...Accreditation Audit AFT Task 1 Roland Helmuth Western Governors University Accreditation Audit AFT Task 1 Medication Management A. Compliance Status I will be reviewing three specific areas dealing with medication management. They are the following with the correlating Joint Commission Standard following each one: 1. The hospital plans its medication management process, (MM.01.01.01). 2. Label all medications, medication containers, or other solutions on and off the sterile field, (NPSG.03.04.01). 3. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy, (NPSG.03.05.01). In review of standard MM.01.01.01, I see that Nightingale Community Hospital (NCH) has a policy that speaks directly to this standard. The elements of performance are met by the policy that is in place and includes further information to make this important standard compliant with Joint Commission standards. In review of standard NPSG.03.04.01, I do not find the NCH has a policy that addresses this. Seeing that NCH has surgical and sterile procedures performed at its facility this standard needs to have a policy in place. The basis of this is patient safety related to the five rights of medication administration; Right patient, Right medication, Right dose, Right route and Right time. Even in a controlled environment of a surgical suite, this is vital to any procedure performed. In review of...
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...Melissa L. Nelcha AFT2- Task 1 Western Governors University October 25,2013 The Joint Commission has identified four distinct areas of concern within our accreditation audit. They are Communication, Information Management, Infection Control and Medication Management. While each of these is important, and vital in running Nightingale, the focus of this Summary will be on Medication Management. The reasons are as follows: * Errors can lead to increased hospital stays, possible lawsuits, and increased mortality rates, all of which affects our reputation within the community and elsewhere. * Due to the severity of the possible outcomes from medication errors, our company could end up having to pay out large sums of money to deal with repercussions of these errors in legal fees, etc. * Increasing numbers of Adverse Events can lead to a moratorium set on our facility, wherein we would not be allowed to accept any new patients, thereby losing untold amounts of money. A step this drastic can take years to fully recover from. * Having to legally inform the public of each and every adverse event coming from a Medication error could also cost us untold amounts of revenue. The Joint Commission Standard focused on in this summary will be Medication Management. There are three areas covered within the Medication Management Criteria. * Planning Medication Management processes * Labeling of Medications and devices used to administer them * Reducing patient...
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...Executive Summary - Infection Control and Prevention Current Compliance Status for Joint Commission Accreditation Nightingale Community Hospital is committed to providing healthcare excellence, a healing environment and to be the choice for patient care. In order to continue to provide quality healthcare services in accordance with our values of safety, community, teamwork, and accountability Joint Commission Accreditation provides guidelines and standards for the Priority Focus Areas (PFA) for the welfare and quality of patient care. Infection control and prevention extends beyond treating the patient. It encompasses all who work and visit the facility including medical staff, administrative staff, volunteers, vendors, and visitors. Implementing activities and programs to control, treat, prevent and identify sources of infection will help ensure the overall satisfaction and quality of patient care. Based on previous fiscal year data Joint Commission has identified Infection Control as one of the PFAs. In order to be in compliance with the standards and guidelines of Joint Commission Accreditation five areas of Infection Control and Prevention have been identified: 1. The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. 2. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization...
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...The safe and effective care of our patients depends greatly on the efficacy of our communication methods between staff in the same discipline and interdisciplinary staff. Communication among staff about patient care is so important that it is one of the Joint Commission’s National Patient Safety Goals. Joint Commission has elements of performance that has to be met to remain in compliance with their standards. In the area of pre-procedure verification, Nightingale is in compliance with making sure that the patient has an armband that can be used to match the other items in the procedure area to him or her. We also have a policy that states how verification should happen and at what stages. Even though there is a pre-procedure checklist, there is no mention of it in the policy. There is no mention of the latest nursing assessment on the pre-procedure checklist and that is one of the examples of relevant documentation to be present that JCAHO gave. With the standard of marking the procedure site, our policy outlines the need to mark sites before a procedure with the patient if possible especially with procedures that involve laterality, multiple structures or levels. In compliance with JCAHO, the policy went further to indicate other means of identifying locations like X-rays and needle localizations, listing the procedures that are exempt from marking and describing that the marker should be a permanent one. The area we fall out of compliance with the standard of marking...
