Accreditation Audit
Task 1
Western Governors University

A. Compliance Status Nightingale Community Hospital is not-for-profit, acute care hospital that houses 180 beds. Nightingale provides services in many areas such as general medicine, critical care, emergency services, oncology, cardiology, etc. Nightingale has four core values: safety, community, teamwork, and accountability. Nightingale’s vision is that patients, employees, physicians, volunteers, and community choose Nightingale’s as the hospital to receive care or to seek employment. To create a healing environment, with a passionate commitment to healthcare excellence is the goal of Nightingale. The next anticipated Joint Commission visit is about 13 months away. Over 20,000 health care organizations in the United States are accredited and certified by the Joint Commission. To receive accreditation from the Joint Commission is recognized nationwide as a symbol that certain performance standards of quality have been reached. A three-year accreditation cycle is standard for all member health care organizations. A two-year accreditation cycle is standard for laboratories. The Joint Commission provides the organization’s accreditation decision, the date the organization was awarded accreditation, but it does not provide the organization’s findings public. There are four Joint Commission focus areas for Nightingale and they are: Information Management, Medication Management, Communication, and Infection Control. This paper will focus on the area of communication for Nightingale. The way information is exchanged and delivered between individuals, departments, or organizations is the process of communication. There are three standards when it comes to communication. The first standard is UP.01.01.01: Conduct a pre-procedure verification process. The rationale for this standard is to make sure that hospitals are is checking to see that the procedure is what the patient needs and also checking to make procedures are performed on the correct patient. For the hospitals to be in compliance with this standard there are three main elements of performance that have to be met. The first element is to implement a pre-procedure process to verify the correct procedure, patient, and site. When possible, the patient should participate in the verification process. The second element is certain items need to be identified that must be available for the procedure and also a standardized list to verify their ability. Those items, at the minimum, include: documentation (H&P, signed consent form, diagnostic and radiology lab results, any required blood products, devices, implants, special equipment). It must be noted that the exception of this element is that the standardized list is available and consistently used during the pre-procedure process. It is not necessary to document that the list was used for each patient. The third element for this standard is matching the items that are available in the procedure area to the patient. Nightingale has a pre-procedure verification policy in place. This policy states that the correct person, procedure, and site must be verified. This information must be verified at the time of admission, anytime there is a transfer of care of the patient to another caregiver, verification with the patient awake (if possible), before the patient leaves the preoperative area, and immediately prior to the beginning of any procedure. Nightingale also has a pre-procedure hand-off check list that must be signed by the nurse handing off patient and by the nurse accepting the patient. Nightingale is compliant with their policy of getting the patient involved in the pre-procedure process when possible. Nightingale’s pre-procedure hand-off check list is compliant with many areas of element two such as: relevant documentation regarding the H&P, consent form signed, and test results. The areas that Nightingale is not compliant with are listing any required blood products, implants, devices, or special equipment for the procedure. Nightingale also does not have a check and balance systems to match items that are to be available in the procedure are to the patient. The second standard for communication is UP.01.02.01: Mark the procedure site. The rationale for this standard is that wrong site surgery should never happen, yet it is an on-going problem in health care that compromises the patient’s safety. There are five elements of performance for this standard. The first element is identifying the procedures that require marking of the incision or insertion site. A special note is attached to this element regarding spinal procedures. Spinal procedures are required to have a preoperative skin marking but special intraoperative marking maybe used for marking the exact vertebral level. The second element is marking the procedure site before the procedure is performed and involving the patient when possible. The third element is a licensed independent practitioner will do the marking of the procedure site and is ultimately accountable for the procedure and must be present when the procedure is performed. However, the licensed independent practitioner may assign the marking of the site to an individual who is permitted by the organization during limited circumstances. The fourth element is that the method and the type of mark is unambiguous and is used consistently through the hospital. It should be noted that adhesive markers are not the only means of marking the site. The fifth element is a written, alternative process is in place for the patients who refuse site marking or when it becomes impossible to mark the site due to technical or anatomical situations. For example, mucosal surfaces or perineum are situations that involve alternative process. Marking premature infants, for whom the mark may cause a permanent tattoo, is another situation that involves an alternate process. Nightingale is not compliant with the first element because they do not identify the procedures that require a marking. However, they have a policy regarding procedures that are exempt from marking. While that policy can be beneficial, Nightingale needs to add what procedures do require a marking. Nightingale is compliant with the second element because they have a policy in place that states how the site will be marked before the procedure and also that the patient will be available to assist in the marking when possible. The third element is another element that Nightingale is does not meet the compliance standards. Nightingale does not have a policy in place regarding the procedure site being marked by a licensed independent practitioner. Nor, is there a policy regarding the licensed practitioner. Nightingale is compliant with parts of the fourth element. They are compliant in the fact that they have a policy regarding the procedure site remaining visible after skin preparation and draping. Nightingale states that the marking should be made with a permanent marker, but they need to add that adhesive markers are not the sole means of marking the site. Nightingale is compliant with the consistency of the method of marking the site. They outline a good policy regarding how to mark the right side, the left side, or marking bilateral. They also mention how spine markings will be marked for cervical, for thoracic, for lumbar, and for sacral. There is also mention that radiographic films may be used to identify precise levels. Nightingale is compliant in certain aspects of the fifth element. They do have a policy in place if the patient refuses or cannot mark the site and then the provider will be notified. Nightingale mentions their policy about teeth marking how it is not required and also regarding interventional procedures, but there is no policy mentioned for premature infants. The third and final standard for communication is UP.01.03.01: A time-out is performed before the procedure. The rationale behind this standard is to conduct one final assessment to make to verify the correct patient, the correct site, and the correct procedure. There are five elements of performance for this standard. The first element is regarding a time-out is conducted immediately before the procedure is started. The second element identifies that the time-out has the following characteristics: it is standardized and defined by the hospital, it is initiated by a designated member of the staff, and it involves the immediate members of the procedure staff. The third element is when multiple procedures are being performed on the same patient, and there is a change in who is performing the procedure, that a time-out is performed before each procedure is started. The fourth element is during the time-out the staff agrees on: correct patient identity, the correct site, and the procedure being done. The fifth element is to document the completion of the time-out. Nightingale is compliant with the first element because they conduct a time-out immediately prior to beginning of the procedure. They are compliant with certain areas of element two. They are compliant due to the fact that they have a designated employee (the nurse or technologist) who is responsible for calling the time-out. However, Nightingale does not have a policy stating the time-out is standardized as defined by the hospital, but they do state that the team members have the responsibility to make sure that a time-out has been called prior to the procedure. Nightingale is not compliant at all with the third element because they do not have a policy regarding when two or more procedures are performed and a provider changes that a time-out is called before the new procedure begins. Nightingale is compliant with the fourth element because they have a policy set in place what team members will agree on during a time-out. Team members will agree on correct patient identity, correct side and site, correct procedure to be done, correct patient position, and availability of correct implants and any special equipment. Regarding the fifth element, there is policy stating the duration and participants of the time-out are documented but there also needs to be documentation when the time-out is completed.
A1. Plan for Compliance A corrective action plan will be created and focused on ensuring that the identified noncompliant areas are corrected and that opportunities for improvement are evaluated. The corrective action plan will outline who is responsible for implementation, oversight, pilot testing as appropriate, time lines, and strategies for measuring the effectiveness of the actions. Nightingale’s CEO and administrative staff (managers, directors, head nurses, etc.) will be responsible for implementation of the correct action plan and the Standard and Communication director will be in charge of the oversight of the correct plan and report back the findings to the CEO. The first areas of improvement that will be focused on are: * Added list required blood products, implants, and devices, or special equipment for the procedure * Matching the items that are made available in the procedure to the patient.
The required blood products, implant, devices, or special equipment list will be handed to the preoperative/pre-procedure verification process policy and also to the hand-off check list. The policy will also be updated to state that match items that are available in the procedure area to the patient. The preoperative/pre-procedure policy will also be updated to include reference to the hand-off check list.

The next areas of improvement will be focused on: * Identifying procedures that require marking * Implement a policy regarding licensed independent practitioner being responsible for marking sites * Implement policy when patient refuses or cannot mark site * Implement policy for marking site for premature infants.
Nightingale will correct these actions by simply updating their current policies to reflect the above changes.
The final areas of improvement that will be focused on are: * Improving the time-out procedure regarding when two or more procedures are being performed and the person performing the procedure changes * Documenting the completion of a time-out
Nightingale will pilot test the new process when two or more procedures are being performed and the person performing the procedure changes. The pilot test will make sure that a time-out is being called before each procedure is initiated. Nightingale will also update their current polices to reflect the changes. All staff will be required to read and sign the updated polices. Results of the corrective action plan will be examined six months prior to the Joint Commission audit. That will ensure adequate time to develop and implement further corrective actions, if necessary.

A2. Justification
Communication was chosen as the priority focus because effective communication is critical to patient’s safety and quality of care. According to the Communication National Patient Safety Goal Data for Nightingale, 100% compliance is not being reached in certain areas. For example, improving effectiveness of communication regarding critical results, the highest percentage Nightingale reached was 82% in August. The lowest percentage was 56% percent in June. The average overall percentage was 67%. Nightingale only reached 100% one time in regards to improving effectiveness of communication regarding verbal orders/read-backs. Time-outs hospital wide for Nightingale only reached a 100% one time in December.
Wrong site, wrong procedure, wrong patient errors are termed never events. Never events are errors that should never occur and indicate serious underlying safety problems. “Never events happen at least 4,000 times a year according to research from John Hopkins University” (Nordqvist, 2012). Research has also shown that operation on the wrong body party occurs about 20 times a week.
Patients’ perceptions of the quality of care they receive are highly dependent on the quality of their interactions with their healthcare team. There is plenty of research that supports the benefits of effective communication and health outcomes for patients and healthcare providers and teams. If the patient and healthcare team are able to communicate on a high level the patients follow through with medical recommendations and adopt preventative health care habits. If the healthcare team has the ability to explain, listen, and empathize this will result in a profound effect on the patient’s biological and functional health outcomes. Patient satisfaction and quality of care will also be affected in a positive way.
Communication with the patient is obviously important, but good communication between members of the healthcare team is just as important. Effective and positive communication between healthcare team members influences quality of care, the quality of working relationships, and job satisfaction. All of these areas have a profound impact of patient safety. Communication is key in preventing medical errors such as the never events. If team members are not correctly marking sites or not calling time-outs then more medical errors can and will occur. Effective communication is vital in a healthcare setting. The patient and the healthcare team and provider must understand each other in a clear way in order for the patient to receive the best care possible. Providing care to a patient is almost impossible if the patient’s needs cannot be clearly stated. Effective communication eases the patient’s anxiety and stress, eliminates the possibility of errors, and lets each party know what is and what will be expected of them.

Reference Page
Nordqvist, J. (2012, December 22). Retrieved March 18, 2014, from http://www.medicalnewstoday.com