Accredidation auditing

Standard: UP. 01. 01. 01: Conduct a Preoperative Verification Process. At the present time Nightingale Community Hospital is not in compliance with rule UP. 01. 01. 01. Nightingale currently has a five step verification process in regards to Preoperative/Pre-procedure Verification. This does not meet the minimum standard of care regarding verification of correct person, correct procedure and operative site. To become compliant, they must take the following corrective actions.

1. At the time of admission to the facility, the patient must provide identification, verifying name, age, and date of birth. If the patient is unable to do so a family member or staff member from referring agency will verify identity. Identification bands will be placed on the patient during the admission process. The information obtained at the time of admission will be reviewed/verified at the time the bands are placed on the patient. The identifying information must be confirmed by two members of the staff and documented. Personnel involved in this process will include the following: admissions clerk, preoperative nurse, and another person or department that assumes responsibility of the patient.

2. When the patient is transferred from one department to another (ie: radiology, preoperative care, etc), the responsibility of care must be documented. The nurse’s must verify the identity of the patient to which the responsibility of care is being transferred. The time and date of the transfer of care must be signed off on by the nurse handing off and the nurse accepting responsibility for the patient.

3. Verification of the procedure must occur pre operative. The patient can verify the type of procedure with the pre operative nurse. If the patient is unable to verify the procedure an alternative process must be used. This process must involve the checking of documents in the patients file, verifying with the medical professional in charge of the procedure, as well as, having the medical personnel sign off on the verification of procedure.

4. Use at least two patient identifiers when providing care. Double checking of ID bands and ID/Driver’s license of patient if possible. Using labels to mark all materials /items needed for the procedures. A two person check off procedure must be implemented. Items requiring labeling include: patient records, signed consents, and all assessments, diagnostic tests and x-rays.

Also included should be any item that is needed for the procedure (blood products, devices, and equipment). Using a matching system, so that all items in the procedure area are matched to the patient. The matching system must be completed by a minimum of two staff members. These staff members should include a qualified staff member, nursing staff involved in the procedure, recovery room staff, and discharge staff. Standard: UP. 01. 02. 01: Mark the Procedure Site.

At this time Nightingale Community Hospital is not in compliance with rule UP. 01. 02. 01. Steps 1-15 of under the Marking the Operative/Invasive Site does not meet the criteria for compliance with the Joint Commission Standards. To meet compliance, Nightingale Community Hospital must implement the following changes in their Universal Protocol.

1. To verify the site of the procedure, the nurse in charge must check with the patient if possible to verify the type of procedure and location of the procedure. If this is not possible the nurse in charge must verify the site of the procedure with the medical professional in charge, verify through the medical file of the patient and have a second person verify the same information through the same processes. Each step of the verification of site process must be documented and signed off on by a minimum of two medical personnel. Medical personnel involved in the process will include the medical professional in charge, nursing staff, and the anesthesiologist.

2. There must be a universal unambiguous mark for site location used throughout the hospital. The site must be visible when draping is complete. The mark should be done before the patient is moved to the procedure room. There must be adequate training hospital wide regarding what they universal mark will be at the respective facility. This information must be included in the new hire training. Personnel involved in this step of the procedure include the qualified medical professional, nesting staff, anesthesiologist, any other staff that is involved in the procedure.

3. There must be a written alternative plan for those who refuse the marking procedure or the site is non-markable. Examples include teeth, premature infants, or inside of the mouth and other mucous areas. This plan must consist of a specific plan. All staff members must be trained on the alternative plan. Patient records, which includes: medical history, consents, assessments, diagnostic tests, x-rays, and ultrasound films must be displayed in the procedure room as a secondary support to verify the site location. All staff involved in the procedure must be involved in the verification of the site. The ultimate responsibility falls on the most Qualified Staff member in the procedure room.

Standard: UP01. 03. 01: Time-Out Procedures before the procedure. At this time Nightingale Community hospital is meeting the minimum standard for the Time Out before the Procedure. I chose the communication as the priority focus area to review. The reason that I chose this area is that communication is the center of all processes for any business. “ The oft-repeated words “ customer satisfaction” is as important in the field of health as they are in any other successful venture. It is important for health care personnel to understand the doubts, fears and the anxieties of the patients who come to them for treatment. This empathy is possible only if there is proper communication (Gazda, Childers, Walter, 2010)”.

When communication is improved patient care is improved. Communication is an integral part of the healthcare system. Not only is communication important for the patient, it is also necessary to have open and honest communication among staff members, departments, and management within the hospital. “ Study after study has shown that poor communication leads to a shocking number of avoidable hospital injuries and deaths. In fact, the organization that accredits hospitals, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) realized that communication was a major problem that required nationwide correction (Painter, n. d.). “ In 2006, JCAHO used the National Patient Safety Goals to tackle communication problems head-on, specifically as they relate to communication and the nursing staff (Painter, n. d.).”

When hospitals do not assess their communication processes or the competency of their nurses, and in turn the nurses do not communicate key findings to a physician, there are serious consequences that can lead to avoidable patient injury and death. It is our responsibility to eliminate these injuries and deaths, with the proper policies and procedures in place risks to the patients will be minimized.