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Running head: ACCREDITATION AUDIT 1

ACCREDITATION AUDIT 3

Accreditation Audit Task 1

Compliance status

Nightingale Community hospital is Join commission (JACHO) accredited. The hospital has thirteen month until the Join commission audit. The join commission audits include several areas of compliance. The focus area in this report is communication. After reviewing the join commission standards for communication, Nightingale community hospital is not in compliance of the some of the Joint Commission’s standards of communication. the standards of universal protocols (UP) are UP 01.01.01 conduct pre-procedure verification process, UP 01.02.01 mark the procedure side and UP 01.03.01 perform a time-out before the procedure.

The first Universal protocol UP 01.01.01 conduct pre-procedure verification process has three elements of performance (EPs). Nightingale community hospital is in compliance of the first element of performance to have a policy to identify the correct procedure, for the correct patient, at the correct site. Nightingale community hospital is not in compliance with the second element of performance. The hospital does not have an implemented policy to identify the items that must be accessible for the procedure like documentation of physical, laboratory and radiology results, pathology and biopsy reports and blood products,impalns, devices and special equipments that are required for the procedure. Third element is to match all the previous items to be available to the patient.

The second protocol UP 01.02.01 for preventing the wrong site, wrong procedure and wrong person surgery. 01.02.01 has five elements of performance. Not in compliance with third element of performance to mark the procedure site by a licensed practitioner who is accountable for the procedure and will be present during the procedure. No written alternative policy in place for when it is not possible to mark the procedure site.

The third Universal protocol UP 01.03.01 about conduction time out. It has five elements of performance. The second element of performance is not in compliance. The written policy about conducting time out is lacking all immediate members involved in the procedure should be including in the time out, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning. the third element of performance is not in compliance with JACHO standards.’’ When two or more procedures are being performed on the same patient, and the person performing the procedure changes, perform a time-out before each procedure is initiated.’’. The fifth element of performance is not in compliance. There no written policy about documentation of time out completion.

Action plans

1- surgery committee will create about the items that is required in a procedure like documentation of physical, laboratory and radiology results, pathology and biopsy reports and blood products, impalns, devices and special equipments that are required for the procedure. Verify and match the itmes before the procedure to be available to the patient.

2- The surgery committee will develop a policy to name the indivudals who can mark the procedure site to include a listened practitioner who is accountable for the procedure and will be present during the procedure. A licensed individual who performs duties requiring a collaborative agreement or supervisory agreement with the licensed independent practitioner performing the procedure (that is, an advanced practice registered nurse [APRN] or physician assistant [PA]); who is familiar with the patient; and who will be present when the procedure is performed.

3- The surgery committee will add to the current time out policy that all immediate members involved in the procedure should be including in the time out, including the individual performing the procedure, the anesthesia providers, the circulating nurse, the operating room technician, and other active participants who will be participating in the procedure from the beginning. Additionally, when performing more than one procedure on the same patient to change the time out individuals and perform a time out before each procedure and document the completion of the time out.

4- Provide extensive training on the new policies to all surgery staff members and conduct an internal audit in 6 months to monitor the afore mentioned policies.

Importance of communication

Communication is very important when to come to performing procedures on a patient. It provide safety to the patient and the healthcare professionals. Lack of commuinication can results in performing a procedure on a wrong patient and or on a wrong site. It can have a very serious consequences on the patient including death.

References

Joint Commission Manual ; 2018; WGU , AFT 2,; Retrieved June 2018 Cite (JC, 2018 )