Task 1 Aft2

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:

In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.

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

There will be a need for additional catheterization labs, surgical suites and expanded cardiac rehabilitation programs. There needs to be better coordination of care to ensure timely scheduling of procedures. Education programs need to be developed emphasizing cardiac risk factors, healthy living and lifestyle modifications.

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.

For example David Busst would have a significant scar tissue from where he broke his fibula and tibula as when he did break those bones they ripped through his skin meaning it was a compound break. It is likely that he would have a scar from where they bone went through the skin and a scar from where his leg was re straightened and put into his leg again. For example he may have a scar similar to the scar tissue in the diagram below but it may be very deep due to the extent of his injury.

Given the complexity of healthcare system today, effective and efficient collaboration and communication among team members is critical to ensure patient safety. Daniel & Rosentein (2008) reported that during a typical patient’s hospital stay, a patient may interact with 50 different employees that may include doctors, nurses, laboratory technicians, etc. They also reported that when healthcare professional are not communicating and collaborating effectively, patient safety is at risk for several reasons: break in communication flow, misinterpretation of information, incorrect telephone orders and overlooked orders.

For example, a hospital-wide policy can be made making it mandatory for all critical results to be documented and reported within the hour. Attestations can be put in place for all hospital staff to sign, holding them responsible if policies are not followed. Another suggestion would be to have all critical results reported to two sources, for example the patient’s nurse and charge nurse, to increase the likelihood of rapid documentation. The point of the corrective actions is to ensure that each staff member knows what they are responsible for. For example, laboratory staff knows to document the critical values and alert the appropriate nurse or charge nurse, the nurse or charge nurse knows to document the critical lab values or test result and to alert the ordering physician, the ordering physician knows to discuss a treatment plan with the patient and to document appropriately in the chart, etc. The point is, every staff member has a role to play in assisting the hospital in becoming one hundred percent compliant. This corrective action plan holds each staff member accountable. Those who do not comply can easily be tracked and disciplined by their supervisor.

“Errors in communication give rise to substantial clinical morbidity and mortality (Riesenberg, Leitzsch, & Cunningham, 2010).” As a result, the Joint Commission has identified effective communication as one of its National Patient Safety Goals (Dunsford, 2009).

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.

In 1615 the East India Company acquired its first territory in Bombay, India. The East India Company was a British company that traded for goods, services, and raw materials with India. What initially started as a trading company became a company ruling a country with Brittan’s backing. The company established an army in India comprised mostly of local citizens called Sepoys. With help from the British army and navy, the East India Company fought other European countries also occupying India for control of the region. By 1715 the EIC and Brittan had beaten back the French in the Battle of Plassey. This secured their dominance in India and a

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

‘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).