AFT2 - Task 1 Essay

923 WordsMay 15, 20144 Pages
Executive Summary The Joint Commission is scheduled to visit Nightingale Community Hospital for its triennial accreditation survey within the next 13 months. The purpose of this document is to provide senior leadership with an outline of the hospital’s current compliance status in the Priority Focus Area of Communication. Recommendations for corrective action are included in this document which are designed to bring the organization into full compliance in the areas where deficits have been identified. The Priority Focus Area of Communication includes 3 Joint Commission (JC) standards relative to Universal Protocol. These 3 standards, which are components of the National Patient Safety Goals, are aimed at ensuring the correct…show more content…
EP 5 requires a written process for patients who refuse site marking or when it is impossible or impractical to mark the site. This written process is absent in the hospital’s policy. Nightingale’s policy and process must be revised immediately to reflect all the required elements of the standard. Hospital physicians and staff must be educated on the necessary changes and the revised process must be put into action. Once these changes have occurred, I recommend a focused audit to ensure full compliance with the revised policy/process. UP.01.03.01 requires a time-out before the start of the procedure. The Site Identification and Verification policy describes the time-out process however the policy falls short of fully meeting the intent of this standard. EP 2 describes which team members must participate in the timeout, EP 3 requires a time-out before each procedure when two or more procedures are being performed, and EP 5 requires documentation of the time-out. These 3 elements are missing from the hospital policy/process and therefore revisions to the process/policy are necessary to include these 3 elements. Nightingale’s Safety Report reveals increasing compliance (nearing 100%) with the time-out process, however as mentioned above, EP 5 requires documentation of the process. In addition to the policy revision, I recommend the development of a unique form which will be used to document

More about AFT2 - Task 1 Essay

Open Document