Accreditation Audit: Raft Task 1

WGU Accreditation Audit: RAFT Task 1 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).

The Standards of Universal Protocols (UP) are: UP 01.01. 01Conduct pre-procedure verification process UP 01. 02. 01Mark the procedure site UP 01. 03. 01Perform a Time-Out before the procedure. To determine NCH compliance, hospital documentation was used for comparison with the Joint Commission, Elements of Performance.

The following chart specifies which documents were used to show areas in need of improvement. Nightingale Community Hospital Documentation| Compared with|(UP) Elements of Performance| Pre-Procedure Hand-Off check listSite Identification and Verification (UP) (Sub heading) Preoperative Verification Process||UP. 01. 01.

01Description # 1Description # 2| Site Identification and Verification (UP) (Sub heading) Marking the Operative/Invasive Site||UP. 01. 02. 01Description # 5| Safety Report Time-Out Graph||UP. 01. 03. 01Description #1 | Compliance Status Executive Summary and Findings according to the Joint Commission, Elements of Performance. UP. 01. 01. 01 Not in compliance. #1 Implement a pre-procedure process to verify the correct procedure, for the correct patient at the correct site.

The current NCH Pre-procedure list has a line item for – Identification Armband on patient’s arm; however there is no provision for procedure name, or procedure site.

#2 Identify the items that must be available for the procedure and use a standardized list to verify their availability. At a minimum these items include the following: Relevant documentation (for example, nursing and pre-anesthesia assessment. ) Labeled diagnostic and radiology test results. The language needs to be more precise and inclusive of correct terms. There are line items for Patient seen by Anesthesia and Last Vital signs; however these are not precisely assessments. There is a line item for test results but not precisely a line item for Labeled test results. UP. 01. 02. 01 Not in compliance.

#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). The NCH Site Identification and Verification form, subheading, Marking the Operative/Invasive Site # 8 states: Justification for not marking the site must be documented in the pre-operation checklist. There is no line item provided on the checklist. UP. 01. 03. 01Not in compliance. #1 Conduct a Time-Out immediately before starting the invasive procedure or making the incision.

In Hospital-Wide documentation eleven out of twelve months were below 100% compliance. Plan for Compliance UP. 01. 01. 01Recommendation to revise Pre-procedure Hand-Off list. Include more specific terminology and line items for: Procedure name, procedure site, nursing assessment, anesthesia assessment, listed and labeled lab results. Responsible Party: Surgery Leadership Committee. This is the committee who approved the Site Identification and Verification document. Due Date: Document will be due at the committee’s second meeting from now. If the committee meets monthly, they will have the first month to assign the revision.

The document will be due at the next meeting. Results measured: Revised document will be provided for Surgery Leadership Committee to compare with recommendations. UP. 01. 02. 01 Recommendation to provide form or space on pre-operation checklist for written alternative process. If an additional form is included, provide a line item for attention to the form. Responsible Party: Surgery Leadership Committee. This is the committee who approved the Site Identification and Verification document. Due Date: Document will be due at the committee’s second meeting from now.

If the committee meets monthly, they will have the first month to assign the revision. The document will be due at the next meeting. Results measured: Revised document will be provided for Surgery Leadership Committee to compare with recommendations. UP. 01. 03. 01 Recommendation: 1. Provide a Root Cause investigation. 2. Use examples from Joint Commission list of Quality Improvement Activities to A. Design a new service: Provide education for the patient B. Experiment with new ways of carrying out a function: Incorporate Time-Out into Electronic Medical Records (EMR).

Responsible Party: Surgery Leadership Committee. This is the committee who approved the Site Identification and Verification document. Due Date: 1. Root cause is provided below. 2-A. The committee will have 6 months to implement guidelines, specify who will do the teaching, how it will be done and set a start date. 2-B. The recommendation for Time-Out to be incorporated into the electronic medical records assumes the hospital is using an EMR. Even so, it will take co-operation with the medical records staff at the minimum and perhaps the IT department. 6 months may be too soon.

At the minimum, a progress report will be due in 6 months and a new due date set. Results measured: The Surgery Leadership Committee will continue to monitor Time-Out results. Committee will be able to see results through comparing graphed patient chart information from pre-teaching and post teaching and pre-EMR and post EMR documents. Root cause investigation. Stahel, Mehler, Clarke and Varnell (2009), tell us that “wrong site and wrong patient procedures have been defined as “never-events” which are theoretically 100% preventable and thus should never occur”.

They maintain that even with the practice of Universal Protocols, these “never-events” continue to happen for a number of reasons starting with “the degradation of the Universal Protocol to a robotic-hackneyed type ritual will distract from the requisite focus” (Stahel, et. al. , 2009). Other reasons include: ·Multiple procedures performed concurrently or consecutively on the same patient complicating the application of the Time-Out specific to the surgery. ·Addition of secondary safety issues to the official Time-Out reducing the focus away from the protocol’s primary mission.

Joint Commission, Priority Focus Process Summary “examples of Quality Improvement Activities” (Joint commission, 2013), in detail: The first example used is to design a new service. This service will educate the patients so they have full understanding of what “Time-Out” means and its importance. Guidelines already state that whenever possible, patients should be involved in the universal protocols. In addition to this, patients should be educated about the Time-Out process ahead of time and encouraged to be part of the Time-Out team. They should know they have the right and responsibility to pay attention and speak up.

The second example used is to experiment with new ways of carrying out a function. Nightingale Hospital’s pre-procedure verification process is done on a paper check list. Most hospitals have implemented Electronic Medical Records. Using an electronic form of record keeping would give the option for safe guards to be built in. Using fillable forms prevents forward progress until the information is completed correctly. The Time Out time duration and list of participants could become a part of the pre-procedure record or surgical record, whichever the hospital determined to be the better choice.

Justification “Communication issues were identified as a root cause of two thirds of all the sentinel events reported to the Joint Commission since 1995” (Shannon, 2011). The importance of communication cannot be overstated. The implications are staggering when you realize that “Communication failures are considered the leading cause of medical errors” (Gong, Khairat, 2010), and medical errors are one of the highest leading causes of death. Research the internet and claims of medical error deaths range from 44,000 to as high as 98,000 per year.

“Even the lower estimate (44,000) suggests that medical errors are the eighth leading cause of death, higher than motor vehicle accidents (43,458) or breast cancer (42,297) (Premiere Inc. , 2013). References Gong, Y. and Khairat, S[->0]. (2010). Understanding effective clinical communication in medical errors. Pubmed. gov. Retrieved from: http://www. ncbi. nlm. nih. gov/pubmed/20841777 Joint commission. org. (2013). Retrieved from http://www. jointcommission. org/facts about_the_universal_protocol/[->1] Premier Inc. com (2013). Medical errors and the institute of medicine. Premier inc. com. Retrieved from: https://www.

premierinc. com/safety/topics/patient_safety /index_1. jsp#IOM-1 Key Findings[->2] Shannon, D. (2011). Closing communication gaps. Kevin MD. Retrieved from http://www. kevinmd. com/blog/2011/06/closing-communication-gaps-providers. html Stahel, P. , Mehler[->3], P. , Clarke, T. , and Varnell, J. (2009). Patient safety in surgery, Biomed central, ltd. Retrieved from: http://www. pssjournal. com/content/3/1/14 [->0] – .. /.. /.. /Desktop/Khairat, [->1] – http://www. jointcommission. org/facts [->2] – https://www. premierinc. com/safety/topics/patient_safety [->3] – http://www. researchgate. net/researcher/15152148_Philip_S_Mehler/

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