Accredidation Audit

8 August 2016

Nightingale Community Hospital (NCH); a 180-bed, acute care, not for profit organization provides services in critical and emergency care, Oncology, cardiology, general medical and surgical services and neuroscience, vascular, level II nursery units amongst a few others. Providing these services Nightingale has held a commitment of safety, community, teamwork, and accountability. These four values have kept Nightingale compliant in several accreditation functions required by the Joint Commission.

Audits, interviews, observance and chart reviews; the Director of Accreditation has found that NCH has met accreditation standards in performance improvements (PI), rights and responsibilities of the individual (RI), transplant safety (TS), emergency management (EM), infection control (IC), and human resource (HR). Looking to the upcoming accreditation audit NCH has created effective plans in emergency operations, prevention and control, qualifications set for the hospital and staff, adequate data collection, in-depth attention to organ and tissue donation and procurement and patient rights; NCH is ready for audit in theses areas.

Accredidation Audit Essay Example

Discuss any trends evident in that may cause the organization to not be compliant with the Joint Commission standards for patient care. Although, several areas have reached a level of compliance at NCH; others need review to be in compliant and ready for audit. NCH is not compliant within the accreditation functions of the following: Life Safety (LS), Record of Care (RC), Information Management (IM), Universal Protocol (UP), Medication Management (MM), Environment of Care (EC), Provision of Care, Treatment and Services (PC), National Patient Safety Goals (NPSG), Nursing (NR), Leadership (LD), and Medical Staff (MS).

Joint Commission standards LS. 03. 01. 20 and EC. 02. 03. 03 “requires exits, exit accesses, and exit discharges are clear of obstructions or impediments to the public way, such as clutter and the hospital conducts fire drills once per shift per quarter in each building defined as a health care occupancy”. Upon review of the fire drill reports and observance during PPR rounds it was discovered that the fire drill process is inconsistent and did not meet JC standards and clutter was found on multiple floors such as OR and Telemetry.

Is a standard that is seen throughout Nightingale as an area of non compliance but with an average of 81. 25% of verbal orders actually being authenticated within 48 hours this issue can be corrected with an effective implementation plan. The hospital is to follow a list of prohibited abbreviations, acronyms, symbols, and dose designations; by using those prohibited abbreviations in progress, nursing, and physician orders/notes in units 3E, 4E, ICU, and Telemetry Nightingale is out of compliance hospital wide in regard to the IM. 02. 02.

Standard. Nursing (NR) and Leadership (LD) functions require that “nurse executives routinely assume oversight responsibility for the provision of safe, effective, high-quality nursing care throughout the hospital; development, presentation, and management of the nursing services’ portion of the hospital’s budget; work team productivity; consumer satisfaction activities; and staff retention efforts (NR. 02. 02. 01)” and its “leaders provide for the effective functioning of the hospital with a focus on safety and quality (LD. 03. 06. 01).

” Nursing staff on 3E have forgotten the valued culture of quality care, safety, and service. This attitude could possibly have contributed to other areas not meeting compliance on 3E? NGH must review medication policies before audit. Medication management falls out of compliance because nursing staff are not educated on range order policies and therefore are not consistently executing when called for. Also, failure to label medication and equipment in the OR and Cath Lab goes against standards set. NGH is responsible for reducing the potential for medication errors and the misinterpretation of medication orders.

PPR rounds found pre and unlabeled syringes and unlabeled basins throughout the OR. Surgical sites not being marked also have a direct impact on patient safety and Nightingales compliance status. UP. 01. 02. 01 states that wrong site surgery should never happen therefore the Endoscopy and OR; where these issues were sited must reach a level of compliance before the audit and maintain it throughout operation. Patients expect to be protected from illness and other aliments during a stay in the hospital but they are also should be protect from fire and other natural disasters.

Nightingale units are not compliant with maintaining the environment of care (EC. 02. 05. 09 EC. 02. 03. 01 LS. 01. 02. 01 LS. 03. 01. 35). Medical gases are not being checked per policy, smoke wall penetrations and sprinkler issues were noted, or are the Interim Life Safety Measure plan being implemented consistently during construction projects; all negatively affecting the hospital safety causing incompliance. NGH’s provision of care, treatment and services is damagingly out of compliance. Standards state; PC. 01. 02.

The identification and treatment of pain is an important component of the plan of care, PC. 01. 02. 03 each patient is reassessed as necessary…reassessments may be based on the patient’s diagnosis; desire for care, treatment, and services; response to previous care, treatment, and services; and/or his or her setting requirements, PC. 03. 01. 03 the hospital conducts a pre-sedation or pre-anesthesia patient assessment before operative or other high-risk procedures are initiated, or before moderate or deep sedation or anesthesia is administered.

