Raft Task 1 Accredidation Auditing

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RAFT Task 1
Executive Summary
By Cindy Granger
December 1, 2011

Mission: To implement a corrective action plan in the area of Communication for Nightingale Community Hospital as required for Joint Commission Compliance. Corrective Action Plan:
Standard: UP.01.01.01: Conduct a Preoperative Verification Process. At the present time Nightingale Community Hospital is not in compliance with rule UP.01.01.01. Nightingale currently has a five step verification process in regards to Preoperative/Pre-procedure Verification. This does not meet the minimum standard of care regarding verification of correct person, correct procedure and operative site. To become compliant, they must take the following corrective actions. 1. At the time of admission to the facility, the patient must provide identification, verifying name, age, and date of birth. If the patient is unable to do so a family member or staff member from referring agency will verify identity. Identification bands will be placed on the patient during the admission process. The information obtained at the time of admission will be reviewed/verified at the time the bands are placed on the patient. The identifying information must be confirmed by two members of the staff and documented. Personnel involved in this process will include the following: admissions clerk, preoperative nurse, and another person or department that assumes responsibility of the patient. 2.When the patient is transferred from one department to another (ie: radiology, preoperative care, etc), the responsibility of care must be documented. The nurse’s must verify the identity of the patient to which the responsibility of care is being transferred. The time and date of the transfer of care must be signed off on by the nurse handing off and the nurse accepting responsibility for the patient. 3.Verification of the procedure must occur pre operative. The patient can verify the type of procedure with the pre...
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