...are improved when registered nurses carry a bachelor’s degree in nursing. Research conducted by J. Needleman, et al., concluded that reducing the nurse-patient ratio resulted in the patient being at less risk for developing hospital-acquired illnesses as well as a reduced risk of inpatient mortality. The reader will also be informed about the Joint Commission’s protocol for reducing the occurrence of wrong-patient, wrong-site, and wrong-procedure during surgical procedures. Politics, Legislation, and Implications to Patient Care As the American population ages, healthcare and its resources are in greater demand. As the demand for healthcare increases, the topic of patient safety has become increasingly important. Laws and legislation regarding patient care are changing almost constantly to maintain patient safety while still providing comprehensive patient care. This report will focus on informing the reader of recent and upcoming legislation regarding patient care, what has brought those changes about, and the effects it can have on the healthcare industry and patient care. It is important to stay informed of these changes because it may affect the registered nurses education requirements and scope of practice in the future. The Joint Commission has maintained reports of sentinel events since January 1995. They define sentinel events as “…an unexpected occurrence involving death or serious physical or...
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...AFT Task 4: Periodic Performance Review Accreditation Audit Case Introduction The accreditation process is designed to assist healthcare establishment to identify and enhance the patient’s safety and the quality of service delivery. This paper presents a review of the readiness Nightingale Community Hospital for accreditation audit. The paper comprises of a periodic performance review of the establishment. The review has focus of several priority areas. These areas include; assessment and care; quality improvement; patient safety, and staffing effectiveness. Trend within the hospital indicates the Nightingale has made significant progress towards fulfilling the standards of the Joint Review Commission. However, the trends in staffing effectiveness are limiting the organization’s compliance. Periodic Performance Review (PPR) The PPR is based on data collected in the Joint Commission Survey. The survey utilized the priority focus methodology to evaluate the compliance of Nightingale Community Hospital. The priority focus process is a methodology that makes use of data to establish priority areas for reviewing compliance. This process has utilized of both external and internal data to evaluate the compliance of Nightingale Community Hospital. This methodology identified several priority areas. These include; assessment and care services; quality improvement activities, and patient safety. This paper evaluates Nightingale’s compliance in these three priority areas. Compliance...
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...jurisdiction there are some that once said many people are familiar with such as Center for Medicare and Medicaid, CDC (Centers for Disease Control and Prevention, and the FDA(Food and Drug Administration). The state level agencies would consist of the following, welfare department, insurance, and the health department. The private sector brings organizations in which play important roles when it comes to health care laws and regulations. The following are part of the private sector organizations NCQA (National Committee of Quality Assurance) and JCHAO (Joint Commission on Accreditations of the Health care Organization). With so many laws and regulations, only two governmental agencies will be viewed and focused on to try and understand and see how they are used, and work or not work in today’s health care. It is also important to see the cause and effects of regulations. **** The JCHAO which stands for the Joint Commission on...
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...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...
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...COMPLAINCE STATUS Joint Commission clearly explained that a Periodic Performance Review is as an assessment tool designed to help in assisting the healthcare organization contributes greatly in the improvement and monitoring performance all through the year. The periodic performance focuses more on the measures that has to do with patients safety and care and at same time given the facility for unremitting standards fulfillment. NCH is 100% compliance with most standards of Joint Commission in the following area; Emergency Management, Human resources, Infection Prevention and Control, Performance Improvement, Right and Responsibilities of the Individuals, Transplant Safety. During the inspection at the facility, the hospital was found to be non- compliant in this listed areas; Environment of Care, Leadership, Life Safety, universal protocol, Medication Management, Medical Staff, National Patient Safety Goals, Nursing, Record of Care, Treatment and Services, and provision of care During the PPR, the hospital was found with an increase cluster in the hallways, it is a fire hazard and a safety issue. The nurses are not familiar with verbal order procedures, using the range of orders that received and the abbreviations that are prohibited in the documents. From the trend, there are areas at which the hospital needs to implement proper education and audit. An action plan needs to be implemented by the administration to address the fallout to enable the hospital be in full compliance...
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...Executive Summary Hospital compliance status for Nightingale Community Hospital Nightingale Community Hospital (N.C.H) has, for a number of years, been the hospital of choice for patients and family who seek superior and excellent and professional care for themselves and their loved ones. As a premier hospital in the region, it has a reputation of having an unwavering commitment to constantly improve its standards of operation so that its patients can always be assured of having unsurpassed healing and care services in the hospital. In line with its mission to provide and assure patients of its commitment to the provision excellent care and services to its patients, N.C.H gets the joint commission periodically to come in and rate all the departments as well as the quality of care that the hospital provides. This evaluation by the joint commission is important because its seal of endorsement on a hospital means that the hospital rates highly in all aspects of care. Patients and their families constantly look for that supreme seal of excellence. Therefore N.C.H wants to make sure its services measure up to the joint commission standards. The previous findings by the Joint commission showed that there was a problem with communication in the hospital. It revealed that even though there were policies in place to ensure that information is efficiently passed across the channels, the leadership had not properly educated the staff to effectively utilize this information in providing...
