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:
Infection Prevention and Control
Right and Responsibilities of the Individuals
Environment of Care
National Patient Safety Goals
Provision of Care, Treatment, and Services
Record of Care, Treatment, and Services
The hospital has been found to have increase clutter in the hallways, which is a fire hazard and is a safety issue. Nurses were found to be unfamiliar with proper verbal order procedures, how to use the range of orders received and what abbreviations that are prohibited within documentation.
The trend shows areas that the hospital needs to implement audits, and education. An action plan will be devised that meets the needs of each unit and areas of non-compliance with proper follow up. In order to be the hospital of choice, administration needs to implement an action plan to address the fallouts. By reviewing non-compliant areas the hospital can assess how to prevent fallouts. Understanding the importance and benefits of The Joint Commission requirements provides the hospital with standards. These standards continue to help the hospital provide the best care.
A2. Non-compliant Trends –
Utilizing the periodic performance review to the fullest allows the hospital to examine areas of non-compliance in comparison to The Joint Commission standards. The hospital found non- compliant trends through out the hospital that needs to addressed:
Policy and Procedure
oAssessment within Same Day Service Areas
♣Nurses throughout the units are not consistent with assessments and reassessments of patients. A reassessment log will be placed within the patient’s chart that will have to be signed by the primary nurse and co-signed by another nurse. Task reminders will be placed within the computerized charting to prompt nurses to reassess patients.
oLack of labeling in various areas
♣Any specimen sent to the laboratory will be time, dated and double signed by two nurses. The lab will assess for stated information. If not properly labeled the specimen will be sent back to the unit. Any medication not labeled by the pharmacy will require a pre-printed label and double signature by nurses. The patient will mark the appropriate procedure site. The doctor and nurse will then mark the site, in the presence of the patient, with the hospital initials.
Low Performance Scores by the “ORXY initiative”
oEmergency Department assessment and reassessment of pain
♣Task reminder will be placed within the computerized charting after the
charting of any pain medication, to prompt nurses to document pain level before and after administration of medication. oHospital wide use of prohibited abbreviations
♣Every hard chart will have prohibited abbreviation reminder chart. All charting areas will have posters of prohibited abbreviations. oHospital wide verbal order authenticated
♣Task reminders will be placed within the computerized charting to remind nurses to authenticate orders. The order will be flagged if not authenticated within the allotted time frame. Charge nurses will be prompted of unauthenticated orders. oHospital wide reporting critical results.
♣Lab results will be flagged and the nurse will be prompted to take action within the computerized charting. The primary nurse and charge nurse will verify all critical lab results. A critical lab result log will be imitated to verify reporting and require the primary nurse and charge nurse signature.
Mandatory in-services and mandatory weekly audits will be initiated in all areas of non-compliance. Chart reviews, audits and surveys of the staff allow directors and administration to evaluate the required in-services and education provided to staff in regards to the current non-compliant areas. Addressing hospital wide issues with visual reminders and cues. The increase audits and chart reviews will be initiated until the compliance level of “ORXY initiative” is within The Joint Commission requirements of 85% (Commission, 2013).
A3a. Staffing Pattern
Providing the best care to each patient starts with providing the proper amount of staff members to each unit. Looking at the needs of different units not only allows administration to see areas for improvement, but also areas that are being handled correctly. Utilizing the indicators provided by The Joint Commission, 4 East, a pediatric medical/surgical floor, has a high rate of falls and nosocomial pressure ulcers that appears to be related to the increase overtime nurses have been working for that floor (Nightingale, 2010).
Research has shown increases in adverse events have been related to nurses working over 40 hours a week (Bae, 2012). The clutter in the hallway needs to be addressed for the safety of patients, visitors, and nursing staff. This will also improve the efficiency of the staff by removing barriers to traffic flow. The nursing staff will be able to move quickly and more effectively among the patients to prevent time delays resulting in patient falls. In addition, the antiseptic dispensers will be visible and accessible to the nursing staff helping in the reduction of nosocomial pressure ulcers.
The improvements in efficiency and effectiveness will also help reduce the nursing overtime. Utilizing the Plan Do Study Act Model the director of 4 East needs to survey and discuss with staff the current staffing issues. In addition, the working environment needs to be evaluated for efficiency and effectiveness. A hospital functions properly when you look at every aspect as a whole. Every area of non-compliance affects every area of the hospital.
