Executive Summary of Accreditation Audit
I prepared and reviewed an accreditation audit for Nightingale Community Hospital to organize and ensure compliance with Joint Commission standards for our hospital. We are preparing for a site visit that should occur within the next 13 months. I have reviewed the current compliance status of our hospital and will explain our corrective action plan that will ensure compliance with the Joint Commission standards for the focus area of communication.
An accreditation audit was performed by Carl Anderson, Director of Quality. We were only in 100% compliance in December throughout the year in one of the priority focus areas of the Joint Commission standard: Communication; Standard: …show more content…
This will be a double check off to insure safety. We will start a chart audit at projected start date July 1, 2012 and review in 90 days. The checklists will assure that all verifications and site identifications have been carried out.
A focused audit will be done on all patients undergoing operative or invasive procedures for the next year. Results will be analyzed by the nurse manager and discussed at staff meetings. Evaluation of compliance will be done at the staff meetings and any recommendations for improvement will be discussed and approved at these meetings. Implementation of any recommendations will be instituted the following month. Summaries of the audit and any recommendations for improvement will be sent to the PI committee on a quarterly basis.
A PI Coordinator will review all findings at staff meetings, department meetings, medical staff meeting and monthly at the PI Committee meeting. A summary of findings is presented to the governing board on a quarterly basis.
(Commission, 2012) Standard UP.01.02.01 Mark the procedure site. Mark the procedure site before the procedure is performed and, if possible, with the patient and or family involved. The procedure site is marked by a licensed independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed.
(Commission, 2012) The elements of performance state:
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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:
As a clinical requirement for my Adult 1: Medical-Surgical course, I had the opportunity to observe a patient in the Operating Room and in the Post Anesthesia Unit of Advocate Good Samaritan Hospital. The procedure that I observed was a left total knee replacement. The patient needed this surgery because she was experiencing osteoarthritis, and this surgery could alleviate her pain and discomfort. I was with the patient from the end of her stay in the pre-operative holding area to the Operating Room, and then to the Post Anesthesia Care Unit. This paper will include background inquiry, preoperative and operative
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.
Health care organizations generally volunteer to seek accreditations from the Joint Commission by allowing expert surveyors evaluate their facility. The surveyors are made up of a multi-disciplinary team that spends an average of two days inspecting health care facilities. The purpose for the inspection is to evaluate a health care facilities standards, staff, regulations, policies and procedures, and quality improvement, and performance measurement. The Joint Commission surveyors generally look to see if the organizations governing board is taking part in ensuring that the facilities has facilitated safety and quality assurance program.
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.
Nightingale Community Hospital has a Site Identification and Verification policy and procedure. Within this policy, and Preoperative/Preprocedure Verification Process is addressed. There is also a Preprocedure Hand-Off form present. This form is a bit misleading as it is essentially a hand-off
VASNHS Surgical Specialty Outpatient department has a designated pre-operative management unit that oversees the patients undergoing surgery. The predicaments stem from various guidelines or protocol originating from numerous surgeons and clinics. At present, the pre-operative nurses abide simple pre-op instructions (NPO protocol, medications, what to bring, during the surgery, transportation, cancellation instructions) for the entire Surgical Specialty Outpatient department. Surgical procedures are being canceled due to lack of communications and cancelations of patients prior to surgery date.
6. The risk assessment team will conduct an inspection of the department/area being assessed for risk or observe the process being assessed for risk in action. The members of the risk assessment team will individually document their findings on the “ABC Proactive Risk Assessment Worksheet” (Attachment A). To determine the appropriate score for each identified risk, the reviewer will consider information obtained through a physical tour of the facility, review of annual incident
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).
However, documenting the completion of a “time out” is met by the Universal Protocol Policy but also has the added benefit of being stated in the Pre-procedure handout. Upon conduction the accreditation audit for marking the procedure sites, Nightingale Community Hospital has policies in place to make sure they are being met.
A surgical nurse is responsible for monitoring and ensuring quality healthcare for a patient following surgery. Assessment, diagnosis, planning, intervention, and outcome evaluation are inherent in the post operative nurse’s role with the aim of a successful recovery for the patient. The appropriate provision of care is integral for prevention of complications that can arise from the anaesthesia or the surgical procedure. Whilst complications are common at least half of all complications are preventable (Haynes et al., 2009). The foundations of Mrs Hilton’s nursing plan are to ensure that any post surgery complications are circumvented. My role as Mrs Hilton’s surgical nurse will involve coupling my knowledge and the professional
He was asked to be the Subject Matter Expert for creating quality controls for Large Dollar Wire Review, Financial Branch Wires, and IIT Recoveries, thus guaranteeing each process is monitored and a quality sample is completed every month. Harold was an instrumental part in the Retail Bank Fraud Operations internal audit and kept the audit deliverable samples flowing to the Audit Team. This required pulling data on processes from 2013 and tracking every process from start to finish, to identifying gaps and creating solutions to eliminate risk. Angie Baer, Operations Support Senior Analyst who was also the Compliance Audit Retail Fraud Liaison said, “Harold has been instrumental in numerous things, including the sustainability testing for the Wires CAP issue and review of Wires being released in BABO vs IFM. He has created control procedures and helped implement processes to ensure our controls are solid and documented. It has been a pleasure working with Harry in the preparation initiatives for the audit; he has brought leadership and tremendous knowledge base to the team. Thank You Harry for your expertise and