Nightingale Community Hospital Case Study

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.

In Nightingale Square, a small run down ‘mom & pop’ grocery store, a newly updated/built Downtown Store. I noticed many vehicles parked on the streets and residents walking the streets.

The Joint Commission defines the Periodic Performance Review as an assessment tool created to assist health organizations improve and monitor their performance throughout the year. This tool focuses on the processes that influence patient care and safety while providing the structure for unremitting standards fulfillment. Nightingale Community Hospital is compliant with most standards as set forth by the Joint Commission. However, upon inspection and in an effort to stay focused on compliance, our standards committee has located a few discrepancies that must be resolved to maintain our accreditation with the Joint Commission.

13). The clinical services department within the hospital is responsible for the accurate charting of any procedure or service that was provided to the patient. This process begins with patient registration and verification. The healthcare provider then will perform their job as necessary and will indicate what billable tasks were performed which can later be processed. The patient accounts department is responsible for going through the patient’s chart and recording the patient’s bill by use of the hospital’s chargemaster to send the bill to the payer by the health information department. In this department the initial coding of the patient’s medical record is done. Once overviewed for the sake of accuracy, the final coding is done and sent to the payer. Any inaccuracies by any of these departments could directly impact the hospitals reimbursement process through a slowing for the process or simply by failing to bill for a procedure performed, ultimately hurting the hospital’s financial stability. The patient financial services (PFS) department is responsible for ensuring compliance within the billing and coding policies through training and with quality assurance checks and regular audits. This ensures that the revenue and reimbursement cycle continues without any inaccuracies in patient charges. It is especially important to have quality management within this department, as it has the potential to affect the entire organization, reflective of the institutes financial situation. Poor PFS management can lead to a loss in revenue and can lead to a loss in budget if the hospital is losing too much as a result. Ensuring compliance with medical coding and billing guidelines and policies ensures a more accurate representation of the hospitals financial and budgetary situations, while

Willow Bend Hospital’s compliance does indeed have multiple deficiencies and is in need of review as many were updated in 2009 and 2010. All information on deficiencies would be found on the latest updated version of the Joint Commission Information Standards. This should be located within the Corporate Compliance/Risk Manager’s office. As this information is not currently available to this writer without a subscription and fee, I must use the information available to me. So expansion and explanation of policy details are limited.

The purpose of this report is to summarize, analyze and evaluate the compliance status of Nightingale Hospital to Joint Commission requirements. This report will focus on medication management, specifically anticoagulation therapy and the patient and staff education associated with it. In an effort to maintain the highest quality of care for our patients, we must continue to work towards a reduction in adverse anticoagulation related events. This will involve proper pre-discharge

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.

In the essay I will be explaining the important processes in human resources. Within human resources there are many factors to be considered when planning recruitment within health and social care. As a trainee HR officer at St Jude's nursing home the factors to be considered when planning are; corporate objectives, financial strategies, and economic changes.

Over the past two decades, EBP has expanded on Florence's theories. EBP constitutes the combination of clinical expertise, patient values, and research evidence when making decisions about patient care. In the 1990's, it was determined that just increasing knowledge was not sufficient for improving patient outcomes. To obtain better patient outcomes "new knowledge must be transformed into clinically useful forms, effectively implemented across the entire care team within a systems context,

UP.01.03.01 requires a time-out before the start of the procedure. The Site Identification and Verification policy describes the time-out process however the policy falls short of fully meeting the intent of this standard. EP 2 describes which team members must participate in the timeout, EP 3 requires a time-out before each procedure when two or more procedures are being performed, and EP 5 requires documentation of the time-out. These 3 elements are missing from the hospital policy/process and therefore revisions to the process/policy are necessary to include these 3 elements. Nightingale’s Safety Report reveals increasing compliance (nearing 100%) with the time-out process, however as mentioned above, EP 5 requires documentation of the process. In addition to the policy revision, I recommend the development of a unique form which will be used to document

Record-keeping and documentation are a hugely important part of nursing practice that unfortunately is often overlooked. Good record-keeping is in fact an essential element of being a good nurse. This assignment will discuss the importance of record-keeping in the healthcare setting. Record-keeping is vital for three main functions of nursing. It facilitates communication, promotes safe and appropriate nursing care and meets professional and legal standards (CRNBC 2008). These purposes and other important functions of record-keeping will be described in this assignment. The professional and legal implications of poor record-keeping will also be outlined. The topics will only be briefly and broadly discussed due to word count

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

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

Nightingale said, “The very first requirement in a hospital is that it should do the sick no harm”. The history of nursing initially begins with Florence Nightingale. Before her era nurses had a tarnished reputation (Glasper, 2017). They were poorly educated and incompetent people. Nurses such as Mrs. Bedford Fenwick wanted to change the image of nursing. They did this by leading a campaign for professionalism. Which led to the culminated Nurse Bill receiving is royal assent in December 1919 (Glasper, 2017). July 27, 1921 was the official opening of the nursing register, there are currently 688,927 nurses registered with the Nursing Midwifery Council (NMC) (Glasper, 2017). The NMC code has four themes of professionalism, “Prioritizing

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).