Accreditation Audit: Raft Task 1
Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013).
The Standards of Universal Protocols (UP) are: UP 01.01.01 Conduct pre-procedure verification process
UP 01.02.01 Mark the procedure site
UP 01.03.01 Perform a Time-Out before the procedure.
To determine NCH compliance, hospital documentation was used for comparison with the Joint Commission, Elements of Performance. The following chart specifies which documents were used to show areas in need of improvement.
Nightingale Community Hospital Documentation| Compared with|(UP) Elements of Performance|
Pre-Procedure Hand-Off check listSite Identification and Verification (UP) (Sub heading) Preoperative Verification Process||UP.01.01.01Description # 1Description # 2|
Site Identification and Verification (UP) (Sub heading) Marking the Operative/Invasive Site||UP. 01.02.01Description # 5|
Safety Report Time-Out Graph||UP. 01.03.01Description #1 |
Executive Summary and Findings according to the Joint Commission, Elements of Performance.
UP.01.01.01 Not in compliance. #1 Implement a pre-procedure process to verify the correct procedure, for the correct patient at the correct site. The current NCH Pre-procedure list has a line item for - Identification Armband on patient’s arm; however there is no provision for procedure name, or procedure site.
#2 Identify the items that must be available for the procedure and use a standardized list to verify their availability.
References: Gong, Y. and Khairat, S[->0]. (2010). Understanding effective clinical communication in medical errors Joint commission.org. (2013). Retrieved from http://www.jointcommission.org/facts about_the_universal_protocol/[->1] Premier Inc.com (2013)