Executive Summary for Joint Commission

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June 21, 2012
RAFT Task 1
Executive Summary for Joint Commission Standards Compliance
Nightingale Community Hospital provides leadership in quality health services. We also provide compassionate and cost-effective service in the lines of treatment and prevention. Our vision is to be the hospital of choice for patients, employees, physicians, volunteers, and the community. In accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value. I have chosen the priority focus area of Communication to discuss the current compliance standard of our hospital. The focus will be on the standards which failed to meet a 100% compliance with the Joint commission Accreditation.

1.Hospital-Wide Compliance of Reporting Critical results within 60 Minutes: Reporting in a timely fashion as defined in the compliance standards reduces complications and critical outcomes. Or goal s 100% but our performance has ranged from 56% to 75% from January to June and has shown a subtle increase from 57% to 82% in the latter half of the year average. The reasons for delayed reporting were identified: ·Lack of education in staff members regarding critical values and critical tests. ·Lack of personnel in delivering the samples to the lab. ·Delay in communication between staff and Physician either due to unavailability of the physicians after hours contact information or lack of communication. ·Laboratory-based policies directed laboratory staff that critical values are telephoned immediately upon verification of accuracy but no explicit time frames were set if unable to reach care provider. ·Lack of a common shared policy for uniform communication of all types of test results to all recipients. ·Failure of support and maintain systems.

A corrective action Plan is designed as below.

Safe Practice Recommendations|Ideas and Changes|
Identify who should receive the results|Determine short- and long-term goals for who should receive results (ideal to contact the ordering provider for all CTR). Maintain nursing staff as intermediary to receive in-patient and ED CTR.Review ED protocol in place for handling discharged patients' CTR| Identify who should receive the results when the ordering physician is not available|Enforce and monitor compliance with policy rule not to communicate CTR to a non-regulated health professional or team member (e.g., clerk).follow the above changes.| Identify which results require timely and reliable communication|Educate clinical teams and laboratory staff on CTR call parameters.Consolidate lists of all laboratories' critical values within one hospital-wide policy| Identify when test result should be actively reported to the ordering provider and establish time frames for this process.|Set up a time frames for repeating and escalating calls if first call/page unsuccessful.| Identify how to notify the responsible provider(s)|Establish and monitor rules for calls left on voicemail and/or communicated to non-regulated health provider.| Support and maintain systems.|Identify requirements for upgrades and functionality of new systems.|

2. Verbal Order/Read Back Audits:
A review of our Hospital shows that the compliance varied between departments. A 100% was achieved by ED with the lowest being 62% for the orthopedic department. Verbal orders or Read back audits minimize wrong information, misinterpretation, misunderstands regarding treatments and medications for which the consequences can be major. Reasons for this non compliance are listed identified as:

·Human Factors: Unclear voice and accent of the doctors can mislead the staff who is receiving the order. The nurses might not feel encouraged to clarify...
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