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Accreditation Audit

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Executive Summary Accreditation Audit - Communication
Nightingale Community Hospital

A. Compliance Status
Nightingale Community Hospital (NCH) has a vital role as a not-for-profit community hospital providing health care and services in various areas such as critical care, general medical and surgical services, oncology etc.
This executive summary provides overview in terms of NCH`s compliance of priority focus area on communication: * The current status of the NCH`s communication compliance with the communication requirements of the Joint Commission (JC) on Accreditation of Healthcare Organization. * Corrective action plan for a compliance with the JC’s standards for the communication focus area. * Justification of an importance for the communication standards for NCH.
Current Status
NCH Communication standards compliance to 2013 Joint Commission Hospital Standards for Communication NCH current standards and protocols in place | Joint Commission(JC) Standard Number | Joint Commission Standards, retrieved from Joint Commissions on Accreditation of Healthcare Organizations (2013) | NCH Preprocedure Hand-Off form | UP.01.01.01 | Conduct a preprocedure verification process. | Overall finding: Based on the provided material, NCH preprocedure hand-off form, there appears to be a preprocedure verification process in place within the hospital. This form, however, does not have a clear division of information areas that are collected and the data provided is not completely compliant with JC to provide a full list of the required information: | 1. The NCH preprocedure hand-off form provides Y/N response to identification process but lacks an important information such as name of the patient, the patient`s identifier (e.g. date of birth), patient`s signature and date to be recorded on the form. | 1. Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site. Note: The patient is involved in the verification process when possible. | 2. The NCH preprocedure hand-off form provides a certain level of identification and lists a number of items as required by JC. But there is a certain level of a variation and several details are not listed/missing: * It is evident that NCH follows the criteria in this section and is compliant with JC. * Currently a number of details are missing from the NCH preprocedure form. The form does not provide a full list of the test results, as identified by JC, which can be required and displayed, depending on case-by-case. The form lists only few: lab, chest x-ray, and electrocardiogram. * It is evident that the form only informs if any blood products are ordered, rest of the required information from JC is not listed/included. 3. The form contains information what items are available to the patient (e.g. dentures, glasses, hearing aid, jewelry). However it does not provide an opportunity to match the required items nor this section is clearly marked on the form. | 2. Identify the items that must be available for the procedure and use a standardized list to verify their availability: * Relevant documentation (e.g. history and physical signed procedure consent form, nursing assessment, and preanesthesia assessment) * Labeled diagnostic and radiology test results (e.g. radiology images and scans, or pathology and biopsy reports) that are properly displayed * Any required blood products, implants, devices, and/or special equipment for the procedure
Note: The expectation of this element of performance is that the standardized list is available and is used consistently during the preprocedure verification. It is not necessary to document that the standardized list was used for each patient. 3. Match the items that are to be available in the procedure area to the patient. | Site Identification and Verification (Universal Protocol) | UP.01.02.01 | Mark the procedure site. | Overall finding: Based on the provided material, a site identification and verification (universal protocol), there appears to be a policy for marking the procedure site in place within the NCH hospital. This policy, however, does lack some necessary information and not comply with all JC requirements: | 1. It is evident; the policy identifies procedures that require marking and dictates the site marking for any procedure. The policy refers to a specific process when a spine site marking is done, lists X-ray and additional radiographic techniques to identify levels of spine. This step is compliant with JC.2. This criteria is compliant with JC. The policy identifies on two occasions when the site marking is required and identifies the importance of the patient being involved.3.The policy does not clearly identify the staff person responsible and licensed to provide site marking. It is stated that a nurse is responsible for completion of various steps, but the policy lacks definition/requirement that only a licensed practitioner can proceed with procedure site marking. In addition the policy lacks information about line of command – in terms of who from staff can perform the site marking if a nurse is not available. 4. The policy provides sufficient information about what kind of a marker to be used (permanent black). 5. The NCH policy does identify the need for alternative process if a patient refuses site marking, to document the refusal in the preoperational checklist. However the preoperational checklist lacks to provide a specific data why the site markings is not complete/being refused. The policy states additional information when and how the site markings should be done for some areas, but not all: * Minimal access is identified. * Teeth, marking is identified * Premature infants, in this case the policy lacks to provide an alternative process. | 1. Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety.
Note: For spinal procedures, in addition to preoperative skin marking of the general spinal region, special intraoperative imaging techniques may be used for locating and marking the exact vertebral level. 2. Mark the procedure site before the procedure is performed and, if possible, with the patient involved. 3. 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. In limited circumstances, the licensed independent practitioner may delegate site marking to an individual who is permitted by the organization to participate in the procedure and has the following qualifications:
- An individual in a medical postgraduate education program who is being supervised by the licensed independent practitioner performing the procedure; who is familiar with the patient; and who will be present when the procedure is performed
- A licensed individual who performs duties requiring a collaborative agreement or supervisory agreement with the licensed independent practitioner performing the procedure (that is, an advanced practice registered nurse [APRN] or physician assistant [PA]); who is familiar with the patient; and who will be present when the procedure is performed.
Note: The hospital's leaders define the limited circumstances (if any) in which site marking may be delegated to an individual meeting these qualifications. 4. The method of marking the site and the type of mark is unambiguous and is used consistently throughout the hospital.
Note: The mark is made at or near the procedure site and is sufficiently permanent to be visible after skin preparation and draping. Adhesive markers are not the sole means of marking the site. 5. A written, alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (for example, mucosal surfaces or perineum).
Note: Examples of other situations that involve alternative processes include:
- Minimal access procedures treating a lateralized internal organ, whether percutaneous or through a natural orifice
- Teeth
- Premature infants, for whom the mark may cause a permanent tattoo | Yearly charts on National Patient Safety Goal Data: Communication & Time-out Procedure policy | UP.01.03.01 | A time-out is performed before the procedure | Overall finding: Based on the provided material, procedure and chart for NCH on time-out procedure, there appears to be a time-out procedure process in place within the hospital. The data however demonstrates that NCH did not achieve 100% time-out performance throughout the year: | 1.NCH indicates in the policy that time-out must be conducted immediately prior a procedure. This section is compliant with JC.2.NCH has a standardized steps for time-out policy but lacks some specific details:- This criteria is compliant with JC, NCH has a standardized list, approved by a surgery leadership committee. * These criteria are compliant with JC, NCH identified in the list staff members (the nurse or the technologist) to be responsible for calling the time-out. * These criteria are not met, NCH lacks to identify the team members, the policy refers to ‘all members of the team’ which is insufficient information.3. These criteria are not compliant, NCH does not identify in the policy the details for the case as listed in JC column. 4. These criteria are met for JC requirements, NCH does list the minimum information as listed by JC for the team members involved in the procedure to agree on. 5. These criteria are met, NCH does document the completion of the time-out in the record. | 1. Conduct a time-out immediately before starting the invasive procedure or making the incision. 2. The time-out has the following characteristics:
- It is standardized, as defined by the hospital.
- It is initiated by a designated member of the team.
- It involves the immediate members of the procedure team, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning. 3. When two or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated. 4. During the time-out, the team members agree, at a minimum, on the following:
- Correct patient identity
- The correct site
- The procedure to be done 5. Document the completion of the time-out.
Note: The hospital determines the amount and type of documentation. |

