Accreditation Audit: Raft Task 1 Essay example

1480 Words Aug 24th, 2013 6 Pages
WGU Accreditation Audit: RAFT Task 1
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).
The Standards of Universal Protocols (UP) are: UP 01.01.01 Conduct pre-procedure verification process
UP 01.02.01 Mark the procedure site
UP 01.03.01 Perform a Time-Out before the procedure.

To
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Responsible Party: Surgery Leadership Committee. This is the committee who approved the Site Identification and Verification document.
Due Date: Document will be due at the committee’s second meeting from now. If the committee meets monthly, they will have the first month to assign the revision. The document will be due at the next meeting.
Results measured: Revised document will be provided for Surgery Leadership Committee to compare with recommendations.

UP.01.03.01 Recommendation:
1. Provide a Root Cause investigation.
2. Use examples from Joint Commission list of Quality Improvement Activities to
A. Design a new service: Provide education for the patient B. Experiment with new ways of carrying out a function: Incorporate Time-Out into Electronic Medical Records (EMR).
Responsible Party: Surgery Leadership Committee. This is the committee who approved the Site Identification and Verification document.
Due Date:
1. Root cause is provided below.
2-A. The committee will have 6 months to implement guidelines, specify who will do the teaching, how it will be done and set a start date.
2-B. The recommendation for Time-Out to be incorporated into the electronic medical records assumes the hospital is using an EMR. Even so, it will take co-operation with the medical records staff at the minimum and perhaps the IT department. 6 months may be too soon. At the minimum, a progress report will be due in 6 months and a new due date

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