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...trustees, medical executive committee, directors, senior management, nurses, physicians, other healthcare staff and ancillary staff. The senior management members are the role models for the hospital staff. Similarly, all leadership roles within the healthcare organization, formal and informal, must possess and exhibit the identical vision of zero patient harm (Chassin and Loeb, 2013). Additionally, the Risk Manager and Quality Department staff performs an important role in implementing, maintaining, assessing, and auditing quality and patient safety initiatives. In this case analysis, the key roles that influenced the outcome of a wrong-site surgery event include the emergency department triage staff, emergency department staff (physician, nurse, medical assistant or technician, and/or emergency medical technician), holding area nurse, anesthesiologist, surgeons, and operating room staff. There were plenty of opportunities to stop the sentinel event from occurring. The patient went from one caregiver to the next without a proper verification process. The senior management team with the support of the board of trustees and medical executive committee must hold all healthcare staff employees responsible for their part in risk reduction (Health Research & Educational Trust and Joint Commission Center for Transforming Healthcare, 2014)....
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...patients tend to be readmitted into the hospital frequently due to noncompliance. Problem Identification Education of congestive heart failure is one of society’s largest challenges. The need to focus on compliance of treatment plan, self management, and patient education of this disease process is essential for favorable outcomes. The articles chosen for the information retrieval paper were located on line at the University of Texas at Arlington library in the CINHL database. These articles were written between the years of 2006 and 2009. All three articles were peer reviewed. While searching the data base for articles, information regarding education, compliance, and outcomes was a key focus. The articles were chosen for their content related to the education process of the patient with congestive heart failure and how compliance would affect outcomes. The knowledge of congestive heart failure of the medical professional was also explored. Summary of Articles First article Congestive heart failure is a debilitating and chronic illness that affects thousands of patients each day. With the rising cost of health care and the increased mortality rate an increased focus has been placed on educating patients along with their families in order to facilitated optimum patient outcomes. When patients gain knowledge regarding their disease process it improves compliance which in turn decreases multiple hospital...
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...Nightingale Community Hospital provides leadership in quality health services. Its core values focus on safety, community, teamwork and accountability with a vision of being a hospital of choice for all and a mission to create a healing environment with a passionate commitment to health care excellence. This executive summary of the accreditation audit is presented to the senior leadership to outline the compliance, plan of compliance and institution of the hospital under the reviewed focus area of Information Management as per the Joint Commission Standards. COMPLIANCE STATUS. The Joint Commission Standard IM 02.02.01 requires that the hospital effectively manages the collection of health information. Nightingale Community Hospital is in compliance with this standard under its patient care policy which specifies prohibited abbreviations. Its policy states that the use of abbreviations and symbols in the medical record is discouraged to prevent errors; as these can be associated with misinterpretation resulting in medical errors, and patient harm. In case the intended meaning of the abbreviation or symbol in the context of a specific order is not clear, the ordering practitioner must be contacted for clarification. This procedure demands that the elements of performance under IM 02.02.01 of the Joint Commission accreditation requirements are adhered to; 1. That the hospital uses uniform sets to standardize data collection throughout the hospital; The findings by the...
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...Case Law in Health Care Health care all over the world often sometimes face many obstacles, according to (Hammer & Sage) “Lawsuits against hospitals constitute the lion’s share of antitrust litigation. Between 1985 and 1999 hospitals were defendants in 61 percent of 394 medical antitrust disputes that led courts to issue formal opinions (hospitals were plaintiffs in only 6 percent. These numbers understate the burden of hospital antitrust litigation because most filed claims do not result in a published judicial opinion).” Hospital is a business that provides medical service to patients and there will always be competitors that produce social benefits. For example, Medical Malpractice is one of the major area that fail to provide quality health care medical treatment to patients, the victims of medical malpractice seek compensation for their physical or emotional injuries, or both, through a Negligence action. When patients suffered an injury, which he or she should be compensated, the reason for his or her injuries was because the physician’s violation of the standard of care. However, although the physicians is the cause of his or her injuries like according to (Farlex, 2012) “To protect themselves against the massive costs of such claims, physicians purchase malpractice insurance. Physicians' malpractice premiums total billions of dollars each year and add substantially to the cost of health care in the United States. In some specialties, such as obstetrics, 50 percent of...
