Task 4
Nightingale Community Hospital is preparing for a periodic performance review by The Joint Commission. Prior to The Joint Commission coming to complete its unannounced audit, the commission sends the hospital a handbook of standards guidelines each department of the hospital is expected to meet. The accreditation is a very important process to the daily operations of the hospital. The Center for Medicare and Medicaid Services, (CMS) requires hospital to meet and operate to the accreditation standards. This assures CMS that patients, who pay for services with their Medicare or Medicaid insurance, are receiving the best of medical care. It is imperative for Nightingale to meet the Joint Commission requirements not just for the ability to collect revenue, but its symbol of accreditation hanging in the hospital lobby, tells the public the hospital has met national patient standards. The Joint Commission’s job is not to close a hospital doors, nor to deny the hospital to provide medical services. It should be used a tool for good operating standards for a hospital to conduct its business. It takes work and preparation to meet the standards and to make sure all departments are on board, but once nightingale meet the requirements it all about managing and monitoring the daily operations of standards.
It is the Director of Accreditation job of Nightingale Hospital to make sure the hospital is prepared for the Joint Commission audit. It is the directors who reviews all standards and make sure each department within the hospital is compliance with them. It is also the director’s job to make sure the hospital is not placed in non-compliance status, have sanctions place on the hospital and payment withheld for not meet national patient care standards.
A1. The Director of Compliance at Nightingale will conduct a Periodic Performance Review (PPR) which will help each of the hospital’s departments and its personnel to review the applicable standards, assess compliance, develop and implement plans of action, and identify measures to gauge success in carrying out those plans. Doing a PPR will better prepare Nightingale to incorporate Joint Commission standards into the daily operations to ensure that high quality patient care is an ongoing function of the hospital.
The director of compliance and hospital personnel are completely familiar with the current standards, examination processes, policies and procedures relative to the standards and prepare to improve any areas that are not currently in compliance. Nightingale has obtained accreditation in the past and is currently accredit by the Joint Commission. The hospital will remain accredited as long as it staff members can demonstrate proficiency across specific job competencies and receive performance evaluations based on specific job descriptions. Nightingale must be in compliant with joint commission standards four months prior to initial survey.
Being an accredited healthcare institution has giving Nightingale some very important advantages in the market. To name a few: * Educates staff regarding best practices and improves business operations, reducing risks. * Provides a competitive edge in the market place. * Improves quality, safety and overall healthcare experience for patients, families and staff. * Provides professional advice and boosts the quality of staff recruitment and development. * Recognized by insures and third parties and may fulfill regulatory requirements in select states.
Being accredited gives Nightingale good impression when the hospital is trying to recruit top professionals, and administrative staff that will provide patients with high quality care that expect and deserve. The accreditation is a valuable marketing tool for attracting consumers who seek only accredited provider for their healthcare needs.
Nightingale being compliant with the standards of the Joint Commission is a sign of a hospital operating in high quality research and healthcare services. The patients and hospital visitors will see the Joint Commission accreditation symbol hanging in the lobbies of Nightingale to let the public know that this is a hospital that standards are excellent.
A2. Conducting a PPR the director finds 34 areas were Nightingale Hospital is not in compliance with The Joint Commission standards. The areas of noncompliance range throughout various standards. The audit reports of the fire drill history revealed that eleven departments or units of the hospital are not compliant with the fire drill policy or standards. Nightingale’s fired drill policy states one drill per shift per quarter. The fire drill report audit notes that no unit has conduct fire drills as the hospital policy states.
The verbal order audit report indicates hospital wide, that over the last twelve months, verbal order s was not authenticated within 48 hours. The goal of the hospital is to have 100% of its verbal orders authenticated within 48 hours. The PPR audit showed a trend of verbal orders being authenticated 80% of the time over the last 12 months.
The prohibited abbreviation audit report shows, ICU, Telemetry, 3E and 4E, department and units of the hospital, continue to us the wrong abbreviations. The abbreviations “cc” shows a trend that it was used on an average of 27 times a month for the last 12 months within the four departments mentioned. The abbreviation “qd” showed a trend of wrong use on an average of 15 times a month for the last 12 months.
The moderate sedation monthly audit report shows over the last 12 months the 100% goal for pre-procedure, during procedure, and post procedure was not met. In the pre-procedure evidence of inform consent and time out documents average 100% but other areas did not meet the 100% goal.
Each of the aforementioned PPR audit reports shows that Nightingale hospital is currently noncompliant, and the hospital must correct each standard , and show that the hospital is compliant four months prior to the Joint Commission survey.
A3a. Professional staffing is a major concern for Nightingale Hospital. The hospital plan and design its staff based on each individual unit. Different departments have different personnel needs, and staffing is based on the service the employee is providing the patient. The transportation department will be staff and hired in on different qualifications, than the nursing staff. The hospital use different staffing patterns to hire its employees.
Nightingale is currently focusing on its professional nursing staff on three units. The 3E, 4E oncology and intensive care unit are each represent in the report. The hospital’s goal is to staff each unit with nurses based on competency, and skill mix of staff in relation to the capacity of patients it can house on a unit.
The goal of the hospital is to hire quality nurses and provide them with continue education classes on particular studies, of the type of patient they are servicing. This will help the nurses to better their patients. After reviewing the staffing effectiveness report, it shows the hospital invested in advance training to improve the rate of patient falling on three units. The nurses on unit 3E where trained and most attend a nursing improvement care class. The 3E Oncology unit reduced its falls, and while working within the assigned hour of their schedule shift.
On unit 4E and the ICU unit nurses where not trained like the nurses on 3E and the result were much different. Instead of reducing patient falls, the falls increased the nurse’s work hours increased too. It is the job of the director of compliance and nursing director to create a manageable solution to reduce falling of patients and not over working the staff. It is not totally clear if the nurses on the other units are lack training or competency, it could be the data represent only one nurse, who was over work.
It is important that Nightingale staff its hospital with a good ratio of nurses to patients, in order to provide the best of care.
A3b. Staff planning for nurses is very important in a hospital. Nightingale hospital goal and mission is to offer the best quality healthcare services to its patients. In order to provide this high quality care it must employee high quality nurses. It is nationally know there is a shortage of nurses in the industry. The hospital must be prepared to be competitive to hire the best nurses in the market. There is shortage of nurses in the industry, and the demand for nurses makes it much easier to leave one company and go to another.
It is important that Nightingale establish a staffing plan that will hire quality nurses, to better serve their patients to reduce falling. The plan will start with using a nurse to patient ratio to determine how many nurses is need on the unit at a time. Base on the ratio and patient data, it that will let the hospital know how to many nurses to hire, full time and part-time.
The plan must include a way of creating a more favorable work environment for the nurses. With the nursing shortage nurses are more overwhelming than ever before. Being overwhelm impacts the quality of nursing care. The hospital must develop ways to change the roles of nursing so they will not get overloaded. This can be achieving by adding staff and nurses to the ratio of patients.
Although the evidence is not conclusive, it does suggest that increases in nurse-to-patient ratios and nursing skill mix are related to a number of positive patient outcomes. Education is another component to add to the plan. The data show on 3E the nurses attended NICHE, and was provided with a skin specialist on the floor, their behavior change toward their patients and the quality of care increased.
B. Staffing Pattern (2009) http://xnet.kp.org Joint Commission(2013)http://. https://www.e-dition.jcrinc.com