Accreditation Audit

In accordance with the World Health Organisation (WHO 2008) checklist and Local trust policies, a team briefing was held before the day’s list started. The checklist is part of a second Global Patient Safety Challenge initiative entitled ‘Safe Surgery Saves Lives’, aimed at reducing the number of surgical deaths worldwide and was launched in June 2008. This not

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient

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

The Joint Commission (n.d.) states that, “Verbal orders are authenticated within the time frame specified by law and regulation”( Joint Commission, n.d., RC.02.03.07 - 4). With so many departments found to be in non-compliance during the process of just one audit this trend proves this issue is likely widespread throughout the entire hospital and that NCH is regularly non-compliant with this issue. The departments that did not show to have this non-complaint issue were: Cardiac Cath Lab, Endoscopy, ICU, OR, and Surgery Pre-op. To fix this issue, it is advisable to ascertain why and how some departments are meeting the standard while others are not. This issue may stem from improper procedures, training, a deficiency in staffing, or a lack of leadership in the non-compliant departments. Comparing and contrasting the departments should assist in resolving this non-compliant issue.

"To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (Jointcommission.org, 2015). These requirements are regimented in the National Patient Safety Goals and are enforced via surveys and internal inspections to ensure that healthcare institutions abide by the safety mechanisms put in place to facilitate the optimal patient outcomes and environments.

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

In 2003, as an outcome of all the sentinel events reported to the Joint commission lead to the creation of the “The Universal protocol for preventing wrong site, wrong procedures, and wrong person surgery” (Mulloy & Hughes 2008). So, one of the ways that could have potentially prevented the situation from happening at the first place was implementing the universal protocol procedure. According to the protocol the conduction of proper pre as well as post-operating procedures are extremely mandatory. Therefore, by enforcing a standardized routine pre-operating procedure such as verifying the patient as well as the correct site for the procedure, by having the medical staff or preferably the physician marking the operating site with his or her initials before the surgery will be an effective preventive measure (Mulloy & Hughes 2008).

The Joint Commission defines the Periodic Performance Review as an assessment tool created to assist health organizations improve and monitor their performance throughout the year. This tool focuses on the processes that influence patient care and safety while providing the structure for unremitting standards fulfillment. Nightingale Community Hospital is compliant with most standards as set forth by the Joint Commission. However, upon inspection and in an effort to stay focused on compliance, our standards committee has located a few discrepancies that must be resolved to maintain our accreditation with the Joint Commission.

A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began

a. Have all employees sign an acknowledgement form that they understand the new policy and corresponding procedures, and received training within 14 days of establishment of the new policy

5. The Patient Safety Officer will train the risk assessment team members on the proactive risk assessment process and how to conduct a proactive risk assessment, including the assessment of risk, itself.

‘Clear and complete communication between health care providers is a prerequisite for safe patient management. Which is a major priority of the Joint Commission's 2008 National Patient Safety Goals and long-term care (LCT). (Commission, 2008)

Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal 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).

Patient safety one of the driving forces of healthcare. Patient safety is defined as, “ the absence of preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient’s underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)”. It was just as important in the past as it is day. Our healthcare field continues to strive to make improvement toward safer care for patients across the country.

Open communication is essential part to a successful healthcare team that directly impacts patient’s lives. In the video “Just a Routine Operation, ” by Laedal Medical Human Factors in Patient Safety, physicians and nurses demonstrates how different human factors contribute to the overall outcome of the patient. Elaine, the patient in the video came into the hospital for a reconstruction surgery. However, during the surgery Elaine had a complication and because the lack of communication, assertiveness, self-awareness, decision-making, teamwork, and prioritization, Elaine did not survive the surgery. This situation shows how important these characteristics are when dealing with emergency care. Even the health care professional with the years