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...Accreditation Audit Task 1. A1. Communication, this is the key focus area that is evaluated in this summary. Communication is a key focus area of the joint commission audit and is also a key area in which Nightingale Community can make enhancements. Communications must be a two way free flow of information. The information exchanges occur between providers, staff, and patients or clients. This was an area that needed improvement was noted in the previous accreditation audit. Some noted prior issues from 2 years ago included patient and family education and information not being properly disseminated to the nursing staff. These are areas where we have targeted and currently meet. Some areas that we continue to work on are as follows. We currently need to address our time out policy. During the last year there were three months that Nightingale Community did poorly in this area. We must make sure that the time outs are not only conducted properly but more importantly documented in the patients chart. If the time out is not properly documented in the patients chart the organization will not receive credit, it will be as though it never occurred. We must make sure that all providers and clinical staff have appropriate training and training materials provided for the time out policy. We will continue to quantify our efforts monthly in this key area. We as an organization must make this goal monthly. Critical results are an issue of concern for the organization. Critical results...
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...Tracer Patient Audit AFT2 Accreditation Audit October 10th, 2014 Tracer Patient Audit With an audit by the Joint Commission (JC) in the near future, Nightingale Community Hospital (NCH) is performing a tracer patient survey to measure our compliance and identify issues that are in need of remediation. The practice of this type of survey tracks a patient’s care for the duration of their stay starting from the admission process and ending when they are discharged. This system allows us to assess our strengths and weaknesses concerning policy, procedures, and systems in place to provide quality care in conjunction with the standards set forth by the JC. Summary of Tracer Patient Audit Findings This particular survey was conducted concerning a patient that is a 67 year old female, presenting with fever and drainage approximately 5 weeks after an open hysterectomy. The tracer patient was subsequently admitted for a possible postoperative infection. The tracer patient then endured another surgery to treat the infection that started after the original surgery. The patient also received a central line which is used to administer long-term antibiotics. NCH is arranging to discharge the patient to go home with home health, with the aid of her husband, to help administer her antibiotic therapy after discharge. The audit of this particular patient’s care revealed areas that present an opportunity for correction and improvement. Specifically, the patient...
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...Running Header: Task I 1 Task I Abigail M. Garcia Western Governor’s University: Accreditation Audit Running Header: Task I 2 Executive Summary Nightingale Community Hospital is committed to providing quality care and aims to be the first choice hospital for patients in the community. Four core values represent the passion Nightingale has for excellence: Safety, Community, Teamwork and Accountability. The goals of the hospital are to uphold an atmosphere of healing, promote the benefits of health, and to provide a compassionate experience for all. Overview In order to reach the aforementioned goals, values and commitments, Nightingale Community Hospital must be in compliance of regulatory agencies which outline specific, goaloriented sets of standards. The Joint Commission is one such agency that provides assistance and support to health care facilities to ensure that certain standards are met, education for implementing new standards and feedback of current healthcare practices as part of the accreditation process. According to Facts about Hospital Accreditation (2014), the “Joint Commission standards address the hospital’s performance in specific areas, and specify requirements to ensure that patient care is provided in a safe manner and in a secure environment (p. 1).” This agency uses a Priority Focus Process methodology to identify areas within healthcare organizations which have a significant impact on patient safety and quality of care. One of these...
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...1. Outstanding Patient Care Issue: There were several deficiencies made evident by the tracer patient during the survey conducted at Nightingale Community Hospital. There was no documentation of a medical history for the 67-year-old female patient who was admitted to the hospital. Furthermore, the female patient did not receive a physical until 72 hours after she was admitted. In addition, a function assessment was triggered based on the patient’s admission assessment but no record was found. It is crucial to gain knowledge of the patient’s history and perform a physical within 24 hours of admission to provide the patient with safe and quality medical care. Another deficiency noted in the survey was the initial nursing plan of care was documented but was not updated since surgery. During treatment, it is important to collect and record accurate and most up-to-date information from the patient to ensure the best possible care. Other deficiencies made evident by the tracer patient were a nurse’s inability to explain the range order policy when administering medication to patients. Pain medications are to be check for effect within 1 hour after ingestion but documentation showed the last 4 times that checking for effect exceeded 1 hour after administering pain medication to the patient. It is recommended to start with the lowest dose ordered and work up if necessary. Finally, the hand-off process noted in the survey as disjointed as well as the use of hand-off form was inconsistent...