A1. Plan for Compliance
It is listed in the general information, NCH is 13 months away from the next JC visit. NCH has a deficiency level in few areas as captured in the executive summary; therefore it is inevitable to make changes immediately in order to reach a continuous compliance with the JC requirements. A strict timeline will be set for incorporating the changes and review process within the next two months. After the initial steps, the adjusted forms and protocols will be reviewed and re-evaluated, NCH leadership will reassure that all NCH staff participate in the course of action. NCH leadership will work closely with the NCH management staff and staff in charge in every department to monitor how the change impacts the NCH`s performance. NCH management will report back to NCH leadership after trial period of 30 days and then after 60 days to verify the data.
Based on the constant monitoring of NCH improvement, NCH will be able to demonstrate through the documentation and records that NCH has a strong commitment on a long-term basis to follow all essential prescribed regulations by JC. . By following a precise action plan NCH will be able to reach a 100% full compliance with JC requirements. NCH must undertake and follow the proposed action items in the plan below.
Plan for Compliance
NCH Communication plan for compliance to 2013 Joint Commission Hospital Standards for Communication NCH’s plan for standards and protocols compliance | Joint Commission(JC) Standard Number | Joint Commission Standards, retrieved from Joint Commissions on Accreditation of Healthcare Organizations (2013) | NCH Preprocedure Hand-Off form | UP.01.01.01 | Conduct a preprocedure verification process. | Overall corrective action plan: Based on the evidence and the executive summary of the NCH current compliance status with JC standards it is recommended that: NCH will review and adjust the requirements/data listed for a collection and data purpose, because the current form is not compliant with JC to provide a full list of the required information that is required for collection. The new version of the form needs to contain a list of items categorized on the form in sections e.g. based on the purpose i.e. Personal, Identification, Emergency, Nutrition. This version will provide overall more organized information overview, an easy-accessible clarity of the collected and recorded data in case there is an emergency situation with a patient and for the purpose of a consistency. Implementation date: Immediate action.Execution process: * The administration office will: * Notify all NCH staff about the change, * Set a date when a new version of the form will be used (with NCH leadership committee approval), * Ensure that old blank forms will be recycled, * Present the new form to be reviewed by the NCH leadership committee prior the first circulation and after if any additional changes are made, * Monitor during a trial period set for 30 days (approved by NCH leadership committee) to use the new form and review if comments and suggestions received from the NCH staff to improve the form further beyond JC requirements * Encourage NCH staff to participate and provide feedback within the 30 daysDetailed changes for correction are listed below for each section: | 1. The NCH is required to add the missing information to the preprocedure hand-off form: * name of the patient * the patient`s identifier (e.g. date of birth) * the site details * patient`s signature and the date the patient signed when verifying the details. | 1. Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site. Note: The patient is involved in the verification process when possible. | 2. The NCH is required to amend this section on the preprocedure hand-off form. Because there is a certain level of a variation and several details are not listed/missing, it is recommended that: * No changes required for this section. * NCH will include missing information for a collection and a record: * Radiology images * Scans * Pathology reports * Biopsy report * Confirmation that each record is labeled and properly displayed * NCH will include missing information for a collection and a record requirements to keep consistency: * Implants devices * Special equipment for the procedure 3. NCH will identify on the form a section where the items are listed for a patient’s availability in the procedure area, as it is not clear on the form unless the whole form is reviewed. | 2. Identify the items that must be available for the procedure and use a standardized list to verify their availability: * Relevant documentation (e.g. history and physical signed procedure consent form, nursing assessment, and preanesthesia assessment) * Labeled diagnostic and radiology test results (e.g. radiology images and scans, or pathology and biopsy reports) that are properly displayed * Any required blood products, implants, devices, and/or special equipment for the procedure
Note: The expectation of this element of performance is that the standardized list is available and is used consistently during the preprocedure verification. It is not necessary to document that the standardized list was used for each patient. 3. Match the items that are to be available in the procedure area to the patient. | Site Identification and Verification (Universal Protocol) | UP.01.02.01 | Mark the procedure site. | Overall corrective action plan: Based on the evidence and the executive summary of the NCH current compliance status with JC standards it is recommended that: NCH will review and add the missing requirements. The policy has to be consistent with the JC list of requirements. The policy has to be remodeled and provides list according to JC description and order. In this order, the policy will be consistent and each section of the policy will provide a clear direction to the staff and define their roles in the site identification and verification process.Implementation date: Immediate action.Execution process: * The administration office will: * Notify all NCH staff about the change, * Ensure that copies of old protocol forms will be recycled, new protocol is circulated and available to all NCH staff and on a display on NCH premises * Monitor during a trial period set for 30 days (approved by NCH leadership committee) to use the new form and review if comments and suggestions received from the NCH staff to improve the form further beyond JC requirements * NCH leadership committee will: * Set a date when a new version of the protocol will be in place * Review and approve the new protocol prior the first circulation and after if any additional changes are made, * Encourage NCH staff to participate and provide feedback within the 30 daysDetailed changes for correction are listed below for each section: | 1.This step is compliant with JC and no additional correction is required.2. This step is compliant with JC and no additional correction is required. 