AFT Task 1
A. Compliance Status
Nightingale Community Hospital is a healthcare leader that believes in providing the best quality care to all of their patients. As part of Nightingale’s mission to put the patient first, the hospital must meet National Patient Safety standards established by the hospital in accordance with the Joint Commission. As such, Nightingale Hospital participates in the Surgical Infection Prevention Program for the collection of core measures as it pertains to Universal Protocol (UP) and National Patient Safety Goals (NPSG). Nightingale’s NPSG data reveals that Nightingale hospital did not meet its goal of 100% compliance with time out procedures hospital wide for 11 out of 12 months. A Time Out is the method of verifying the correct patient, the correct procedure and the correct procedure site prior to the start of the procedure.
As noted in the rationale for Joint Commissions’ UP.01.01.01.01- UP.01.03.01, Universal Protocols are implemented most successfully in hospitals with a culture that promotes teamwork and where all individuals feel empowered to protect patient safety. Universal Protocols are critical for Nightingale Hospital because wrong surgical procedures result in sentinel events (an unexpected occurrence involving death or serious physical or psychological injury). Sentinel events are tracked through The Joint Commission sentinel event database. Increased sentinel events would reveal poor quality of care and lack of awareness for patient safety that Nightingale hospital provides to its patients.
A readiness review was conducted of Nightingale Hospital’s Universal Protocol in preparation for a Joint Commission audit. The Joint Commission standards that were a part of this review consist of: UP.01.01.01; Conduct a pre-procedure verification process, UP.01.02.01; Mark the procedure site, and UP.01.03.01; A time-out is performed before the procedure. Nightingale Community Hospital documentation identified for this review is as follows:
Nightingale Community Hospital is a healthcare leader that believes in providing the best quality care to all of their patients. As part of Nightingale’s mission to put the patient first, the hospital must meet National Patient Safety standards established by the hospital in accordance with the Joint Commission. As such, Nightingale Hospital participates in the Surgical Infection Prevention Program for the collection of core measures as it pertains to Universal Protocol (UP) and National Patient Safety Goals (NPSG). Nightingale’s NPSG data reveals that Nightingale hospital did not meet its goal of 100% compliance with time out procedures hospital wide for 11 out of 12 months. A Time Out is the method of verifying the correct patient, the correct procedure and the correct procedure site prior to the start of the procedure.
As noted in the rationale for Joint Commissions’ UP.01.01.01.01- UP.01.03.01, Universal Protocols are implemented most successfully in hospitals with a culture that promotes teamwork and where all individuals feel empowered to protect patient safety. Universal Protocols are critical for Nightingale Hospital because wrong surgical procedures result in sentinel events (an unexpected occurrence involving death or serious physical or psychological injury). Sentinel events are tracked through The Joint Commission sentinel event database. Increased sentinel events would reveal poor quality of care and lack of awareness for patient safety that Nightingale hospital provides to its patients.
A readiness review was conducted of Nightingale Hospital’s Universal Protocol in preparation for a Joint Commission audit. The Joint Commission standards that were a part of this review consist of: UP.01.01.01; Conduct a pre-procedure verification process, UP.01.02.01; Mark the procedure site, and UP.01.03.01; A time-out is performed before the procedure. Nightingale Community Hospital documentation identified for this review is as follows: