Accreditation Audit Essay

With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards. Standard: UP.01.01.01: Conduct a preprocedure verification process. 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 form in general with a few extra boxes possible for check-off. To prepare for inspection and audit, NCH should create and implement a form for use within the Operating Theater or wherever procedures are performed, such as bedside procedures. This form needs to be more specific in addressing at least the minimum requirements by JC. The form needs to cite that all relevant documentation is present, such as signed consent form, nursing assessment, preanesthesia assessment, history and physical. The form also needs to specify that the necessary diagnostic and radiology test results, rather they be images and scans, or biopsy reports, and properly displayed and labeled. Finally, to fulfill the minimum requirements by JC, any and all required blood products, implants, devices, and special equipment needs to be labeled and matched to the patient. Standard: UP.01.02.01: Mark the procedure site. NCH covers the procedure site marking standard fairly well within their Site Identification and Verification Policy. It mentions that site marking is needed for those cases involving laterality, multiple structures, or levels. Several times in their policy NCH mentions that it is best to have the patient involved, if at all possible. If the patient is unable to mark the site, the policy states that the physician will be called to mark the site. The policy states that the mark shall be made in permanent black marker so it will remain visible after skin preparation, and also in a location that will remain visible after sterile draping is in place. The policy also  includes circumstances in which the marking will be unable to be performed based on the location of the surgery being in an area that is unable to be marked. Standard: UP.01.03.01: A time-out is performed before the procedure. Nightingale Community Hospital has an adequate procedure in place for the time-out performance. Within the Site Identification and Verification Policy, the Time-Out Procedure complies with JC standards. A time-out is to be conducted immediately prior to performance of the procedure, it is initiated by the nurse or technologist, it involves all personnel involved in the procedure, the team members agree to a minimum of patient identity, correct site, and correct procedure to be performed, and all of this information is documented in the record, including those involved and the duration of the time-out. The only issue not addressed fully is the possibility of multiple procedures occurring on the same patient by different practitioners, and in that case, an additional time-out needs to be done for every new procedure. The Communication priority focus area is an extremely important area for any hospital. This is a common sense area that should be able to reach complete compliance. A wrong-patient, wrong-site issue should never arise and is completely avoidable. In 2010, Joint Commission reported that wrong-patient/site surgeries continued to be the most frequently reported sentinel event(Spath 2011).Jay Arthur states that JC reports between four and six wrong-site surgeries per day(2011). The World Health Organization believes that at least 500,000 deaths per year could be prevented if the WHO Surgical Safety Checklist was correctly implemented. These numbers, when compared with the possibility of 100% compliance, are astounding and completely avoidable. Nightingale Community Hospital is well on their way to avoiding these types of sentinel events through usages of proper protocol, procedures, and policy as is seen by the upward trend from their last year of self-checks. With continued diligence and appropriate modifications made, this can be an area that NCH, and any other hospital can be fully compliant in. References Arthur, J. (2011). Lean six sigma for hospitals: Simple steps to fast, affordable, flawless healthcare. New York, NY: McGraw-Hill. Spath, P. L. (2011). Error reduction in health care: A systems approach to improving patient safety (2nd ed.). Hoboken, NJ: Jossy-Bass. WHO (2013). WHO | Safe surgery saves lives. Retrieved from http://www.who.int/patientsafety/safesurgery/en/ [Last Accessed November 5, 2013]. Accreditation Audit Essay A1. Evaluation Nightingale Community Hospital (NCH) is committed to upholding the core values of safety, accountability, teamwork, and community. In preparation for the upcoming readiness audit, NCH will be launching a corrective action plan in direct response to the recent findings in the tracer patient. Background information on the tracer patient is as follows: 67 year old female postoperative patient recovering from a planned laparoscopic hysterectomy turned open due to complications. Patient developed infection that formed an abscess and was readmitted to the hospital for surgical abscess removal and central line placement for long term IV antibiotics. The tracer methodology was employed when auditors reviewed this patient’s course. Many things were done well and right with this patient and NCH is pleased to know that the majority of items analyzed with this patient proved that NCH was in compliance with regulatory standards; however, there were some troublesome areas that we need to focus on. The primary focus area that we will put our energies into will be the fact that there was not a history and physical completed on the patient within 24 hours of admission, and in fact it was greater than 72 hours before one was completed. See more: My Writing Process Essay The Joint Commission mandates standards that are to be met in order to maintain compliance. Standard PC.01.02.03 states that history and physicals must be documented and placed in the patient’s medical record within 24 hours of admission and prior to procedures involving conscious sedation or anesthesia. History and physicals are also considered in compliance if documented 30 days prior to procedures as long as there are no changes documented or the changes in status are specifically noted. (Joint Commission Update, n.d.) A2. Plan Often, rules and regulations are met with disdain and it is usually because there is no explanation provided as to why the rule exists. The rules for History and physical documentation are in place for a reason and are not just to make things more complicated. History and physicals provide  all health care providers that participate in a patient’s care a glimpse into that patient’s health status and immediate concerns. (Shuer, 2002) The information provided in a history and physical paints a portrait for all other health care team members to follow and treat accordingly. Often, emergent situations may arise where other health care specialty providers may not have the time to glean medical background information from patients and/or their representatives and the history and physical then serves as the go to source of information. Compliance regulations can be hard to understand the reasoning behind them sometimes, but if we all work together to make sure that we meet them, then NCH will continue to embrace the core values that we have worked so hard to instill and embrace. The following outline is a corrective action plan that will ensure compliance with the Joint Commission and bring us up to par for the readiness audit. Action Accountable Parties Timeframe Measurement History and Physical Physicians & physician assistants 1. Within 24 hours of admission. 2. Within 30 days prior to a procedure involving conscious sedation or anesthesia. Chart reviews and if requirements are not met, patients will be held in the surgical admitting unit and procedures will be delayed. There must be 100% compliance. B. Sources Joint Commission Update Study Guide. (n.d.). Retrieved August 31, 2014, from med2.uc.edu/libraries/GME_Forms/Joint_Commision_Upd_1.sflb.ashx Shuer, L. M. (2002). Improvement needed on h&p documentation. Medical Staff Update, 26(5), Retrieved from med.stanford.edu/shs/update/archives/May2002/chief.html