1. Compliance Status
Following rules and regulations is important for institutions and any type of establishment to maintain organization and most importantly provide safety for those involved. For the organization and safety of everyone involved, it is important to comply with particular criteria.
Hospitals are one of the many organizations that must comply with regulations to keep patients and staff safe and as well as maintain the quality of care. Ideally, a good care system for patients includes medical professionals as well as friends and family to compliment each other in providing for patient needs. Because patients require care from medical professions in hospitals, there are provisions that the hospital must follow. “Compliance means conforming to a rule, such as a specification, policy, standard or law. Regulatory compliance describes the goal that corporations or public agencies aspire to in their efforts to ensure that personnel are aware of and take steps to comply with relevant laws and regulations (Compliance and Regulatory Compliance, 2013)”.
For this reason there are terms of compliance that hospitals must adhere to. The Joint Commission Handbook serves as a means of regulation and compliance for hospitals and other such facilities. There are four categories that the Joint Commission focuses on during the accreditation audits for a hospital: Information Management which involves the efficient management of health information and accuracy, Medication Management involving labeling and sterility, Communication involving verification, and Infection Control to minimize spread and infection.
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We will be performing an accreditation audit to confirm that compliance standards are met for Nightingale Community Hospital. This accreditation audit will focus on Nightingale Hospital and the maintenance of communication within the hospital. Communication is the activity of conveying information through the exchange of thoughts, messages, or information, as by speech, visuals, signals, writing, or behavior. (Communication)”. We will be conducting an executive summary to chart the current compliance standards based on the Joint Commission Handbook.
Nightingale Community Hospital has a summary of current compliance data for their particular hospital. There are a few priority focus areas that we will be focusing on for Nightingale Hospital based on the information provided for an accreditation audit. The first priority focus area under communication compliance standards that Nightingale Hospital is focusing on is the conduct of pre-procedure verification process.
Based on the joint commission handbook, there are a few elements of performance that Nightingale Community Hospital must meet to be in compliance. The first standard under communication division is, conducting a pre-procedure verification process for the patient. There are elements of performance that must be met under this standard for compliance. The first is performing a pre-procedure verification to identify the correct procedure, patient, and site. This element of performance is met by Nightingale under the Hospital Universal Protocol Policy and a pre-procedure handout for the verification of patient on an armband. The next two elements of performance are the identification of items that must be on hand during any procedure and matching the items that need to be available to the patient. Based on the information that was given, Nightingale Community Hospital does not meet these elements of performance under this standard for communication.
The next standard for communication is marking the procedure site. There are five elements of performance that must be met for this standard. The first is identifying procedures and incision site, particularly for spinal procedures. The second bullet is marking the site before a procedure begins. The third is having the procedure site market by a licensed practitioner. The fourth is making sure the marked site is not vague and consistent throughout Nightingale Hospital. All of these elements of performance are met in the Universal Protocol Policy. However, documenting the completion of a “time out” is met by the Universal Protocol Policy but also has the added benefit of being stated in the Pre-procedure handout. Upon conduction the accreditation audit for marking the procedure sites, Nightingale Community Hospital has policies in place to make sure they are being met.
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The final standard under communication is the performance of a “time out” before a procedure. There are also elements of performance that must be met to be in compliance for this standard. The first is conducting a “time out” before every procedure. This is met by the Universal Protocol Policy. The Universal Protocol Policy also meets the next bullet point of standardizing “time out” for Nightingale Hospital and having them started by an elected team member with the involvement of team members. The third element of performance is performing a “time out“ between a change of people performing a procedure on a patient.
This is unfortunately not met by any protocol in the information provided by Nightingale Hospital. Having team members agree the correct patient identity, the correct site, and the correct procedure to be done on a patient is the next element of performance. The final element of performance is the documentation of “time outs”. Though there are no policies bases on the information given from Nightingale Hospital of “time outs”, there is a graphical analysis of “time outs” hospital wide indicating the compliance percentage for each month during the year. The graph indicates that for the entire year, December was the only month where required “time outs” were performed one hundred percent of the time.
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2. Plan for Compliance
We will be implementing a corrective action plan to bring Nightingale Community Hospital into compliance for communication.
The first standard in communication has several areas of performance. Since the first element of performance is met, it is imperative to initiate a plan for the second and third elements of performance. To meet the second area of compliance, Nightingale Hospital will need to have a system in place to identify the items needed for any type of procedure. We will need to create a standardized list including relevant documentation, labeled tests results, and required equipment needed for the specific procedures (i.e. blood products).
This standardized list must also have a section delegated to matching the items to the patient in order meet the last element of performance for the pre-procedure verification standard. Implementing these standardized lists will insure that this standard is met.
The next standard to be met is marking the procedure site. Nightingale
Community Hospital has routines in place for all of the elements of performance for this standard therefore, there will not be a corrective action plan implemented for this standard.
The final standard is performing a time out before every procedure. There are five elements of performance in this standard which include: conducting a “time out” before stating a procedure, making sure “time outs” are standardized and initiated by a member of the team with involvement from the entire team, making sure “time outs” are performed during a change in person that are performing the procedures and finally, the documentation of “time outs”. Three of these elements of performance are met for this standard but, the act of performing “time outs” during changes of the person performing the procedures does not occur based on the evidence of Nightingale Community Hospital.
To remedy the lack of this performance element, we will be implementing a corrective action plan to include this in the policy. Since having a change of person does not call for a pre-procedure handout, a professional starting a new procedure will be required to fill a different procedure handout than prior to starting the procedure. The documentation of these time outs is also not indicated anywhere within Nightingale Community Hospitals policy. There is however a graphical analysis of the compliance percentage for the year indicating that there is a method of recording “time outs (Figure 1).
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A corrective action plan for this would be for Nightingale Community Hospital to implement this into the Universal Protocol Policy and the pre-procedure handout to eliminate any discrepancies. This will ensure that compliance standards are met for all areas.
3. Justification
Nightingale Community Hospital has provided data on previous compliance standards. Figure 1 shows the percentage of areas for improvement on identifying and labeling specimens. For the past year, Nightingale Hospital has had eighteen percent opportunity for improving standards and for the current year there is a forty-two opportunity percentage for improvement. This means that between the past year and the current year, there were more discrepancies reported. This provides substantial support and reason to implement a corrective plan for a pre-procedure verification process in order to meet all of the elements of performance.
Figure 1: Opportunities for Improvement
The third standard of performing time outs, has three elements of performance that lack compliance standards. Figure 2 shows the percentage of calling “time outs” every month for the year. Based on the information, December was the only month that was one hundred percent in compliance for the year which means there needs to be a system in place to eliminate discrepancies and make sure time outs are always called.
Figure 2: Hospital Wide Time Outs
Figure 3 shows percentage of verbal read backs to insure information is correct. This graph shows that only one department hospital wide has met one hundred percent compliance for verbal orders and read backs. Because only one department was in compliance, it supports the evidence that a corrective action plan is needed to ensure that information is correct by means of verbal read backs.
Figure 4 shows the percentage of reporting critical results of documentation. The highest percent of compliance is eighty-two which means that there is room for improvement. By having figure 2, 3, and 4 in one hundred percent compliance, this will ensure that the” time out” standard be met fulfilled.
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Making sure institutions are in compliance with regulations will help insure the safety of everyone involved.
Bibliography
Communication. (n.d.).
Retrieved from Wikipedia : http://en.wikipedia.org/wiki/Communication
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D. Kaluzny. Health care management: organization, design, and behavior. 5th ed. Clifton Park, NY: Thomson Delmar Learning, 2006. Print. Williams, Stephen J., and Paul R. Torrens. Introduction to health services. 7th ed. Clifton Park, NY: Thomson Delmar Learning, 2008. Print.
(2013, 2).
Compliance and Regulatory Compliance. (L. J. Gumm, Interviewee)