Task 1 JCO Exec summ
docx
keyboard_arrow_up
School
Western Governors University *
*We aren’t endorsed by this school
Course
AFT2
Subject
Health Science
Date
Dec 6, 2023
Type
docx
Pages
7
Uploaded by jlluker
Executive Summary
WGU
Jordone Luker
11/26/2023
Nightingale Community
Hospital
EXECUTIVE SUMMARY
Overview
This executive summary is an assessment and overview of the facility's current
compliance status to prepare Nightingale Community Hospital for the upcoming Joint
Commission survey and to uphold the facility's core value of safety. The facility has identified
the review area of communication as one of four primary performance areas before the next JC
survey, which is anticipated to take place in 13 months, so this document's evaluation will
primarily focus on that area. Even though there is an increasing trend in compliance, NCH still
has room for improvement in the performance area of communication.
Compliance Status
Three specific Joint Commission standards are assessed for compliance status in this
executive summary.
UP 01.01.01 refers to the conduction of a preprocedural verification site.
UP.01.02.01 refers to marking the procedure. UP.01.03.01 refers to performing a time out prior to
a procedure. These standards have been predetermined by the facility's executive leadership and
will be the focus of this audit of the communication policies.
Preprocedural Verification Process
Creating and developing a standardized process to verify the correct procedure, correct
patient, and correct site including the patient in their care as much as possible. Based on the
Site Identification and Verification Policy, NCH is compliant. Creating a standardized list to
utilize before each procedure can be beneficial before each procedure to ensure all items
needed for the procedure are required and available. The checklist may include items such as
all relevant documentation, test results, and any special equipment needed for the procedure.
Findings suggest compliance of NCH regarding this element of performance when using the
Preprocedural Hand-Off form. Design a process ensuring all items available in the procedure
area are corresponding to the correct patient. Findings suggest compliance of NCH regarding
this element of performance.
Procedure Site Marking
Determine all procedures that require site marking. Finding suggest compliance.
Implementation of marking the procedure site prior to the procedure. Findings suggest
compliance. The licensed practitioner who is responsible for the procedure must mark the
procedure site personally. This practitioner must remain present throughout the entire procedure.
Findings suggest NCH is currently not compliant in this category. Design a routine or standard
that will be used hospital wide to mark the procedure site. Findings suggest NCH is compliant in
this category. Design and create and alternative process to site marking for when the patient is
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
refusing or if the provider is unable to mark the site. This must be written and documented.
Findings suggest NCH is compliant in this category.
Time Out
Per protocol, a time-out is required to any cut or invasive procedure. Findings suggest NCH
is compliant in this category. A time-out includes but is not limited to a facility designed standard
or protocol, a provider that will initiate the time out, and ensuring the time-out involves everyone
participating in the procedural area. Findings suggest NCH is compliant. When performing a
series of procedures or more than one on any given patient, a time-out must be performed in
between each procedure. A time-out must also be performed if providers change out during the
procedure. Findings suggest NCH is not compliant in this category. While performing the time-
out, all members of the healthcare team must be in agreeance that they have the correct patient,
site, and procedure prior to beginning. Findings suggest NCH is compliant in this category. The
hospital has a standard protocol or process that every time-out should include and the same
standard protocol for time-out documentation. Findings suggest NCH is compliant in this
category.
Action Plan
Two of the thirteen performance criteria set forth by The Joint Commission and included
in the three communication standards under review are presently not being met by the facility.
The actions that must be taken to guarantee compliance, who will be held responsible when these
obligations must be fulfilled, and how the implemented measures will be measured are all
described in the action plan that follows.
Site Marking and Time-Out
The third element of performance within site marking standard states the
procedure site must be appropriately marked by a licensed practitioner who is held
accountable for the procedure and is present throughout the duration of the procedure
(The Joint Commission, 2023). This element of performance is not compliant because it
does not specify that site markings must be carried out by a certified licensed
practitioner. The current protocol will need to be changed to reflect the requirement that
the procedure site be marked by a licensed independent practitioner prior to initiating the
surgery and that practitioner be present when the procedure is performed in order to
ensure compliance. This will be the responsibility of the directors within the surgical
department and hospital administration. This modification to the current protocol will be
finished in 45 days, and for 90 days after it is put into effect. There will also be surgery
audits performed routinely during this process.
The third element of performance within the time-out standard is noncompliant at
NCH. When performing a series of procedures or more than one on any given patient, a
time-out must be performed in between each procedure. A time-out must also be
performed if providers change out during the procedure. The current protocol at NCH
does not include a standard protocol for switching providers or multiple procedures. The
surgical team and surgical directors are ultimately responsible for designing and
implementing a policy that offers a time-out procedure for situations in which multiple
procedures are being performed on the same patient or when there is a change in provider
during a procedure. Within 45 days, this addition to the current time-out procedure will
be finished, and for 90 days following its implementation, and charts will be routinely
audited to ensure protocol is being followed.
Justification
It is essential that the aforementioned steps be taken to enhance communication in effort
to uphold the facility's mission statement, vision statement, and core values. “
Effective
communication is essential for multidisciplinary collaboration within and between healthcare
settings is, thus a key indicator of quality of care, yet it has not been systematically reviewed and
synthesized” (Sheehan et al., 2021).
Enhancing these communication gaps will guarantee the
best possible patient care and safety standards in addition to compliance with The Joint
Commission.
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
Reference
The Joint Commission. (2023).
https://e-dition.jcrinc.com/MainContent.aspx
Sheehan, J., Laver, K., Bhopti, A., Rahja, M., Usherwood, T., Clemson, L., & Lannin, N. A.
(2021). Methods and Effectiveness of Communication Between Hospital Allied Health
and Primary Care Practitioners: A Systematic Narrative Review.
Journal of
multidisciplinary healthcare
,
14
, 493–511. https://doi.org/10.2147/JMDH.S295549