3.The policy has to provide a clear definition who can provide a site marking. NCH must state in the policy that only a licensed independent practitioner is able to provide the site marking. In addition NCH will provide a line of command – in case of an emergency circumstances, who else from staff can be identified to perform the site marking if the licensed practitioner is not available.4.This step is compliant with JC and no additional correction is required.5.The NCH policy does need to revise this section for the alternative process purpose. The preoperational checklist will include information of a reason why the patient refused a site marking or it was not technically/anatomically impossible.-Along the NCH will add an alternative option for the premature infants. As an alternative can be used non-permanent marker, however used right before the procedure. The staff who performs the site marking will ensure and notify the physician who will perform the procedure about the alternative site marking process. | 1. Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are marked when there is more than one possible location for the procedure and when performing the procedure in a different location would negatively affect quality or safety.
Note: For spinal procedures, in addition to preoperative skin marking of the general spinal region, special intraoperative imaging techniques may be used for locating and marking the exact vertebral level. 2. Mark the procedure site before the procedure is performed and, if possible, with the patient involved. 3. 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. In limited circumstances, the licensed independent practitioner may delegate site marking to an individual who is permitted by the organization to participate in the procedure and has the following qualifications:
- An individual in a medical postgraduate education program who is being supervised by the licensed independent practitioner performing the procedure; who is familiar with the patient; and who will be present when the procedure is performed
- A licensed individual who performs duties requiring a collaborative agreement or supervisory agreement with the licensed independent practitioner performing the procedure (that is, an advanced practice registered nurse [APRN] or physician assistant [PA]); who is familiar with the patient; and who will be present when the procedure is performed.
Note: The hospital's leaders define the limited circumstances (if any) in which site marking may be delegated to an individual meeting these qualifications. 4. The method of marking the site and the type of mark is unambiguous and is used consistently throughout the hospital.
Note: The mark is made at or near the procedure site and is sufficiently permanent to be visible after skin preparation and draping. Adhesive markers are not the sole means of marking the site. 5. A written, alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (for example, mucosal surfaces or perineum).
Note: Examples of other situations that involve alternative processes include:
- Minimal access procedures treating a lateralized internal organ, whether percutaneous or through a natural orifice
- Teeth
- Premature infants, for whom the mark may cause a permanent tattoo | Yearly charts on National Patient Safety Goal Data: Communication | UP.01.03.01 | A time-out is performed before the procedure | Overall corrective action plan: Based on the evidence and executive summary, NCH must pay a close attention to achieve the goal - 100%performance throughout a whole year.Implementation date: Immediate action.Execution process: * The administration office will: * Notify all NCH staff about the change, * Ensure that copies of old protocol forms will be recycled, new protocol is circulated and available to all NCH staff and on a display on NCH premises * Monitor during a trial period set for 30 days (approved by NCH leadership committee) to use the new form and review if comments and suggestions received from the NCH staff to improve the form further beyond JC requirements * NCH leadership committee will: * Set a date when a new version of the protocol will be in place * Review and approve the new protocol prior the first circulation and after if any additional changes are made, * Encourage NCH staff to participate and provide feedback within the 30 daysBelow are identified corrective items that will assist NCH to fulfill the JC requirements to achieve a compliance with JC and to achieve the 100% goal: | 1. This section is compliant with JC, not additional correction is required.2.In order NCH to be fully compliant with JC requirements it is recommended: * -These criteria needs to be met, NCH will include in the policy and identify the team members, who are required to participate in the time-out procedure as listed by JC.3. NCH will add and include in the policy the requirement to perform the time-out procedure under the circumstances as identified in point 3 by JC. | 1. Conduct a time-out immediately before starting the invasive procedure or making the incision. 2. The time-out has the following characteristics:
- It is standardized, as defined by the hospital.
- It is initiated by a designated member of the team.
- It involves the immediate members of the procedure team, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning. 3. When two or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated. 4. During the time-out, the team members agree, at a minimum, on the following:
- Correct patient identity
- The correct site
- The procedure to be done 5. Document the completion of the time-out.
Note: The hospital determines the amount and type of documentation. |

