Joint Commission Executive Summary
Ryan Lefever
Western Governors University

Joint Commission Executive Summary
Nightingale Community Hospital strives to provide compassionate care in a safe environment. In the competitive market of healthcare, it is imperative to meet The Joint Commissions’ standards. The goal of the Joint Commission is to provide up to date patient safety standards for healthcare organizations to meet. While these safety issues are important in their own right, the accreditation is used by Medicare as validation that the facility meets their standards resulting in full reimbursement of medical costs in the care of Medicare patients. Without the accreditation the hospital would most likely go bankrupt
To ensure that Nightingale Community Hospital will meet The Joint Commissions standards, they have collected data in the focus areas of the commission to see where improvement is needed. The hospital appears to be doing well in many of the areas, but infections control could be improved over the period before the next inspection. Within this area the hospital has decided to seek improvement with a focus on central line bloodstream infections (CLBSI). To improve compliance and safety involving central line use with Nightingale Community, a new central line protocol will be introduced. The policy is planned to begin a phased roll out to the nursing units over the next month. The hospital has been broken down into three phases, so that the nursing educators and an IV team representative will be able to round on the units to assist with the roll-out. The new protocol has been approved the critical care doctors, IV team, interventional radiology and the policy committee.
The policy is available below for reference. The policy will also be available for review by the staff at all times on the hospital intranet under the policy section.

Nightingale Community Hospital
Central Line Protocol
The central line management policy was put into effect using CDC recommendations. These policies have been developed to minimize the risk of a patient developing an infection related to the central line.

Insertion
1) Central Line of any type (PICC, Cordis, Triple Lumen etc.) may only be inserted by the Intensivist or ICU PA
2) Sterile technique must be used using a max barrier kit with chlorhexdine. If the proper technique is not being followed, the nurse should stop the procedure.
3) After insertion the site must be sterilely secured with non-suture device, covered with biopatch and a transparent dressinfg

Care
1) Universal hand hygiene prior to use
2) 15 second alcohol cleanse prior to using hubs, allow to dry
3) No blood draws unless approved by inserting practictioner
4) Change dressing every 7 days and when soiled as needed
5) Change IV tubing every 48 hours
6) Flush line every 8 hours and aftger every medicine infusion

Documentation
1) RN will determine on a daily basis need for central line and document reason.
2) If line is no longer needed a MD order will be obtained to remove within 4 hours