Essay on Accreditation Audit Raft 1

EP 5 requires a written process for patients who refuse site marking or when it is impossible or impractical to mark the site. This written process is absent in the hospital’s policy. Nightingale’s policy and process must be revised immediately to reflect all the required elements of the standard. Hospital physicians and staff must be educated on the necessary changes and the revised process must be put into action. Once these changes have occurred, I recommend a focused audit to ensure full compliance with the revised policy/process.

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.

Often there are delays in surgeries. Some operations can take longer than expected, unexpected emergencies come up. Staff can feel rushed to move forward to prevent further delays. Also, there can be times when staff are overworked due to being short-staffed. Being overworked has the potential for fatigue causing staff to be less aware and skip or forget about steps in an otherwise established process.

This service was provided during the postoperative period for a previous related procedure conducted by the same surgeon.

The hospital already has protocols in place, but the need for education regarding these protocl is great.The need on these protocols are great

A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began

* The registrar should also be granted access to the surgeon’s office notes to review any demographic information. This will ensure consistency and identification of information that may not have been documented during the surgical check-in process.

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.

We will make sure that per our hospital policy we will I.D. the site at admission, whenever there is a patient transfer, and at preop we will communicate this with the patient whenever the patient is aware. We will strive to make sure that the surgical sites are appropriately marked per the site I.D. policy and that the patient is interactive in the process when applicable. As part of this policy we will also make sure that all necessary medical records and labs are readily available for the procedure. We will also make sure that all possibly needed equipment and supplies are present.

Develop health and safety and risk management policies procedures and practices in health and social care (M1)

6. The risk assessment team will conduct an inspection of the department/area being assessed for risk or observe the process being assessed for risk in action. The members of the risk assessment team will individually document their findings on the “ABC Proactive Risk Assessment Worksheet” (Attachment A). To determine the appropriate score for each identified risk, the reviewer will consider information obtained through a physical tour of the facility, review of annual incident

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).

In order to submit with the use of modifier -22, Increase Procedural Services, the medical record must contain documentation that substantiates that the service was unusual in some way such as statements about increased risk to the patient, the difficulty of the situation. For example: Excessive blood loss, Extensive well-documented adhesions in abdominal surgery, Trauma extensive enough to complicate the procedure and the complication is not reported separately, The service rendered was significantly more complex than described in the code description and/or other pathologies, tumors, malformations that directly interfere with the procedure but are not reported

Monitor vital parameters like temperature, pulse, blood pressure and ECG to ensure that patient is fit for surgery. Keep the blood results in her file a with the INR results for further reference.

Using computer the Cadence software program the surgical associate (SA) checks the patient in at the surgical registration desk (Barton,2015). This associate acknowledges the patient signature on the forms received at the general registration desk. The SA then prints and places an armband on the patient, after the patient verifies information, number on the armband. To complete this step the associate need the patient’s birth date, allergy information and the medical record number. The AA calls the designated procedural area to inform the nurse of the patients arrival.