Day of Procedure, and pain reassessments are consistently missing from records and importantly pre-sedation ASA and plans for anesthesia are nit being noted. Due to the severity of these deficiencies NGH must correct to be audit ready and decrease chance of patient injury. Medical staff is the key piece to making a hospital operate. Medical staff has to be qualified, competent, professional, and provide exceptional patient care. The OPPE process evaluates the performance of practitioners when issues affecting the provision of safe, high quality patient care are identified.

Conducting root cause analysis revealed there were no direct trends related to the clinical indicators and the human resource indicators (nursing care hours and overtime). With no evident trending reports and realizing that these numbers still exceeded linear measurements; 3E took a vase approach to decreases these numbers by focusing on additional training and staffing. Nursing staff attended the Nurses Improving Care for Healthsystem Elders program (NICHE).

This training program focused on improving nurses’ sensitivity to the aging community and recognition of age related changes. With this training nurses’ took action; improving patient care and sharing with other colleagues what they had learned. Considering most falls on the unit occurred when patients found themselves trying to maneuver to the restroom without assistance a void schedule was implemented; prompting and assisting patients to the restroom every two hours. This voiding schedule not only helped reduce the number of falls but also decreased the number of incontinent patients.

Incontinence may cause pressure ulcers and skin breakdown; these numbers were reduced as well. Staffing changes were made in 3E; a skin care representative is being used to educate on pressure ulcer development and skin care. The skin care representative receives continuous education and serves as a vital resource to the nursing staff. Skin care representatives have expertise in the causes and treatment of pressure sores; which gives nursing staff daily training and support.

The NICHE program and skin care representatives have aided in 3E’s in the reduction of falls to 5.45, falls with injury to 0. 42, and the rate of nosocomial pressure ulcers had dropped to 1. 23%; putting 3E at or below the linear measurements. While 3E saw a decrease in the number of falls ICU’s numbers however increased. Once at 0. 41 for the previous year ICU is not at a rate of 1. 9. Five out of the total seven falls occurred within the first quarter of the fiscal year. Ventilator associated pneumonia was also at an increase. VAP increased from 2. 2(one infection) per 1000 ventilator days to 3. 0 (two infections) per 1000 ventilator days.

Again after analyzing the effectiveness report here too there was no correlation between nursing hours, falls, and VAP cases. In order to decrease theses number the ICU took a similar approach to 3E. After sighting the fall and VAP frequency at the beginning of the year ICU currently has a Fall Prevention Team; whose representatives investigate falls and reports data found with care providers. These representatives also serve as another resource of knowledge to nursing staff in the ICU. With information about how and why a patient falls can decreases the likelihood of falls occurring continuously.

Studies have shown that oral care, including timed tooth brushing, combined with the VAP bundle can mitigate and prevent the occurrence of VAP. The VAP bundle implementation and sedation vacation, oral care protocol and daily intensivist rounds have been implemented in the ICU. The nurse manager will monitor these implementations as the year continues. Unlike, the previous units 4E has seen a significant increase in the number of patient falls and the nosocomial pressure ulcers. From 1. 47 the previous year to 4. 37 this year the number of falls per 1000 patient days has is alarmingly higher than the hospital target rate of < 3.

The Fall Prevalence vs. Nurse Care Hours chart identified relational trends between falls and nursing care hours. As the nursing hours increased so did falls and as the hours decreased the number of falls took a reduction as well. Only in the months of January and August were there zero falls reported. 4E has yet to devise a plan to decrease the number of falls and reduce the human resource indicators (nursing hours and overtime). Develop a staffing plan to minimize the number of falls in the patient care unit.

In order for any organization to be audit ready the staff must be present, educated, qualified, and ready to perform at a level that promotes care, service, and excellence. If staffing patterns are revised than many of the non compliant areas at Nightingale and the fall prevalence in 4E could decline. Trends identified in 4E show that nursing hours were related to patient falls; an increase in hours compared to an increase in falls and vice versa. These trends are contradictory to studied nursing hour measures; which state that a higher number of nursing hours may indicate that a hospital provides a higher level of patient care.

Staffing research showed that 4E is understaffed causing nurses to work longer workdays; spanning from 14-18 hours. The risks of making errors are significantly increased when staff works longer than twelve hours; posing serious challenges for the delivery of safe and effective nursing care for patients and their safety. Ten months out of the current year 4E reported nursing hours to be 12 hours or more with a median being approximately 15 hours. In order to truly see a decrease in the patient falls Nightingale has to staff 4E illustrated below:

A limited
time offer!
Save Time On Research and Writing. Hire a Professional to Get Your 100% Plagiarism Free Paper