...expecting an audit from the Joint Commission in 13 months, and the areas of Information Management, Medication Management, Communication, and Infection Control all need to be addressed before the visit. The purpose of this executive summary is to review and outline the current state of compliance at Nightingale Community Hospital in a specific priority focus area discussed below. Information Management is one of the areas of focus for the Joint Commission visit, and it is being explored in depth in this summary. Here are the Joint Commission Standards in regards to the area of Information Management: IM.02.02.01 : The hospital effectively manages the collection of health information. A: Compliance Status Under the standard IM.02.02.01 in The Joint Commission Edition, there are three elements of performance. One of these states “The hospital follows its list of prohibited abbreviations, acronyms, symbols, and dose designations” (The Joint Commission EDition). While most of these elements of performance are being followed, Nightingale Community Hospital is at 99.6% compliance for unacceptable abbreviations, and needs to strive to reach 100%. From December to January, items that are on the list of unacceptable abbreviations were brought down to 0% in many cases, such as using the abbreviations ...
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...Executive Summary Accreditation Audit- Task 1 Maggie Miklos January 25, 2014 Executive Summary At Nightingale Community Hospital (NCH) one of our core values is to provide superior service and outstanding clinical care as noted in our safety statement. We welcome The Joint Commission (TJC) to survey our facility on a triennial basis to ensure compliance with their established standards and Priority Focus Areas: Infection control, Communication, Medication Management, and Information Management. In anticipation of the unannounced site visit, I have reviewed our current state of compliance for gaps in the Communication focus area and have prepared actions to close the gaps to ensure compliance. To gauge NGH’s compliance in the Priority Focus Area, Communication, I have reviewed the following Universal Protocol Standards depicted in TJC Handbook. This 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). Within each standard our facility must meet the Elements of Performance criteria. The three standards I will be reviewing are: UP.01.01.01: Conduct a preprocedure verification process. (Commission 2013) UP.01.02.01: Mark the procedure site. (Commission 2013) UP.01.03.0: A Time-out is performed before the procedure. (Commissions 2013) The rationale...
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...Running Header: Task I 1 Task I Abigail M. Garcia Western Governor’s University: Accreditation Audit Running Header: Task I 2 Executive Summary Nightingale Community Hospital is committed to providing quality care and aims to be the first choice hospital for patients in the community. Four core values represent the passion Nightingale has for excellence: Safety, Community, Teamwork and Accountability. The goals of the hospital are to uphold an atmosphere of healing, promote the benefits of health, and to provide a compassionate experience for all. Overview In order to reach the aforementioned goals, values and commitments, Nightingale Community Hospital must be in compliance of regulatory agencies which outline specific, goaloriented sets of standards. The Joint Commission is one such agency that provides assistance and support to health care facilities to ensure that certain standards are met, education for implementing new standards and feedback of current healthcare practices as part of the accreditation process. According to Facts about Hospital Accreditation (2014), the “Joint Commission standards address the hospital’s performance in specific areas, and specify requirements to ensure that patient care is provided in a safe manner and in a secure environment (p. 1).” This agency uses a Priority Focus Process methodology to identify areas within healthcare organizations which have a significant impact on patient safety and quality of care. One of these...
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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 Accreditation Audit - Communication Nightingale Community Hospital A. Compliance Status Nightingale Community Hospital (NCH) has a vital role as a not-for-profit community hospital providing health care and services in various areas such as critical care, general medical and surgical services, oncology etc. This executive summary provides overview in terms of NCH`s compliance of priority focus area on communication: * The current status of the NCH`s communication compliance with the communication requirements of the Joint Commission (JC) on Accreditation of Healthcare Organization. * Corrective action plan for a compliance with the JC’s standards for the communication focus area. * Justification of an importance for the communication standards for NCH. Current Status NCH Communication standards compliance to 2013 Joint Commission Hospital Standards for Communication NCH current standards and protocols in place | Joint Commission(JC) Standard Number | Joint Commission Standards, retrieved from Joint Commissions on Accreditation of Healthcare Organizations (2013) | NCH Preprocedure Hand-Off form | UP.01.01.01 | Conduct a preprocedure verification process. | Overall finding: Based on the provided material, NCH preprocedure hand-off form, there appears to be a preprocedure verification process in place within the hospital. This form, however, does not have a clear division of information areas that are collected and the data provided...