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...Introduction In preparation for an accreditation audit, I will discuss the current communication compliance status of the organization based on the Nightingale Community Hospital’s previous Joint Commission Survey. A corrective action plan will be submitted to ensure compliance with the Joint Commission along with a brief summary on why a communication review is important to the hospital. Body A. In reviewing the Joint Commission (TJC) survey results on Nightingale Community Hospital from 2 years prior, communication was cited on a direct finding relating to a Leadership Standard (Joint Commission Perspectives, 2013). Further review indicates that miscommunication is associated to the other 5 findings, as well. Noguchi (2013) discusses medical errors resulting from miscommunication, adding that medical errors may rank as the third leading cause of death in America. For the purpose of this executive summary, the focus will remain on Leadership standard LD.04.01.05 and its direct finding that hospital leaders did not effectively communicate a functional screening criteria policy to staff nurses. Nightingale Community Hospital (NCH) currently utilizes a pre-procedure hand-off form and site identification and verification process/policy to ensure that correct patient, site, and procedure is completed in surgery. The pre-procedural hand-off is a detailed checklist that aids the nurses from hand-off to accepting patient prior to a procedure. Although detailed, several key...
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...Executive Summary of Accreditation Audit June 2012 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: UP.01.03.01; A time out is performed before the procedure. See chart below: This is the universal protocol for preventing wrong site, wrong procedure, and wrong Patient Surgeries. In evaluating this, I must review all standards that go hand in hand with the time-out standard; per Nightingale Community Hospital policy, Site Identification and Verification (Universal Protocol). I will address the elements of performance for all three: UP.01.01.01; Conduct a preprocedure verification process. UP.01.02.01; Mark the procedure site, and UP.01.03.01; A time-out is performed before the procedure. I will then address the items that are not addressed in Nightingale's policy in my corrective action plan and add any updates. (Commission, 2012) Standard...
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...Jenny Windler Student ID: 000329547 Accreditation Audit (AFT2) Task 1 A. Compliance Status Nightingale Community Hospital is a complete and leading healthcare facility that believes in providing the best quality care to all of their patients. As part of Nightingale’s mission to put the patient first, the hospital must meet medication management standards set forth by the hospital and the Joint Commission. Medication management often involves the efforts of multiple services and disciplines. It is part of Nightingale’s policy that a patient’s information is accessible to a physician, pharmacist or nurse in the management of a patient’s medication. Nightingale Hospital has all the policies in place that the Joint Commission looks for to keep the hospital accredited. A1. Plan for Compliance In reviewing the safety of using medication associated with Anticoagulation Therapy, Nightingale Hospital needs some improvement. There was only one month out of the year that patients did not experience any adverse effects related to Anticoagulation Therapy. Numbers were high at the beginning of the year and tapered off by the end of the year, but Nightingale Hospital should be experiencing more months where there are no adverse events. In combination to the Joint Commission’s finding 2 years ago regarding the lack of documented evidence that the patient’s ability/readiness to learn, learning preference, or educational needs were assessed and documented in the file, we have much...
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...Continuous Accreditation Compliance - Task 4 AFT2 Accreditation Audit October 31st, 2014 Continuous Accreditation Compliance - Task 4 Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment that provides for proper care and emphasizes patient safety. NCH has shown to be 100% compliant with the majority of standards including: Infection Prevention and Control, Right and Responsibilities to Patients, Human Resources, Transplant Safety, Emergency Management, and Performance Improvement. During the last inspection NCH was found to be non-compliant in the following areas: National Patient Safety Goals, Record of Care, Environment of Care, Nursing, Treatment and Services, Leadership, Life Safety, Provision of Care, and Universal Protocol. Trending Areas of Concern The PPR revealed numerous issues in all areas of NCH. In order to address issues that affect patient safety and accreditation it is necessary to focus on issues that are found to be present in several areas of the facility. These patterns and trends of non-compliance often expose a weakness in policy, procedure, or training that needs to be addressed in order to ensure patient safety and accreditation compliance...