A2. Justification NCH is an institution providing a healthcare service. By identifying and addressing the communication gaps and aligning NCH’s policies with Joint Commission requirements can avoid and prevent the future fatalities and the healthcare errors causing. The importance of the communication standards can be supported by the fact that “hospitals admit more than 37 million people each year” (Williams & Torrens, 2008, p.206), therefore even one error in one procedure form can represent a high risk in one person’s life and become life threatening. The communication represents a core value in order for NCH to keep its patients safe and necessary to NCH’s staff to access the correct data anytime. NCH staff will appreciate the assurance that the organization’s policies are aligned and in compliance with JC requirements.

Reference List Joint Commissions on Accreditation of Healthcare Organizations (2013), National Patient Safety Goals, Retrieved February 10, 2013, from https://e-dition.jcrinc.com/MainContent.aspx Williams, S. & Torrens, P. (2008). Introduction to health services (7th ed.). Clifton Park, NY: Delmar, Cengage Learning.

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...Executive Summary - Preparation for Accreditation Audit AFT2 Accreditation Audit September 26th, 2014 Executive Summary - Preparation for Accreditation Audit Nightingale Community Hospital (NCH) offers comprehensive care for a wide range of conditions and is a leader amongst its peers in providing compassionate and quality care. To meet their main mission of putting patients care first, NCH consistently endeavors to meet and exceed standards set forth concerning medication management by the Joint Commission. This is exemplified in NHC’s clear and concise policies concerning medication administration, medication safety, and anticoagulation therapy. These policies and programs provide the framework upon which NHC meets Joint Commission Accreditation requirements. Current Compliance Status During the next audit, in 13 months, the Joint Commission has three priority focus areas concerning medication management which includes: 1. Planning of Medication Management Process 2. Labeling of all medications in all areas, all forms 3. Reduce Patient harm associated with anticoagulant therapy Currently NCH has appropriate measures, policies, and programs in place concerning medication management to meet accreditation requirements. Policies and programs are thorough and include protocols for collecting information that would spotlight an area of opportunity for improvement. Through the use of data collection it has been determined...

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Wgu Aft2 Accreditation Audit Task 1

...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......

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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......

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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.......

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