Executive Summary Joint Commission Standards Compliance
Prepared by: AK- Joint Commission Priority Focus Area: Communication RAFT Task 1
The Joint Commission Priority Focus area for Nightnigale included the four areas: • • • • Information Management Medication Management Infection Control Communication
All these priorities focus on the national patients safety goal as the most important in patient management and treatment, and guide the hospitals toward appropriate policies and protocols to follow and to minimize any possible mistakes or patients harm. I choose the priority focus area of Communication to discuss the current compliance status of our organization concentrating on the ...view middle of the document...
Usually results delivered to unit clerk who could take long time in delivering the important message to medical staff.
2. Verbal Order / Read Back elements: Goal is 100%. • This is so important to minimize any wrong information or orders misunderstanding, or even misinterpretation. The lack of full compliance increase the risk of wrong treatments, medications and the consequences could be major. Our institution compliance varied between departments, and was noticed that surgical and in specific orthopedic department was the least compliant with verbal order policy. The compliance in this department was 62%. Reasons for this non compliance include: a. Lack of pathways for specific medical problems, where standard orders are the acceptable route to minimize inappropriate orders. b. Timing of the verbal orders, specifically during the night, where most of non-compliance documented. c. Surgical and specifically orthopedic department have a significant trust between surgeon and staff, which lead to non-compliance. These elements should be addressed aggressively to avoid harm.
3. Unacceptable Abbreviations: Goal 100%. • • • Despite the significant reduction in using unacceptable abbreviation, it still exists in some departments and by specific physicians. Our institution compliance was 99.6%. This is significant because of the number of orders analyzed, suggesting despite the better % that it still a huge number of orders or unacceptable abbreviations used in our hospital. Analysis of this non compliance identified the following: a. Most of the non-compliance was by attending physicians. It is much less by medical residents and extremely rare by nursing staff b. Patient volume have a significant effect on the percentage of unacceptable abbreviations c. Most of the unacceptable abbreviation was noticed on paper medical records.
4. Time Out: Goal 100%. • Time out as a standard will make sure of appropriate treatments and surgical procedures to be delivered to the right patients. The importance of this policy was magnified after the national statistics suggested a significant increase in specifically surgical procedures mistakes. Our institution compliance range between 90% in January to 100% in December. Despite all departments noticeable improvement in this element, we still identify some non compliance due to: a. Number of areas the patients move to before and after procedures. b. Number of staff that transfer patient care to each other, which lead to some miscommunication and then noncompliance. c. Lack of following Time Out procedure when supervisors are not available: suggesting that staff lack enough education and understanding for the reason behind this policy.
Corrective Action Plan: Understanding some of the above reasoning will lead us to a significant improvement in our compliance with the Joint Commission standards. In further discussion with medical staff, nursing representatives, pharmacy and laboratory...