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...A1 EXECUTIVE SUMMARY Nightingale Community Hospital is a 180-bed acute care center that provides a myriad of services for our local community. From our state of the art Vascular Lab to our Neuroscience Unit we strive to provide cutting edge technology with exceptional care. Our vision is to be the hospital of choice for patients, employees, physicians, volunteers and the community. Our mission is to create a healing environment, with a passionate commitment to healthcare excellence. Through our vision and mission, Nightingale Hospital strives to meet and exceed all expectations during our next Joint Commission visit. Before we address the aspects of our upcoming visit from Joint Commission, we must address the foundation of what Joint Commission is. One of the definitions of Joint Commission is, “Joint Commission Accreditation of Healthcare Organizations (JCAHO) is an organization that develops and maintains standards to promote compliance in regards to acceptable levels of care that should be given to patients” (About the Joint Commission). Accreditation from JCAHO provides Nightingale Community Hospital with the gold seal of approval signifying exceptional care. Currently Nightingale Hospital has the JCAHO stamp of approval. However we as an organization should strive to achieve a higher standard of care for our employees and patients as well as our community. With the upcoming visit from JCAHO approaching we need address the past JCAHO visit and...
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...The Joint Commission As someone who recently entered the health care workforce with very minimal knowledge about the health care world, the Joint Commission seems like a viable choice to understand why this organization is important to the health care community. To understand why it is important to have the Joint Commission in the health care system is as simple as reading rules in a classroom on the first day. By understanding its history, the services it offers, and they serve can bring a brief glimpse into what The Joint Commission is about. The Joint Commission: Brief History The history starts with the American College of Surgeons (ACS), founded in 1913 and had developed the Minimum Standard for Hospitals manual and improved standard care within 30 years. With the help of the American College of Physicians (ACP), the American Hospital Association (AHA), the American Medical Association (AMA), and the Canadian Medical Association (CMA), they joined ACS as corporate members to form the Joint Commission on Accreditation of Hospitals (JCAH) in 1951 (Joint Commission History, 2012) . Its sole purpose is to provide voluntary accreditation. The Joint Commission is administered by a 32-member Board of Commissioners that includes physicians, nurses, educators, employers, administrators, and others to bring an assorted array of experience in public policies, health care, and business whom the corporate members appoint. By 1987, JCAH changed the name to Joint Commission on Accreditation...
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...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 Director of accreditation notes that this standard is not indicated anywhere in...
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...Executive Summary of Accreditation Audit June 2012 I prepared and reviewed an accreditation audit for Nightingale Community Hospital to organize and ensure compliance with Joint Commission standards for our hospital. We are preparing for a site visit that should occur within the next 13 months. I have reviewed the current compliance status of our hospital and will explain our corrective action plan that will ensure compliance with the Joint Commission standards for the focus area of communication. An accreditation audit was performed by Carl Anderson, Director of Quality. We were only in 100% compliance in December throughout the year in one of the priority focus areas of the Joint Commission standard: Communication; Standard: UP.01.03.01; A time out is performed before the procedure. See chart below: This is the universal protocol for preventing wrong site, wrong procedure, and wrong Patient Surgeries. In evaluating this, I must review all standards that go hand in hand with the time-out standard; per Nightingale Community Hospital policy, Site Identification and Verification (Universal Protocol). I will address the elements of performance for all three: UP.01.01.01; Conduct a preprocedure verification process. UP.01.02.01; Mark the procedure site, and UP.01.03.01; A time-out is performed before the procedure. I will then address the items that are not addressed in Nightingale's policy in my corrective action plan and add any updates. (Commission, 2012) Standard...
