Answer

Table of Contents

1. Compliance Status……………………………………………………………….…….3
2. Action Plan for Compliance……………………………………………………………5
3. Justification…………………………………………………………………………….6
4. References ……………………………………………………………………………8

NCH Accreditation Audit Task 1

This paper aims to provide Nightingale Community Hospital (NCH) senior leadership with NCH present compliance status in the priority focus area of communication using the Universal Protocol Standards from the Joint Commission Handbook. NCH is dedicated to expanding communication between patients and the staff to avert wrong procedures and surgeries.  The Director of Accreditation’s role is to confirm that NCH conforms with the Joint Commission’s National Patient Safety Goals.  Currently, NCH meets seven of the thirteen evidence of performance listed in the Joint Commission Standards in the communication area. This paper details the present NCH compliance level, outline an action plan to bring NCH into compliance, and offers a justification for the suggested action plan. 

1. Compliance Status: Communication

Upon assessing the internal pre-procedure hand-off checklist and the internal site identification and verification (Universal Protocol) process both given by NCH, lack of communication conformity with the following criteria from the Joint Commission was discovered:

UP.01.01.01 Conduct Verification Process Pre-procedure. This performance element, as a Joint Commission standard, ensures that a hospital is regularly doing procedures on the right patient. Under this standard, there are three compliance codes that NCH should be following.

1. The element of Performance (EP) 1- Pre-procedure procedure verifies that the intervention and intervention location is accurate for the intended patient. NCH met this requirement by the Site Identification and Verification Policy and is also backed by the Pre-procedure Hand-off Checklist.
2. EP 2- Identify the required items for the procedure and employ a standardized list in verifying their availability. The items entail pertinent documentation like nursing and pre-anesthesia evaluation and labeled diagnostic and radiology test outcomes. NCH hand-off form has a line item for test results; however, not precisely line item for labeled test results; hence NCH is not compliant in this area.

• EP 3-Execute a pre-procedure method to validate the precise procedure for the right patient and the accurate site. NCH presently has a written policy to perform pre-procedure authentication and a pre-procedure hand-off form to certify that information is communication. Though the present hand-off form has a section to validate the patient identification/arm-band and whether the site is marked, there is no section to confirm the patient procedure and site hence making NCH not conform to the standard. Also, the hand-off form lacks the compulsory part stipulating diagnostic and radiology test results. Likewise, the form lacks a list of the needed devices, blood products, implants, and the special equipment for the procedure.

UP.01.02.01: Mark the procedure site. This performance evident ensures that wrong-site surgeries do not occur by appropriately marking surgical sites.  There are five codes the NCH must comply with.

1. EP1- identify those procedures that need incision or insertion site marking. At a minimum, sites are marked when the likely surgery location is more than one. When the method, if the procedure is done in a different location, would adversely impact quality or safety. NCH is compliant with this code recorded in the Site Identification and Verification guidelines under Marking the Operative.
2. EP 2- The procedure site is marked before performing the procedure. NCH complies with this code under Marking the Invasive Site.

• EP 3- A licensed independent practitioner should mark the procedure site. NCH is not compliant with this performance element. NCH policy indicates that the patient should mark the site, and the doctor will only mark the site if there is an issue. This section of the written policy is in direct incongruity to the JCAHO standard.

1. EP 4- Under the Operative Site Marking policy, it indicates that the kind of marker must be permanent and the different lettering for every form of surgery. The technique of site marking and the sort of mark is explicit and is utilized regularly in NCH.NCH site identification policy does indicate processes for marking sites but lacks the need to detect breast biopsies using needle localization.
2. EP 5- A written optional process exists for patients who decline site marking or when it is technically or anatomically impractical to mark the site like mucosal surfaces. NCH under Marking the Invasive Site under number six of the policy indicates that validation for lack of site marking should be documented in the pre-operation checklist. But the pre-procedure hand-off form lacks a section to record that validation.

UP.01.03.01: A time-out is done before the procedure. This performance element is the last check that the exact process, right patient, and accurate site is identified before beginning the system. 

1. EP 1- Perform a time-out instantly before beginning the invasive procedure. NCH complies with this code, and as December NCH was one hundred percent conforming with this protocol.
2. EP 2- The time-out is defined by standardization. A designated team member does it. It entails the immediate procedure team comprising the person doing the procedure, the anesthesia providers, and other active persons engaged in the procedure form the start. NCH conforms, as its Time-Out Process Policy outlines that all the team members are responsible.

• EP 3- When two or more surgery is one on this same patient, and the individual doing the surgery changes, a time-out is done before each procedure is begun. NCH is not compliant with this component because there is no policy for separate time-outs for every process.

1. EP 4- During the time-out, the team members must settle on the actual patient identity, the right site, and the surgery. NCH conforms with this protocol.
2. EP 5- The time-out completion must be documented. NCH is not in conformity with this performance element as the policy only indicates on recording the time-out participants and time and not the conclusion.
3. Action Plan

In terms of UP.01.01.01, The Chief Nursing Officer (CNO) will create a checklist to cross-check that all items are available for the procedure. This list will be used regularly during the pre-procedure verification. The revision of the form should incorporate a space to fill the patient’s name, exact procedures done, and the sites for performing the procedures. The form should include a section for equipment required for the patient’s procedure, nursing and anesthesia evaluation, and labeled lad results. These corrective processes should be completed by 3/8/2020. Presently there is no documentation of this in the Pre-procedure Hand-off document. The documents will be kept in every patient’s record and audited weekly.

Regarding UP.01.02.01, the Nurse Director will make changes to the "Marking the operative/invasive site” policy to include that that a licensed practitioner will mark the site and not the patient. Also, the revised policy will consist of the practitioner accountable for the surgery, date, and any explanation for mot marking the site. This checklist will be filled regularly before any procedure is started and filed in the EMR. Weekly audits will be done by the Nurse Director to ensure compliance. Also, staff training on the revised policy will be completed by 20/8/2020. 

Regarding UP.01.03.01, the Chief Nursing Officer will revise the present time-out policy to incorporate the need for time-outs between two or more processes, meaning a time-out before every separate procedure. The Operations Room Nurse will call the time-out after completion of every procedure. The time-out duration and completion will be recorded in the patient's chart. Also, patients should be enlightened concerning the time-out procedure in advance and persuaded to become part of the time-out team. Patients should know they have the right and duty to pay attention and voice their concerns (Stahel, Mehler, Clarke, & Varnell, 2009).  The Chief Nursing Officer will revise this policy and do the staff training on the revised plan by 30/8/2020. The patient charts will be audited weekly by the CNO to ensure compliance.

Justification

Communication challenges were recognized as the root cause of the two-thirds of sentinel actions reported to the Joint Commission since 1995. Khairat & Gong (2010) state that the significance of communication cannot be overstated. The effects are incredible because communication failures are perceived as the leading source of medical errors, and medical mistakes are amongst the highest leading causes of death (Stahel et al., 2010). For NCH, enriching communication standards will create better patient satisfaction, an enhanced reputation for a higher standard of care, and offer an environment favorable to fewer errors for surgical and testing processes. Whether surgical sites are being explained or time-outs are being done, excellent communication is fundamental to successful treatment.

In conclusion, this paper has adequately discussed the NCH lack of communication compliance, a corrective action plan to ensure compliance in areas NCH lacks in communication conformity, and justification why communication is significant for NCH.