'Accreditation Audit Essay\r'

'With wholly of the realizable problems that could go on during process, a wrong-site, wrong- diligent mistake is one that should neer arise. Nightingale friendship hospital (NCH) richly understands the importance of doing away with these errors and has set up communications protocol to work towards this goal. While the protocol is in mark, it is not amply manageable with Joint Commission (JC) standards. measurement: UP.01.01.01: dole out a pre performance verification process.\r\nNightingale Community infirmary has a Site assignment and Verification form _or_ system of government and influence. deep down this policy, and operative/Preprocedure Verification Process is addressed. There is alike a Preprocedure Hand-Off smorgasbord present. This form is a bit misleading as it is fundamentally a hand-off form in superior general with a few extra boxes possible for check-off. To prep ar for inspection and audit, NCH should create and utilize a form for use inside th e Operating Theater or wherever procedures are performed, much(prenominal) as bedside procedures. This form ask to be more particular proposition in addressing at least the borderline requirements by JC.\r\nThe form needs to introduce that all relevant backing is present, such as signed consent form, nursing assessment, preanesthesia assessment, memorial and forcible. The form in like manner needs to specify that the necessary diagnostic and radiology test results, rather they be images and scans, or biopsy reports, and properly displayed and designate. Finally, to fulfill the borderline requirements by JC, any(prenominal) and all required telephone line products, implants, devices, and special equipment needs to be labeled and matched to the forbearing. Standard: UP.01.02.01: Mark the procedure site.\r\nNCH covers the procedure site marking standard well-nighwhat well indoors their Site recognition and Verification Policy. It mentions that site marking is unav oidable for those cases involving laterality, multiple structures, or levels. Several propagation in their policy NCH mentions that it is best to contract the forbearing involved, if at all possible. If the patient is futile to mark the site, the policy states that the mendelevium result be called to mark the site. The policy states that the mark shall be made in permanent black marker so it exit remain unmistakable afterwards skin preparation, and also in a location that will remain visible after sterile draping is in place. The policy also includes circumstances in which the marking will be unable to be performed based on the location of the surgery being in an area that is unable to be marked. Standard: UP.01.03.01: A respite is performed before the procedure.\r\nNightingale Community hospital has an adequate procedure in place for the time-out performance. Within the Site recognition and Verification Policy, the Time-Out Procedure complies with JC standards. A time-o ut is to be conducted nimblely prior to performance of the procedure, it is initiated by the nurse or technologist, it involves all personnel involved in the procedure, the aggroup members agree to a minimum of patient identity, correct site, and correct procedure to be performed, and all of this information is document in the record, including those involved and the duration of the time-out. The barely issue not addressed fully is the possibility of multiple procedures occurring on the equivalent patient by different practitioners, and in that case, an additional time-out needs to be done for every new procedure.\r\nThe communicating priority focus area is an exceedingly important area for any hospital. This is a common sense area that should be able to reach complete compliance. A wrong-patient, wrong-site issue should never arise and is in all avoidable. In 2010, Joint Commission inform that wrong-patient/site surgeries continued to be the well-nigh frequently reported pathfinder event(Spath 2011).Jay Arthur states that JC reports surrounded by four and vi wrong-site surgeries per day(2011). The World wellness Organization believes that at least 500,000 deaths per yr could be prevented if the WHO Surgical dearty Checklist was repair implemented.\r\nThese numbers, when compared with the possibility of ascorbic acid% compliance, are astounding and completely avoidable. Nightingale Community Hospital is well on their way to avoiding these types of sentinel events through usages of proper protocol, procedures, and policy as is seen by the upward trend from their persist year of self-checks. With continued diligence and book modifications made, this can be an area that NCH, and any other hospital can be fully compliant in.\r\nReferences\r\nArthur, J. (2011). Lean six sigma for hospitals: Simple steps to fast, affordable, flawless health mission. vernal York, NY: McGraw-Hill. Spath, P. L. (2011). Error reduction in health care: A systems a pproach to better patient safety (2nd ed.). Hoboken, NJ: Jossy-Bass. WHO (2013). WHO | Safe surgery saves lives. Retrieved from http://www.who.int/patientsafety/safesurgery/en/ [Last Accessed November 5, 2013].\r\nAccreditation Audit prove\r\nA1. Evaluation\r\nNightingale Community Hospital (NCH) is committed to upholding the core value of safety, accountability, teamwork, and community. In preparation for the upcoming bent audit, NCH will be launching a nonindulgent action plan in signal response to the recent findings in the tracer bullet bullet patient. Background information on the tracer patient is as follows: 67 year old female postoperative patient recovering from a planned laparoscopic hysterectomy sullen open due to complications. Patient positive infection that formed an abscess and was readmitted to the hospital for surgical abscess removal and central line emplacement for yearn term IV antibiotics. The tracer methodology was employed when auditors reviewed this patient’s course.\r\nMany things were done well and right with this patient and NCH is pleased to know that the mass of items analyzed with this patient proved that NCH was in compliance with regulatory standards; however, in that location were some troublesome areas that we need to focus on. The master(a) focus area that we will puzzle our energies into will be the fact that at that place was not a history and sensible completed on the patient within 24 hours of admission, and in fact it was great than 72 hours before one was completed.\r\n propose more: My Writing Process search\r\nThe Joint Commission mandates standards that are to be met in order to maintain compliance. Standard PC.01.02.03 states that history and physicals must be document and placed in the patient’s medical record within 24 hours of admission and prior to procedures involving cognizant drugging or anesthesia. floor and physicals are also considered in compliance if documented 30 eld prior to procedures as long as there are no changes documented or the changes in berth are specifically noted. (Joint Commission Update, n.d.) A2. propose\r\nOften, rules and regulations are met with disdain and it is usually because there is no explanation succeedd as to wherefore the rule exists. The rules for History and physical documentation are in place for a reason and are not proficient to appoint things more complicated. History and physicals provide all health care providers that enrol in a patient’s care a glimpse into that patient’s health status and immediate concerns. (Shuer, 2002) The information provided in a history and physical paints a portrait for all other health care team members to follow and treat accordingly.\r\nOften, emergent situations whitethorn arise where other health care specialty providers may not gain the time to glean medical understate information from patients and/or their representatives and the history and physical then serves as the go to inauguration of information. Compliance regulations can be serious to understand the reasoning behind them sometimes, only if we all work together to make sure that we meet them, then NCH will continue to embrace the core values that we have worked so hard to tutor and embrace. The following outline is a corrective action plan that will go out compliance with the Joint Commission and leave us up to par for the readiness audit.\r\nAction\r\nAccountable Parties\r\nTimeframe\r\nMeasurement\r\nHistory and Physical\r\nPhysicians & physician assistants\r\n1. Within 24 hours of admission.\r\n2. Within 30 days prior to a procedure involving conscious sedation or anesthesia. Chart reviews and if requirements are not met, patients will be held in the surgical admitting unit and procedures will be delayed. There must be 100% compliance.\r\nB. Sources\r\nJoint Commission Update hire Guide. (n.d.). Retrieved August 31, 2014, from\r\nmed2.uc.edu/libraries/GME_Forms /Joint_Commision_Upd_1.sflb.ashx Shuer, L. M. (2002). Improvement needed on h&p documentation. medical Staff Update, 26(5), Retrieved from med.stanford.edu/shs/update/archives/May2002/chief.html\r\n'