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...the Joint Commission (JC) in the near future, Nightingale Community Hospital (NCH) is performing a tracer patient survey to measure our compliance and identify issues that are in need of remediation. The practice of this type of survey tracks a patient’s care for the duration of their stay starting from the admission process and ending when they are discharged. This system allows us to assess our strengths and weaknesses concerning policy, procedures, and systems in place to provide quality care in conjunction with the standards set forth by the JC. Summary of Tracer Patient Audit Findings This particular survey was conducted concerning a patient that is a 67 year old female, presenting with fever and drainage approximately 5 weeks after an open hysterectomy. The tracer patient was subsequently admitted for a possible postoperative infection. The tracer patient then endured another surgery to treat the infection that started after the original surgery. The patient also received a central line which is used to administer long-term antibiotics. NCH is arranging to discharge the patient to go home with home health, with the aid of her husband, to help administer her antibiotic therapy after discharge. The audit of this particular patient’s care revealed areas that present an opportunity for correction and improvement. Specifically, the patient did not have a history and physical completed until more than 72 hours after being admitted to NCH. The Joint Commission (n...
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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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...Case summary White Sands Healthcare system, L.L.C., is a Physician-Hospital Organization in Alamogordo. It was created in 1996.It consists of Alamogordo Physicians, an Independent Practice Association, which has 45 Physician members ,representing 84% of all physicians practicing independently in the area.; Gerald Champion Regional Medical Center, the only hospital in the Alamogordo area; and 31 non-physician health care providers, including all five nurse anesthetists in the area.. It has violated the section 5 of the FTC act, 15 U.S.C. § 45 that prohibits unfair or deceptive acts or practices that affects the commerce.(2) Here, In this case white sands has increased the consumer cost by jointly fixing the prices charged...
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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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...A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness. Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in rootcause analysis and to assist in development of preventative measures. The Joint Commission tracks events in a database to ensure events are adequately analyzed and undesirable trends or decreases in performance are caught early and mitigated. Contents * 1 Specific Events requiring review * 2 Actions and reporting * 3 Joint Commission actions * 4External links * 5 Notes | Specific Events requiring review Besides "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof", sentinel events also include the following, even if the outcome was not death or major permanent loss of function: * Infant abduction, or discharge to the wrong family. * Unexpected death of a full term infant. * Severe neonatal jaundice (bilirubin over 30 milligrams/deciliter). * Surgery on the wrong individual or wrong body part. * Surgical instrument or object left in a patient after surgery or another procedure. * Rape in a continuous...
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...L. Willemen Edited by F. Monforti EUR 25108 EN - 2011 The mission of the JRC is to provide customer-driven scientific and technical support for the conception, development, implementation and monitoring of EU policies. As a service of the European Commission, the JRC functions as a reference centre of science and technology for the Union. Close to the policy-making process, it serves the common interest of the Member States, while being independent of special interests, whether private or national. Contributions to this report from: Institute for Energy and Transport: F. Monforti (editor), K. Bódis, J.-F. Dallemand, T. Huld, M.Moner-Girona, I. Pinedo, S. Szabó, U. Tromboni. Institute for Environment and Sustainability: A. Beward, B. Bisselink, A. Brink, A. de Roo, F. Kayitakire, P. Mayaux, H. Sint, J. Thielen, L. Willemen Cover picture: Towards Koyiria Market (Niger), Picture by E. Bartholomé, JRC European Commission Joint Research Centre Contact information Address: F. Monforti-Ferrario , Via E. Fermi 2749, TP 450, I-21027 Ispra (VA), Italy E-mail: fabio.monforti-ferrario@ec.europa.eu http://www.jrc.ec.europa.eu/ Legal Notice Neither the European Commission nor any person acting on behalf of the Commission is responsible for the use which might be made of this publication. Europe Direct is a service to to your questions about the European Union Freephone number (*): 00 800 6 7 8 9 10 11 (*) Certain mobile telephone operators do not allow access to 00 800 numbers...
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