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...Accreditation Audit AFT Task 4 Regulatory Audit Organization Plans Compliance Facility Compliance The following represents the level of compliance in the pain assessment area of patient care that was audited for Nightingale Community Hospital: There were 3 departments audited for Pain Assessment compliance over a 12 month period, NIGHTINGALE COMMUNITY HOSPITAL averaged 86.94% compliance. Audit | Audit Period | Location | Compliance % | Pain Assessment | 12 Months | ED | 70.66% | Pain Assessment | 12 Months | 3E | 93.5% | Pain Assessment | 12 Months | PACU | 96.66% | There were 3 departments audited for Pain Reassessment compliance over a 12 month period, NIGHTINGALE COMMUNITY HOSPITAL averaged 80.415 % compliance. Audit | Audit Period | Location | Compliance % | Pain Reassessment | 12 Months | ED | 54.83% | Pain Reassessment | 12 Months | 3E | 92.916% | Pain Reassessment | 12 Months | PACU | 93.5% | The following are the results of the audit that was completed for use of prohibited abbreviations in an aggregate of ICU, Telemetry, 3E and 4E over a 12 month period: Audit | Audit Period | Abbreviation | Occurrences per 50 opportunities | Prohibited Abbreviations | 12 Months | “cc” | 33.75 | Prohibited Abbreviations | 12 Months | “qd” | 15.916 | Fire Dill History of drills held once per shift per quarter over a 12 month period: Quarter | Shift 1 | Shift 2 | Shift 3 | Compliance Analysis | 1st (Jan-Mar) | √ | √ |...
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...Regulatory and Compliance: Hospital Communication and Wrong Site Surgery Prevention March 21st, 2014 Accreditation Audit Regulatory Audits and Compliance Hospital Communication and Wrong Site Surgery Prevention Background: Wrong Site Surgery is costly and horrifying experience for the patient, the physician and the hospital. It is considered a preventable medical error. In 1999, the Institue of Medicine report, To Err is Human states that “clinicians were unaware of the number of surgery-associated injuries, deaths, and near misses because there was no process for recognizing, reporting, and tracking these events.” (LT Kohn, 2000) Physicians and nurses do not wake up desiring to harm patients, in fact, they take an oath to do not harm, but humans make mistakes. Unlike a mechanic or a car salesman, nurses and physicians are caring for people, and their mistakes can be detrimental to the patients to the point of death. The reasons safety nets need to be put into place to ensure compliance for the patient are obvious, but additionally for the physician and facility the cost of wrong site surgery (WSS) can be detrimental “State licensure boards are imposing penalties on surgeons for WSS, and some insurers have decided to no longer pay providers for WSS or wrong-person surgery, nor for leaving a foreign object in a patient’s body after surgery. Surgery performed on the wrong site or wrong person has also often been held compensable under malpractice claims. Seventy-nine...
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...A1- Sentinel Event A 3 year old female patient was admitted to the Ambulatory Surgical Unit for an outpatient procedure to place tubes in her bilateral ears. The patient’s mother was advised that the procedure would take approximately 45 minutes and that the patient would remain in recovery for at least an hour. The patient’s mother advised that she needed to leave the facility to deal with an older child and gave Greta, the pre-op nurse, her cell phone number and asked that she be contacted if the patient was done with her procedure sooner than the expected time. The patient was then handed off to Rosemary, the OR nurse, who provided care during the procedure. Following the procedure, the patient was handed off to Jon, the recovery nurse, who provided post-anesthesia care until the patient was ready to be transitioned to the discharge area. Jon received report from Rosemary and provided care until the patient awakened. While the patient was coming out of anesthesia, Jon called out to the waiting room and paged for the patient’s mother without a response. The patient was recovered and then taken to the post-operative area and released to Kim, the discharge nurse, and gave report and advised that the mother wasn’t in the waiting area. Kim received a call from Tim, the security officer, who advised the patient’s father was at the main reception area. The father was brought back to the discharge area and the patient recognized the gentleman as her father and after another...
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