Nightingale Community Hospital Jcaho Audit Preparation: Information Management

Mission: To implement a corrective action plan in the area of Communication for Nightingale Community Hospital as required for Joint Commission Compliance.

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.

Preparing for The Joint Commission, Nightingale Community Hospital reviews areas of compliance and non-compliance. A periodic performance review, which is a self-evaluation, is utilized by Nightingale Community Hospital, to prepare for The Joint Commission. The Joint Commission has eighteen accreditation requirements. (Commission, 2013) The periodic performance review found the hospital to be compliant and non- compliant in the following areas:

The Office of Inspector General (OIG) has established a set of guidelines (e.g., auditing, monitoring, internal controls, sampling, due diligence, and standards of organizational and employee behavior, etc. Page 508 of the textbook) that physician practices should follow when creating a compliance plan. State an opinion as to which OIG guideline would be the single most significant aspect of a compliance plan for a small practice. Provide a rationale for your response.

The four main areas of focus for the Joint Commission for Nightingale Hospital include Communication, Information Management, Medication Management and Infection

In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.

Nightingale Community Hospital (NCH) is a hospital that states they are leaders in quality healthcare. To remain a leader in hospital care it is crucial for the hospital to adhere to standards developed by the Joint Commission Accreditation on Healthcare Organizations (JCAHO). JCAHO is the organization that accredits and certifies hospitals that meet certain performance standards nationally. Only those hospitals that have the JCAHO accreditation are ensured to be in compliance with specific guidelines in each Priority Focus Areas: Infection control, Communication, Medication Management, and

The Joint Commission on Accreditation of Healthcare Organizations or JCAHO was founded in 1951 as a private nonprofit organization that established guidelines for the running and management of hospitals and health care facilities in the United States. According to its website (n.d.), JCAHO’s primary mission is, “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest

One of the central codes of practice in health and social care has been provided by the GSCC and it sets standards of practice and behaviour for staff working in that field, including standards

In addition to the core elements, providers will have to choose any five of the ten additional tasks to implement in 2011-2012. Some examples of these might be clinical lab results, patient appointment reminders and drug-formulary checks. This gives the providers a chance to choose their own path toward full EHR implementation and meaningful use. Legislation ties payments to the achievement of advances in health care processes and outcomes. The regulations are specific as to when providers will have to use particular functions in order to be considered meaningful users. The meaningful use rule acknowledges the urgency of adopting the electronic health record and recognizes the challenges it will pose on all providers.

The CNO outlined professional standards for nurses to comply with. The seven that are outlined are accountability, continuing competence, ethics, knowledge, knowledge application, leadership, and relationships. “A standard is an authoritative statement that sets out the legal and professional basis of nursing practice” (College of Nurses of Ontario, 2009, p. 3). Although each standard has different meaning, they all work together in order to provide the best possible patient care.

AHIMA recognizes that superior quality health care and clinical data are critical resources needed for effective healthcare, and works to assure that the health information used in care, research, and health management is valid, accurate, complete, trustworthy, and timely. This group is concerned about the effective management of health information from all sources and its application in all forms of healthcare and wellness preservation. Health issues, disease, and care quality also transcend across national borders. AHIMA’s professional interest is in the application of best health information management practices when and wherever they are needed. (The American Health Information Management Association, 2010).

Record keeping provides evidence of any interaction or intervention involving a patient. It needs to be comprehensive enough to determine that the nurse has fulfilled his/her legal and professional duty of care (Griffith 2007).

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 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).