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...Stagen was awarded Ernst & Young's Entrepreneur Of The Year award in the Greater Los Angeles region in 2007 • Founded the National Association of Travel Healthcare Organizations (NATHO) in 2008 2 Today’s Agenda • A Look at Today’s Healthcare Workforce • Reviewing the KPMG U.S. Hospital Nursing Labor Costs Study Results • Strategies for Optimizing the Nursing Workforce 3 Learning Objectives • Understand how to successfully blend full-time and contingent labor to achieve financial and patient care goals. • Develop proactive contingent staffing strategy to attract highest quality nurses. • Leverage new research to understand the impact of contingent staffing on quality and patient outcomes. 4 State of the Healthcare Workforce • Healthcare employment up 360,000 in last 12 months1 • The average age of a Registered Nurse is 472 • Nurses looking at job changes3 – 42% are not satisfied with their current job – 24% plan to seek new employment if economic recovery continues – 32% plan to take steps to leave nursing in the next 1-3 years 1 Bureau of Labor Statistics, 2 & 3 AMN Healthcare 2011 Survey of Registered Nurses 5 Proactive Planning Hospital executives need to be asking: How do I control my workforce expense budget most efficiently? 6 Equation for utilization of Permanent RNs vs. Temporary RNs has changed dramatically •...
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...Christina Ninh November 10, 2014 HCA 6225 Fall 2014 Case Study #6 Effective communication is the foundation of any health care team; and conversely, poor or nonexistent communication in a health care setting can negatively impact patient care. Preventing such medical miscommunication means fewer medical errors. And like the Case of Jesica Santillon, deaths occur in the US each year because of medical mistakes; the biggest factor being miscommunication or lack thereof between multiple health care professionals. In the Case of Jesica Santillon, Duke University Hospital, one the nation’s top medical center, transplanted a heart and two lungs into 17-year-old Jesica Santillon in a rare and difficult operation, whose miscommunication resulted in her receiving organs of the wrong blood type, and ultimately an untimely death. Jesica was smuggled by her parents from Mexico to the United States in search of treatment to a life-threatening heart and lung disorder that doctors in Mexico could not fix. Through charity, enough money was raised for her to receive a transplant, however the procedure went wrong and lead to severe brain damage. When informed by the doctors that they planned to stop treatment, her mother announced at a press conference via a translator that “they are taking her off of the medicine little by little in order to kill her. They want to rid themselves of this problem.” It is evident that social and cultural barriers made it difficult for doctors...
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...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 discovered...
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...Today’s healthcare institutions and providers strive to be safe places for patients to receive care, but past data indicates it has not always been so. The Institute of Medicine determined in the late 1990’s that 44,000 to 98,000 patients die from medical mistakes each year (Wachter, 2008). This tremendous number of deaths places medical care mishaps between the fifth and eighth leading causes of deaths in the United States (Kizer, 2001). In 2002, The Joint Commission established National Patient Safety Goals (NPSG) to help accredited organizations with patient safety in specific areas. An advisory group comprised of nurses, physicians, pharmacists, risk managers, clinical engineers, and others with appropriate experience advises The Joint Commission on how to address emerging patient safety issues. This group also periodically develops and updates the goals. The goals are grouped into broad categories and for 2011-2012, cover such categories as patient identification, health care-associated infections, improving communication, medication safety, reducing falls, and risk assessment. A discussion of selected elements underlying the current NPSG such as hand washing techniques, training, and lack of communication between healthcare personnel that can lead to medication errors, to falls, and even death, plus other related factors such as staffing shortages, problems with using outdated equipment, considerations in using the electronic medical records, and compliance with statutes...
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...sample statistics (Bennett, Briggs, & Triola, 2009). Inferential statistics uses sample data from a population to gather data (Bennett, Briggs, & Triola, 2009). There are many ways descriptive statistics is used in my workplace; one is the use of Press Ganey to evaluate the patient’s experience. Press Ganey is an independent company who mails surveys to patients that was discharged home. Each patient who is selected to be mailed a survey is assigned a code that reflects the unit the patient was discharged from as well as the discharged diagnosis. The survey consists of 20 questions about their impressions of the hospital, the staff, and the physicians. The surveys are than sent back to the company where the data is analyzed and forwarded back to our hospital. The data not only provides the quality of care provided, but also compares our hospital to other hospitals within the Press Ganey database. The data is analyzed by the leadership team and determined what areas need improvement. The drawback of Press Ganey is the amount of returned surveys. An example of inferential statistics used in my workplace is...
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