Executive Summary of Accreditation Audit
I prepared and reviewed an accreditation audit for Nightingale Community Hospital to organize and ensure compliance with Joint Commission standards for our hospital. We are preparing for a site visit that should occur within the next 13 months. I have reviewed the current compliance status of our hospital and will explain our corrective action plan that will ensure compliance with the Joint Commission standards for the focus area of communication.
An accreditation audit was performed by Carl Anderson, Director of Quality. We were only in 100% compliance in December throughout the year in one of the priority focus areas of the Joint ...view middle of the document...
(Commission, 2012) The elements of performance state:
1. Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site.
Note: The patient is involved in the verification process when possible.
2. Identify the items that must be available for the procedure and use a standardized list to verify their availability. At a minimum, these items include the following:
- Relevant documentation (for example, history and physical, signed procedure consent form, nursing assessment, and preanesthesia assessment)
- Labeled diagnostic and radiology test results (for example, radiology images and scans, or pathology and biopsy reports) that are properly displayed
- Any required blood products, implants, devices, and/or special equipment for the procedure
Note: The expectation of this element of performance is that the standardized list is available and is used consistently during the preprocedure verification. It is not necessary to document that the standardized list was used for each patient.
3. Match the items that are to be available in the procedure area to the patient
Nightingale’s policy in regards to the second section; Preoperative/Preprocedure Verification Process, is vague in some areas. I would be more descriptive in my corrective action plan in referring to the section under; Verification of the correct person, procedure and site will occur (as applicable)
1. At the time of admission/entry to the facility.
2. Every provider and staff involved in the care of the patient before and during the procedure separately verify: patient identity using two identifiers (e.g., name and birth date).
3. Procedure to be done, site of procedure (compare documents, x-rays/diagnostic tests.
4. Verbal response from patient and/or legal guardian, awake and aware whenever possible.
5. All should be documented by each staff member at each point of the verification process and recorded in the patient record.
6. Immediately before beginning operative/invasive procedure.
7. Preoperative/Preprocedure check sheet from check in of patient to discharge.
This will be instituted to ensure compliance and will be used with Nightingale’s Preprocedure Hand-Off sheet. This will be a double check off to insure safety. We will start a chart audit at projected start date July 1, 2012 and review in 90 days. The checklists will assure that all verifications and site identifications have been carried out.
A focused audit will be done on all patients undergoing operative or invasive procedures for the next year. Results will be analyzed by the nurse manager and discussed at staff meetings. Evaluation of compliance will be done at the staff meetings and any recommendations for improvement will be discussed and approved at these meetings. Implementation of any recommendations will be instituted the following month. Summaries of the audit and any recommendations for improvement will...