AFT2 T1
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AFT2 TASK 1
Cassandra Marker
Western Governors University
Dr. Austen Arenz
May 25, 2023
2
AFT2 TASK 1
Nightingale Community Hospital is anticipating our upcoming accreditation audit from The Joint Commission in approximately 13 months. In preparation for this audit, Nightingale will be reviewing its current compliance status for the Universal Protocols relating to communication. These protocols aim to prevent surgical errors by utilizing consistent communication and identification processes prior to procedures, as well as encouraging patient participation whenever possible during the preprocedural communication. A review of each of the 12 elements of performance within the Universal Protocols has been conducted, identified as compliant or noncompliant, and subsequent action plans to achieve compliance have been created for all elements of performance deemed noncompliant.
A. Compliance Status Listed below are each of the three Universal Protocols and the accompanying elements of
performance (EP) for each protocol.
UP.01.01.01: Execute a pre-procedure authentication process. 1.
Execute a pre-procedure process to accurately identify the correct procedure, for the correct patient, at the correct site. Ensure the patient and/or family is involved in this process when possible. Nightingale has proven to be compliant with this EP, demonstrated in the Site Identification and Verification Policy.
2.
Identify items that must be available for the procedure and use a standardized list to verify their availability. This should minimally include important documentation, radiology exams or previously performed diagnostic results, any blood products, specialized equipment or devices anticipated. Nightingale has proven to be compliant with this EP, demonstrated by their pre-procedure hand off form.
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UP.01.02.01: Mark the procedure site.
1.
Identify those procedures that require marking of the incision or insertion site. At a minimum, sites are identified when there is more than one possible location for the procedure and when completing the procedure in another location would negatively affect quality or safety. Nightingale has proven to be compliant with this EP, demonstrated by the Site Identification and Verification Policy.
2.
Mark the procedure site before the procedure is initiated and, if possible, with the patient involved. Nightingale has proven to be compliant with this EP, demonstrated by the Site Identification and Verification Policy.
3.
The procedure site is marked by a licensed practitioner who is the provider responsible for the procedure and will be in attendance when the procedure is performed. In limited circumstances, the licensed practitioner may delegate site marking to a person who is permitted by the organization to participate in the procedure and has the following qualifications:
a.
A person in a medical post graduate education program who is being supervised by the licensed practitioner performing the procedure; who knows the patient; and
who will be in attendance when the procedure is performed.
b.
A licensed individual who completes duties requiring a collaborative agreement or supervisory agreement with the licensed practitioner performing the procedure (that is, an advanced practice registered nurse pr physician assistant, who is familiar with the patient, and who will be present when the procedure is performed.)
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Nightingale has not provided sufficient documentation that this element of performance is followed and is therefore considered non-compliant.
4.
The method of marking the site and the type of mark is unambiguous and is used consistently throughout the hospital. Nightingale has proven to be compliant with this EP, demonstrated by the Site Identification and Verification Policy.
5.
A written, alternative process is in place for patients who refuse site marking or when it is
technically or anatomically impossible to mark the site. Nightingale has proven to be compliant with this EP, demonstrated by the Site Identification and Verification Policy.
UP.01.03.01: A time out if performed prior to the procedure.
1.
Conduct a time out immediately before initiating the invasive procedure or making the first cut. Nightingale has proven to be compliant with this EP, demonstrated by the Site Identification and Verification Policy.
2.
The time-out has the following characteristics:
a.
It is standardized, as defined by the hospital.
b.
It is started by a designated member of the team.
c.
It involves the immediate members of the procedure team, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active partners who will be in the procedure from the start.
Nightingale has proven to be compliant with this EP, demonstrated by the Site Identification and Verification Policy.
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3.
When two or more procedures are being performed on the same patient, by multiple providers, perform a time out before each procedure is initiated. Nightingale has not provided sufficient documentation that this element of performance is followed and is therefore considered noncompliant.
4.
During the time-out, the team members agree, at a minimum, on the following:
a.
Correct patient identity
b.
The correct site
c.
The procedure to be completed.
Nightingale has proven to be compliant with this EP, demonstrated by the Site Identification and Verification Policy.
5.
Chart the completion of the time out. Nightingale has proven to be compliant with this EP, demonstrated by the Site Identification and Verification Policy.
A1. Plan for compliance Findings show that Nightingale has a high rate of compliance under the Universal Protocols. Two elements of performance were noncompliant.
The first non-compliant element falls under UP 01.02.01. EP3 states that the surgical site can be marked by a licensed practitioner, or a licensed person who is supervised by the practitioner and is involved in the patients care and attending the procedure. The current standing
policy for Nightingale directs the patients to mark their sites, and if unwilling or unable, defers to
the physician for site marking. This directly conflicts with the element of performance put forth by the Joint Commission. The action plan to reach compliance will be to amend the Site Identification and Verification policy. The practice of patients marking their sites should be eliminated, and to be compliant with current standards, the addition of Licensed independent
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providers, or appropriate advanced practice delegates participating in the patients care and procedure should be added to all sections in the policy that discusses or identifies who can mark surgical sites. The policy should include the practice of adding initials on the surgical of the individual who marked it, to monitor compliance of site markings by providers. The owner of this action plan will be the director of surgical services, in addition to risk management and/or quality director to assist with appropriate verbiage and compliance. The timeline for completion of the above action plan will be 30 days, to allow for policy amendment and approval of policy change through the surgical leadership committee. Once approved, education will be sent to both nursing and physician partners to ensure knowledge of change is dispersed through the department. This education will be provided the day of approval. To measure compliance after the policy change, the director of surgical services will partner with unit charge nurses to real time audit 5 surgical site markings daily, and who completed them, for 30 days. Once compliance has been achieved, a monthly audit of 15 surgical cases will continue for maintained accountability and compliance.
The second area of noncompliance is UP.01.03.01 EP3 when multiple procedures are being performed on the same patient, and the person performing the procedure changes, a time out must be performed for each event. The policy for Nightingale does not include a time out process for multiple procedures happening, or multiple providers within those procedures, therefor poses a risk for patient safety and does not comply with the element of performance. The action plan to obtain compliance will be to amend the Site Identification and Verification Policy to include a standard that states if multiple procedures with multiple providers occurs, a separate time out for each procedure is required before initiation of each procedure. This action plan will be owned by the director or surgical services and risk management. The timeline for
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completion of the above action plan will be 30 days, to allow for policy amendment and approval
of policy change through the surgical leadership committee. Once approved, education will be sent to both nursing and physician partners to ensure knowledge of change is dispersed through the department. This education will be provided the day of approval. To measure compliance the director or surgical services will partner with the unit charge nurses to audit 100% of all cases that include multiple cases and providers for 60 days to hard wire compliance. After the 60 days, when compliance has been achieved, a monthly audit of 15 charts including multiple procedures and providers will be completed by the director of surgical services to maintain accountability and compliance. A2. Justification Communication was the focus point for Nightingale because good communication is one of the most important elements of patient safety. Communication failures are the leading cause of inadvertent patient harm. Analysis of 2455 sentinel events reported to the Joint Commission for Hospital Accreditation revealed that the primary root cause in over 70% was communication failure. (Leonard et al., 2004) By reviewing current communication compliance, it allows Nightingale to find opportunities for improvement related to patient safety with communication and provides the hospital the ability to reduce near misses, sentinel events, and patient harm. This leads to a higher performing surgical department, higher patient satisfaction, and improved surgical metrics.
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References Leonard, M. (2004). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care
, 13
, i85–i90. https://doi.org/10.1136/qshc.2004.010033