EXECUTIVE SUMMARY

PURPOSE
The purpose of this report is to assess the compliance of Nightingale Community Hospital (NCH) in accordance with the Joint Commission’s National Patient Safety Goals for 2012. This report will focus exclusively on the Priority Focus Area of Communication and its subsequent standards: * UP.01.01.01 – Conduct a preprocedure verification process. * UP.01.02.01 – Mark the procedure site. * UP.01.03.01 – A time-out is performed before the procedure.
BACKGROUND
NCH is 13 months away from its next Joint Commission audit. It is imperative that NCH is in complete compliance with the Joint Commission.
METHODOLOGY
In order to determine the degree of compliance with the aforementioned standards, the following NCH documents were cross-referenced: * Preprocdure Hand-Off
>cross-referenced with standard UP.01.01.01

* Site Identification and Verification
>cross-referenced with standard UP.01.02.01

* Site Identification and Verification, subheading Time-Out Procedure
>cross-referenced with standard UP.01.03.01
FINDINGS
Standard UP.01.01.01.
NCH is not in compliance with standard UP.01.01.01. The first element of performance of this standard requires NCH to conduct a preprocedure verification process. Although NCH currently has a Preprocedure Hand-Off form that highlights the process, it could be improved by the inclusion of more precise language. Three recommendations are suggested for this improvement: (a) procedure to be performed, (b) patient on whom the procedure will be performed, (c) site where the procedure will be performed.
The next element of performance whereby NCH could improve its compliance is by including more specific language. The inclusion of specific language will mitigate and potential errors caused by ambiguous language.
NCH is in compliance with the third element of performance for standard UP.01.01.01. This requires the matching of the items that are available in the procedure area to the patient.
Please refer to Table 01 on the next page for a comprehensive overview.

Priority Focus Area | Joint Commission Standard | Elements of Performance | Is NCH Compliant? | Recommended Solution(s) | | | Description | Yes | No | | Communication | UP.01.01.01Conduct a preprocedure verification process. | 1. Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site.Note: The patient is involved in the verification process when possible. | | X | Include precise language on the Preprocedure Hand-Off (PHF) form that specifies verification of the correct:1a. procedure to be performed;1b. patient on whom the procedure will be performed;1c. site where the procedure will be performed. | | | 2. Identify the items that must be available for the procedure and use a standardized list to verify their availability. At a minimum, these items include the following:-Relevant documentation-Labeled diagnostic and radiology test results-Any required blood products, implants, devices, and/or special equipment for the procedure | | X | Include precise language on the PHF form that specifies the existence of the:2a. signed procedure consent form and its subsequent attachment.Include precise language on the PHF form that specifies the existence of the following categories and commencing with a conspicuous subheading:2b. nursing assessment2c. preanesthesia assessment2d. radiology images and scans2e. pathology and biology reports | | | 3. Match the items that are to be available in the procedure area to the patient. | X | | n/a |
Table 01: NCH Compliance on Standard UP.01.01.01

FINDINGS
Standard UP.01.02.01.
NCH is in compliance with the first two parts of the Elements of Performance related to standard UP.01.01.01. However, the last part reflects some deficiencies. In order to remedy this, it is suggested that NCH include unambiguous language indicating that the procedure site will be marked by a licensed independent practitioner. As it stands, this language is omitted from the existing Site Identification and Verification form.
Please refer to Table 02 on the next page for a comprehensive overview.