A3b. Staffing Plan
As a team, administration and the director of 4 East will review the purposed staffing plan and form an action plan to address non-compliant areas. Addressing the needs of each unit, specifically 4 East, requires staff to understand the dynamic patient acuity. The patient’s needs may change from shift to shift, e.g., need for a blood transfusion, or the need for aggressive respiratory toleting. As the needs of the patient change so does the acuity for nurse to patient ratio; however, the hospital has to remain in compliance with California state laws.
California laws require a minimum nurse to patient ratio of pediatric patient to be 1:4 (“70217. Nursing service staff.” 2003). Following a classification system, manually or by a computer, can determine the acuity of each patient, which categorizes the patient as low or high (Jones 2009). By spreading high and low acuity patients amongst the nurses it allows the nurses to accomplish tasks, provide time to finish required charting, and decrease stress levels. Providing the proper staffing ratio allows for proper break coverage and support from fellow floor nurses.
Nightingale Community Hospital administration will work hard with the director of 4 East to implement polices that will protect the welfare of the staff. Research has shown that increased stress and overtime leads to decrease nurse retention and increase adverse events (Bae, 2012 & Foundation, 2012). By implementing a policy of no extra shifts will be granted unless the nurse has had twenty-four hours off work, will allow nurses time to rest. Managing the nurse to patient ratio provides compliance with state laws, but also provides support to the nurses during a shift.
The census of the unit has to be taken into when determining the nurse to patio ratio. Keeping in mind the dynamics of a hospital floor, this staffing plan allows for admissions during any shift, enough staff to support if the unit gets busy and the unit always remains in compliance. The following information shows Nightingale’s purposed staffing plan that is compliant with California state laws for 19 patients.
Time |Charge Nurse|RN/LPN|PCA|PCA/WS|WS|
RN: Registered Nurse LPN: Licenses Practical Nurse
PCA: Patient Care AssistantWS: Ward Secretary
Keeping the patient safety is a priority. The director of 4 East will address educational needs of the unit by providing in-services for the staff regarding:
Effect of Overtime
Prevention of Hospital Falls
Prevention of Nosocomial Infections
New Hourly Rounding Log
Addressing the 3 P’s: Pain, Potty and Possessions
Current Fall Policy
oGRAF PIF scores every shift
oIdentifying Fall Risks
oLabeling Patient’s chart, assignment board and patient at risk oPlacing
call light within patient’s reach
oProviding color specific slip proof socks to the patient
Discussing the current policy with staff, involving floor nurses in the Fall Risk committee and providing more awareness of how to prevent falls, facilitates nurses to be more aware of fall risk precautions. Using the predetermined quality improvement tool, The Plan-Do-Study-Act Model, feedback of the purposed staffing plan, education and survey of the work environment will be reviewed and the director of 4 East will inform administration of changes needed to improve the efficiency and effectiveness of the work environment. Implementing dynamic policies and reviewing them for results will keep Nightingale Community Hospital compliant with The Joint Commission requirements.
Bae, S. (2012, April). Nursing overtime: Why, how much and under what working conditions? Nursing Economics, 30(2), 60-71. Retrieved from https://www.nursingeconomics.net/ce/2014/article30026071.pdf
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Commission, T. J. (2013). Accreditation requirements. Retrieved from https://e-dition.jcrinc.com/MainContent.aspx
Foundation, Robert Wood Johnson. (2012). States cap on mandatory overtime for nurses having intended effect, new study finds. http://www.thelundreport.org/resource/states%E2%80%99_caps_on_mandatory_overtime_for_nurses_having_intended_effect_new_study_finds[->1]
Hospital, Nightingale Community. (2010) Staffing Effectiveness Report.
Hospital, Nightingale Community. (2010) PPR Findings.
Jones, L. (2009, October). Staffing online information outlined. Retrieved from www.oocities.org/womenscentertwu/ldrshp2StaffingCh12.doc Olds, D.M., & Clarke, S.P. (2010). The effect of work hours on adverse events and errors in health care. Journal of Safety Research, 41(2), 153-162.
[->0] – http://www.cd
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