Accreditation Audit

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Accreditation Audit
RAFT Task 1

Executive Summary

Nightingale Community Hospital (NCH) is a hospital that states they are leaders in quality healthcare. To remain a leader in hospital care it is crucial for the hospital to adhere to standards developed by the Joint Commission Accreditation on Healthcare Organizations (JCAHO). JCAHO is the organization that accredits and certifies hospitals that meet certain performance standards nationally. Only those hospitals that have the JCAHO accreditation are ensured to be in compliance with specific guidelines in each Priority Focus Areas: Infection control, Communication, Medication Management, and Information Management. Here at Nightingale Community Hospital safety is our top core value and in recent evaluations done by JACHO it obvious that there is are some problematic areas in Communication preventing us to pass compliance standards with 100% marks. I will review current Communication policies and assess proposed changes that can be implemented to increase the future compliance standard percent. Priority Focus Areas standards of Communication in each Element of Performance are as follows: A.

UP.01.01.01: Conduct a pre-procedure verification process - The first Element of Performance within the PFA of the Communication policies within NCH requires the hospital to conduct a pre-procedure verification process to ensure that the correct procedures being performed will be done on the correct person and site. The current standard of conducting a pre-procedure verification process is written in the policy, however, on the Hand-off form there is no area to verify the patient, procedure or site, only if the site has been marked. In the second Element of Performance of this standard, NCH is not in compliance in communicating what equipment will be needed and identified with the patient and the procedure to be done. Again, the Procedure Hand-off form lacks the information that identifies items needed for the procedure and how the items will be matched with the patient.

UP.01.02.01: Mark the procedure site – NCH has a policy in place that is required by JCAHO standards regarding marking the operative/ invasive site, however not all Elements of Performance standards are in compliance with JACHO. The first Element of Performance is met by NCH, insofar, as stating that sites needing markings need to be identified, while also noting that spinal procedures require additional imaging for exact vertebrae location. However, in this element the policy is noncompliant in relating to breasts can be identified by needle localization for biopsies. NCH is in compliance with the second element as it is included in their policy that the procedure site needs to be marked. The policy is not fully compliant in the third Element of Performance in stating that the patient shall mark their operative site. NCH is compliant in the forth element of performance as their policy does so include sites will be marked unambiguous for specific sides indicating RT, LT, Bil, or C, T, or L for the spine with a permanent marker. NCH is only in compliance with the fifth Element of Performance in this section as their policy states justification must be documented for non markings of sites and discloses the body parts that do not need marking while noncompliant in this area as the NCH policy has no mention of how to mark premature infants prior to a procedure.

UP.01.03.01: A time-out is performed before the procedure – NCH has initiated a standardized policy in adherence to the JCAHO requirement to conduct a final assessment of patient, procedure, and site to take place, known as a time-out. The time-out will ensure that right before a procedure is going to take place it is the correct person, procedure, and site. This policy meets most requirements of JCAHO. Although the NCH policy does have a designated member of the...
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