WGU 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:
Conduct pre-procedure verification process
Mark the procedure site
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. At a minimum these items include the following: Relevant documentation (for example, nursing and pre-anesthesia assessment.) Labeled diagnostic and radiology test results. The language needs to be more precise and inclusive of correct terms. There are line items for Patient seen by Anesthesia and Last Vital signs; however these are not precisely assessments. There is a line item for test results but not precisely a line item for Labeled test results.
UP.01.02.01 Not in compliance.
#5 A written alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (for example mucosal surfaces or perineum). The NCH Site Identification and Verification form, subheading, Marking the Operative/Invasive Site # 8 states: Justification for not marking the site must be documented in the pre-operation checklist. There is no line item provided on the checklist.
Not in compliance.
#1 Conduct a Time-Out immediately before starting the invasive procedure or making the incision. In Hospital-Wide documentation eleven out of twelve months were below 100% compliance.
Plan for Compliance
Recommendation to revise Pre-procedure Hand-Off list. Include more specific terminology and line items for: Procedure name, procedure site, nursing assessment, anesthesia assessment, listed and labeled lab results. Responsible Party: Surgery Leadership Committee. This is the committee who approved the Site
Identification and Verification document.
Due Date: Document will be due at the committee’s second meeting from now. If the committee meets monthly, they will have the first month to assign the revision. The document will be due at the next meeting. Results measured: Revised document will be provided for Surgery Leadership Committee to compare with recommendations.
UP.01.02.01 Recommendation to provide form or space on pre-operation checklist for written...
References: Gong, Y. and Khairat, S[->0]. (2010). Understanding effective clinical communication in medical
Joint commission.org. (2013). Retrieved from http://www.jointcommission.org/facts about_the_universal_protocol/[->1]
Premier Inc.com (2013)
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