AFT2- Task 1

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Western Governors University *

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AFT2

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Information Systems

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Jan 9, 2024

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docx

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Task 1- Executive Summary for Joint Commission Compliance AFT 2- Accreditation Audit Western Governor’s University XXXXXXXXX 02/23/2023

Summary of Compliance Status The Joint Commission (JC) is scheduled to visit Nightingale Community Hospital in thirteen months. The JC will be reviewing Nightingale's communication policies and verifying that the policies are in compliance with the National Patient Safety Goals (NSPG) Universal Protocols (UP). In anticipation of this visit, Nightingale’s Site Identification and Verification (Universal Protocol) policy for compliance with all thirteen elements of performance (EP) from the JC that are associated with the UP. Action Plans for any EP not in compliance can be found in the action plan section of this report. UP.01.01.01-Conduct a Verification before the Procedure EP1- Establish a verification process that confirms the procedure a patient is about to have is accurate, the facility the procedure will take place at, and verifies the patient. Nightingale is currently in compliance with EP1 according to the organization’s Site Identification and Verification policy. EP2- Verify all required materials needed to perform the procedure. This should include documentation, blood products, implants, test results, or other specialized equipment. Nightingale currently maintains a preprocedural hand-off checklist, Nightingale is currently in compliance with EP2. UP01.02.01- Use a marking to identify where the procedure should take place.

EP1- Use an identification mark for procedures that require incisions on the exact location where the procedure should occur. At the very least, this should include surgeries where there could be more than one insertion site for the procedure. Nightingale is currently in compliance with EP2 according to the Site Identification and Verification policy. EP2- Use an identification mark on the procedure site before the procedure is performed and, if possible, with the patient involved. Nightingale is currently in compliance with EP3 according to the Site Identification and Verification policy. EP3- The site of where the procedure will take place must be marked by a Licensed Practitioner (LP) who is responsible for the outcome of the procedure and must be in the operating room throughout the entire process. In extraordinary circumstances the LP may allow another individual to mark the site. This person must have a graduate degree in a medical program and be supervised by the LP. The designated person must be familiar with the patient and must be present during the entire procedure. Nightingale’s compliance with EP3 is not evident and no documentation is provided for compliance with this EP. EP4- The marking used must be recognizable and not open for interpretation. The marking should be standard across the organization. Nightingale is currently in compliance with EP4 according to the Site Identification and Verification policy. EP5- An alternative plan must be in writing for circumstances when the patient refuses the marking on the site or for when it is not possible to make a mark due to anatomy or when making

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