of Joint Commission Standards (JCS) for PC.01.02.03 which states: “The hospital assesses and reassesses the patient and his or her condition according to defined time frames.” (Joint Commission, 2014 August). The violations are as follows: 1) When bleeding was detected, the doctor made the determination that the less invasive laparoscopic hysterectomy the patient was scheduled to undergo would need to be changed to an abdominal hysterectomy. The tracer shows no evidence that neither the doctor nor anyone else associated with the surgery including the Anesthesiologist asked for a new H&P to determine the possible complications the bleeding might have on the choice of surgical procedure. The violation relates to JCS PC.01.02.03 Element of Performance (EP) 3 which states: “Each patient is reassessed as necessary based on his or her plan for care...
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...A.1: Description of the Sentinel Event At about 12:30 PM on Thursday, September 14th, a sentinel event occurred that involved a potential child abduction. Tina, a 3 year old child, was scheduled for a routine, same-day surgery at Nightingale Community Hospital to have ear tubes put in both ears. Tina was brought to the hospital by her mother, who had recently been divorced from Tina’s biological father; Tina’s mother has full custody of the children, including Tina. After Tina was registered and taken to the pre-op area of the hospital, the pre-op nurse informed Tina’s mother that the actual surgery would take approximately 45 minutes, and then Tina would need to stay in recovery for at least an additional hour. Tina’s mother informed the pre-op nurse that once Tina had gone to the operating room, she would be leaving the facility to run an older sibling on an errand, but she would be back to pick up Tina after she was released from recovery. The mother gave her cell phone number to the pre-op nurse, who wrote the phone number down on a note-pad the nurse carries in her pocket. Tina’s mother asked for the nurse to call her on her cell phone if Tina’s procedure was completed sooner than expected. When Tina was taken into surgery, the mother left the facility to run her errand. After the surgery was completed, Tina was taken to post-op to recover. The recovery nurse paged Tina’s mother, but did not receive a response. Tina was transferred to the Ambulatory Care nurse...
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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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...------------------------------------------------- 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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...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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