Priority Focus Area | Joint Commission Standard | Elements of Performance | Is NCH Compliant? | Recommended Solution(s) | | | Description | Yes | No | | Communication | UP.01.02.01Mark the procedure site. | 1. Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety. | X | | n/a | | | 2. Mark the procedure site before the procedure is performed and, if possible, with the patient involved. | X | | n/a | | | 3. The procedure site is marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed. In limited circumstances, the licensed independent practitioner delegate site marking to an individual who is permitted by the organization to participate in the procedure and has the following qualifications:-An individual in a medical residency program who is being supervised by the licensed independent practitioner performing the procedure; who is familiar with the patient; and who will be present when the procedure is performed.-A licensed individual who performs duties requiring a collaborative agreement or supervisory agreement with the licensed independent practitioner performing the procedure who is familiar with the patient; and who will be present when the procedure is performed. | | X | 3a. Include specific language that specifies that the procedure site will be marked by a licensed independent practitioner. |
Table 02: NCH Compliance on Standard UP.01.02.01

Table 02: Continued from Previous Page

Priority Focus Area | Joint Commission Standard | Elements of Performance | Is NCH Compliant? | Recommended Solution(s) | | | Description | Yes | No | | Communication | UP.01.02.01Mark the procedure site. | 4. The method of marking the site and the type of mark is unambiguous and is used consistently throughout the hospital.Note: The mark is made at or near the procedure site and is sufficiently permanent to be visible after skin preparation and draping. | | X | Include clear, unambiguous language on the Site Identification and Verification (SIV) form that specifically states that the:4a. method of marking the site is made “at” or “near” the procedure site;4b. defined method of marking the site will be used consistently throughout the hospital. | | | 5. A written, alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site. | | X | 5a. Initiate a written, alternative process for patients who refuse site marking. |
FINDINGS
Standard UP.01.03.01
NCH is not in compliance with standard UP.01.03.01. The first element of performance of this standard requires the team to conduct a time-out immediately before starting the invasive procedure. The term “invasive” is omitted in the Site Identification and Verification form.
The next part of the Elements of Performance pertaining to this standard requires the specific mentioning of all participating members of the procedure team in the team out. The present language on the Site Identification and Verification form omits the specific members and instead uses the term “all”. This may present itself as problematic. Therefore, it is recommended that the form include all specific members, including, but not limited to: anesthesia providers, circulating nurse, operating room technician, and other active participants who will be involved in the procedure from the start.
The third part of the Elements of Performance of this standard requires that a second time-out occurs when multiple procedures are performed on the same patient. Hence, it is recommended that this language be clearly articulated in the Time-Out Procedure section found on pages two and three of the Site Identification and Verification form.
NCH is in compliance with the fourth part of the Elements of Performance of standard UP.01.03.01.
FINDINGS (continued)
Standard UP.01.03.01
The final aspect of the Elements of Performance related to standard UP.01.03.01 finds NCH is not in compliance. In order to fix this deficiency, it is recommended that separate documentation is included that officially signifies the completion of the time-out.
Please refer to Table 03 on the next page for a comprehensive overview.

Priority Focus Area | Joint Commission Standard | Elements of Performance | Is NCH Compliant? | Recommended Solution(s) | | | Description | Yes | No | | Communication | UP.01.03.01A time-out is performed before the procedure. | 1. Conduct a time-out immediately before starting the invasive procedure or making the incision. | | X | 1a. Insert the adjective “invasive” before the noun “procedure” in the topic sentence of the first paragraph under the subheading “Time-Out Procedure” on the SIV form. For example, the revised sentence will read:Immediately prior to beginning the invasive procedure… | | | 2. The time-out has the following characteristics:-It is standardized, as defined by the hospital.-It is initiated by a designated member of the team.-It involves the immediate members of the procedure team, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning. | | X | 2a. Specifically state the participating members of the procedure team in the time-out:- individual performing the procedure, - anesthesia providers, - circulating nurse, - operating room technician,- other active participants who will be participating in the procedure from the beginning. | | | 3. When two or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated. | | X | 3a. Include language that specifically states when two or more procedures are being performed on the same patient, and the person performing the procedure changes, then another time-out must be performed prior to the initiation of the next procedure. | | | 4. During the time-out, the team members agree, at a minimum, on the following:-Correct patient identity-The correct site-The procedure to be done | X | | n/a | | | 5. Document the completion of the time-out.Note: the hospital determines the amount and type of documentation. | | X | 5a. Include documentation that signifies the completion of the time-out. |
Table 03: NCH Compliance on Standard UP.01.03.01