Aft2 Task 1

Preparing for The Joint Commission, Nightingale Community Hospital reviews areas of compliance and non-compliance. A periodic performance review, which is a self-evaluation, is utilized by Nightingale Community Hospital, to prepare for The Joint Commission. The Joint Commission has eighteen accreditation requirements. (Commission, 2013) The periodic performance review found the hospital to be compliant and non- compliant in the following areas:

Nightingale Hospital complying with Joint Commission’s is not occurring. The Universal Protocols (UP) met on some months and not on others. The Time-Out Hospital Wide UP looks like hospital was increase in compliance over the year and reached the one hundred percent make until December. This protocol should be preform at every surgery or minor procedure (where necessary) according to hospital policy in which involves laterality. The National Patient Safety Goal Data (NPSG) for communication in Hospital Wide Compliance of Reporting Critical Results within sixty minutes met one hundred percent, zero

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.

Electronic health records can lessen the disintegration of care by refining care coordination. The use of electronic health records will deliver providers with accurate information. This is especially important for those that see multiple specialists, and enable a smooth transition between care settings and receive treatment in emergency

Nightingale Community Hospital identified a recent sentinel event involving the ambulatory surgical center. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). A three year old female presented to the hospital on September 14th for a planned outpatient procedure. The child was accompanied by her mother. The mother registered the patient with the registrar prior to the procedure. The patient and her mother went to the pre-operative area to complete the informed consent and the necessary physical assessment. The pre-operative nurse obtained the necessary contact

EHRs can also improve quality of nursing care by providing nurses with education on the latest in evidence based practices relating to their patients’ conditions. “In order to bridge the gap between research and practice and to improve the quality of care, evidence-based Clinical Practice Guidelines (CPGs) can be incorporated into homecare agencies’ EHRs” (Topaz, Radhakrishnan, Masterson, & Bowles, 2012, p. 25). By incorporating this technology, EHRs go further to empower nurses to make prudent care decisions based on the latest research on best practices.

This sentinel event involves child abduction from the surgical unit of Nightingale Community Hospital on Thursday, September 14, 2014 at approximately 1230hrs. The patient, a three-year old female, arrived accompanied by her mother, for an outpatient surgical procedure at 0800hrs and proceeded to registration where all currently required documentation was completed and signed by the mother; this included the authorization forms for the surgery. After registration, the patient and her

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

* Personnel Issues: One of the key barriers to effective interaction for the pre-op nurses is that they are not getting any information from the registrar or the surgeon related to the patients unique circumstances. There is not a communication process in place for the pre-op nurse to actively communicate with the surgeon or his office regarding a patient’s care during their day of surgery. An additional factor in this situation was the pre-op nurse documented the mother’s contact information in her notepad, but not on the

The tracer was performed as part of a process improvement to assess compliance with The Joint Commission standards (The Joint Commission, 2015). In this process, a random patient chart was chosen and the process followed from admission to discharge including any directly related follow-up or readmission.

The four main areas of focus for the Joint Commission for Nightingale Hospital include Communication, Information Management, Medication Management and Infection

In preparation of a review from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Nightingale Community Hospital will focus on improving its communication process in the operating room. The purpose of communication in the healthcare setting is to disseminate information in such a way as to create shared understanding about the patient and about what needs to be done for a positive outcome. (synergia.com) A patient is at his most vulnerable state during procedures that require sedation or anesthesia. The patient is releasing his decision making ability and safety into the control and care of the healthcare team. Therefore, effective communication on behalf of the patient is

As our Joint Commission audit approaches, Nightingale Community Hospital has conducted a tracer patient survey to assess our compliance. The tracer methodology tracks a selected patient's care from admission to discharge, allowing us to evaluate our systems of providing care and to ensure that we are meeting the Joint Commissions standards of providing safe, quality healthcare.

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

Communication is the key to relating in all environments. When communication lines are broken, it makes take in jobs and personal relationship suffer. In medical environment communication is key in running hospital, nursing home and community care providers. With technology our communication has advanced because now we have electronic medical records. Electronic medical records are a way of providing the medical staff and insurance on the patient health information and insurance coverage. As stated by About.com, “This also provide the doctors away to for individual patients, access to good care becomes easier and safer when