Accreditation Audit Task 1

5. Compliance of hospital policy regarding H&P completion within 24 hours of admittance will be reassessed in 90 days with a random sample of 20 patient charts. If compliance is rated at <98% the action plan will be reassessed and additional solution and sanctions will need to be implemented.

With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.

Giving and receiving an incomplete or inadequate patient hand-off could mean the difference between life or death. In 2006, The Joint Commission addressed hand-off communication as a National Patient Safety Goal, and in 2010, the objective became a standard. However, evidence still shows there are gaps and that “substandard or variable hand-offs have contributed to errors, care omissions, treatment delays, inefficiencies from repeated work, inappropriate treatment, adverse events with minor or major harm, increased length of stay, avoidable readmissions, and increased costs” (Halm, 2013). The Joint Commission reported in 2017 that “ineffective hand-off communication was the cause of the majority of medical errors, including sentinel events” ("Inadequate Handoff Communication," 2017). The hospital I selected for my clinic hours uses a communication form that has not been updated in several years. These are the reasons why I chose to update and improve the current hand-off form for my sustainable product to promote better communication and increase patient safety. Furthermore, research proves that “successful hand-off improvement programs have the potential to substantially improve patient safety” ("Inadequate Handoff Communication," 2017).

While touring with Dr. Willig, we observed the general process of a physician who rounds for an internal medicine service on 9 South, one of UAB’s Internal Medicine floors.  The physicians rounding on this particular floor are considered “Adult Specialists” per Dr. Willig.  Patients are routed to 9 South through a variety of entry portals into the health system: the Emergency Department by way of EMS, ED walk-in patients, ambulatory surgery patients requiring post-op admission, or by direct admission from an outside hospital.   Dr. Willig explained that direct admissions are routed through Bed Control who is responsible for deciding where a particular patient will be placed within the hospital.  This decision is made using clinical judgment in reference to each patient’s particular illness/disease process as well as Teletrac, UAB’s software for tracking the clean status and availability of their patient rooms (Willig, 2017).

The inconsistency in our markings is the reason why we are out of compliance with that element of performance. A time-out is the final verification step taken before the start of the procedure and all members of the team present are required to participate. Our policy states that the nurse or technologist will call the time out and all other members of the team will participate. It goes further to list the information that should be verified like patient, procedure, site and side and patient position. The above exceeded the JCAHO recommendations and put us in compliance on that facet. A patient can develop complications in surgery and need a different procedure by a different provider to correct the complication; if the above happens, the Joint Commission requires that a new time-out be called. Our current policy does not address the above.

Many modern-day health care facilities have a 23 hour observation unit is constantly busy. I work on one of these units. When giving a telephone handoff report subtle elements of the patient’s current condition can be ignored. To avoid exclusions to the handoff report a change is required. The change will provide ideal patient results for all patients that are admitted to the floor from the observation unit (McHughs & Van Dyke, 2011).

For example the enrolled nurse may need to visit a client immediately after Mr Gallway to administer medications by a certain time. The enrolled nurse would contact each client and discuss time of arrival and different options available including Mr Burke. As the delay at Mr Gallway’s will cause the enrolled nurse to work longer than the standard 8 hr shift, the enrolled nurse will have to contact the office and explain the situation requesting approval for overtime or asking that another enrolled nurse assist with the schedule. For each patient that is affected by the time delay, the enrolled nurse will document this in the progress notes for each client, especially for instances of medication administered later then the original

We expect to accomplish this 50% reduction in waiting time by improving efficiency of operation and adding new staff if necessary in order to accomplish our goals. The final flow diagram will reveal a plan to better organize the registration process, the triage process and other processes that a patient may undergo during his matriculation through the emergency department. We will submit contingency plans that can be used when patients do not fit in to a specific category of acuity or when the condition of a patient deteriorates suddenly. The diagram will also offer plans for patients who arrive by paramedic

Handing over or handoff is the transfer of relevant information to one person to another at the end of the shift that plays a vital role in communication. This process demands the healthcare member provide accurate and pertinent data to the oncoming nurses crucial for appropriate treatment and nursing intervention to promote quality and effective care. In addition, effective handoffs decreases the risk of medication error and sentinel events. Moreover, quality of nursing care will depend on what information the nurses receives from their coworker thus vulnerability of patient to harm increases whenever there is a break in the chain of communication. Standards and protocols in the nursing practice in different hospitals will vary, however,

A Survey of Surgical Team Members’ Perceptions of Near Misses and Attitudes Towards Time Out Protocols used a cross-sectional study (N = 427) included surgeons, anesthetists, nurse anesthetists, and operating room nurses. The questionnaire consisted of 14 items, 11 of which had dichotomous responses (0 = no; 1 = yes) and 3 of which had responses on an ordinal scale (never = 0; sometimes = 1; often = 2; always = 3). Items reflected team members ' experience of near misses or mistakes; their strategies for verifying the correct patient, site, and procedure; questions about whether they believed that these mistakes could be avoided using the Time Out protocol; and how they would accept the implementation of the protocol in the operating room, (Haugen, Murugesh, Haaverstad, Edie, & Softeland, 2013).

Patient sense a lack of professionalism from the staff. A new admission process with role clarity created by having designated admission staff will improve patient perception, stream line admission times, and create a more professional environment.

On average, the guides took 27 minutes to complete. As results indicate, Hospital A has not implemented some of the recommended practices in the following guides: Computerized Provider Order Entry with Decision Support, Patient Identification, and Test Result Reporting. The total number of these practices is 16 which accounts for 10% of the total recommended practices. Also, there is a number of practices that has been implemented partially in some areas in hospital A. These practices fall into the following guides: Computerized Provider Order Entry with Decision Support, Clinician Communication, High Priority Practice, Organizational Responsibilities, and system interfaces which account for 11% of the total recommended practices. The only guides that hospital A is fully complied with are Contingency Planning and System Configuration guides. The total number of practices that have been fully implemented across all guides is 125 which represent 79% of the total recommended practices.

Improving efficiency can make inpatient care more cost-effective, but primarily it helps improve the quality of that care. Clinical policies and protocols give physicians standards by which to assess the efficiency of the care they provide. For a complex case, one physician should act as “commander,” and doctors covering on weekends should be empowered to discharge.

Patients wait for long time to get admitted, sometimes even months. On their admission date, most patients report to the hospital’s admission office on time without drinking or eating. After they reported to admitting office, they will wait hours before they get admitted to their room. If the patients waited for an hour, one can argue that things are appreciable in the hospital. Therefore, an hours is not bad. But, waiting for 3 hours or more is unjustifiable. This the story of my unit when patients directly admitted. I like to redesign this practice to a practices that is more to realistic and mindful to patent’s time and safety. Like, later in the afternoon, a time most likely open beds are available, instead of early morning appointment.

Health care centers typically have different people who provide different services all in the treatment process. For an ordinary routine visit, there are professionals stationed at the reception to receive clients and client information mostly regarding mode of payment. There are the nurses who are stationed at the triage to measure the patients’ vitals. In between that and consultation, there are people who oversee that transition, mostly nurses. The coordination of these activities carried out by different persons is what results in extended