To provide an accurate assessment of the systems and processes for the delivery of care, treatment, and services at the Nightingale Community Hospital, weekly patient chart reviews of patient medical cases is performed using The Joint Commission tracer methodology for a thorough review of current services and possible deficiencies. Recently, the medical record for patient 453355 was reviewed in order to trace their care through departments and services at the hospital.
This patient was recently admitted to the hospital with a post-op wound infection and the recent surgical stay records were chosen by the Risk Management Department to be assessed and evaluated using the tracer methodology to audit Nightingale Community Hospital’s compliance with selected Joint Commission standards. During the tracer for patient 453355, a Surgical Patient Tracer Worksheet was used to review the actions taken during the patient care process from arrival to leaving. Upon review of the Surgical Patient Tracer Worksheet, a deficiency was identified with the read back process when a critical value is called to a caregiver.
During the tracer review, the staff member who was interviewed did not describe the read back process for receipt of critical values or describe how it was documented in the MD notification screen. As part of the Joint Commission Provision of Care requirements, when receiving calls with critical values or test results, staff must record the read back process to verify the information prior to taking action on a verbal order or verbal report of a critical test result (The Joint Commission, 2013).
Patient Tracer Summary To assure compliance not only within the surgical department but hospital wide, a hospital task force was created with representatives from the Laboratory, Imaging, Cardiopulmonary and Nursing- all departments involved with giving and receiving critical values. Department directors along with immediate caregivers to patients were involved in order to provide a thorough roadmap of the process and evaluate the current procedure.
When the task force met, we traced the effectiveness of the communication process by asking staff questions, reviewing past Joint Commission National Patient Safety Goal 2 safety reports and audited additional patient charts for critical value documentation to identify any deficiencies in the process. It was discovered that there was a breakdown in the process at the point of documentation. The read back process is being completed but it is difficult for the RN to consistently document when receiving a report if they do not have immediate access to a computer to document the actions taken in the electronic medical record (EMR).
The current hospital policy on Reporting Critical Test Values was also reviewed by the task force and updated with the following: clear definitions of key terms, outlines provider responsibilities, fail-safe communication of abnormal test values to include read back verification, defined verbal and/or electronic reporting procedures, specify critical tests and acceptable length of time between ordering and reporting to caregivers and patient in order to 3 reflect best practices of the best communication mechanisms from The Joint Commission and the College of American Pathologists.
To improve consistency and accuracy in the documentation process, fluorescent pink stickers were recommended by the nursing staff and have been introduced in to the daily workflow to assist with writing down information being reported and assist in the documentation sequence if a computer is not easily accessible for immediate documentation when receiving a Patient Tracer Summary critical value. These stickers contain all the required elements needing to be documented and 4 will be used if a computer is not readily available to document information.
The sticker will then be placed on the patient’s chart or the information will be transferred to the electronic medical record for documentation. The stickers will capture the critical value being called, time and date called, and by whom the information was called to and received from, along with the date and time, and that the information was read back for accuracy. To document the read back process, there will be a box to check to verify that the read back process was completed at each point of the communication process for communicating critical values.
It will also contain the same information for documentation of calling the critical value information to the patient’s primary care practitioners. The task force team was able to identify the issue, improve the process and choose a reasonable timeline to roll out the improved communication process. It has been communicated to all hospital leaders that the updated communication of critical values will be rolled out in four weeks with all clinical areas of the hospital responsible for educating their department staff through in-services and staff meetings prior to the roll out.
To ensure compliance with the revised process and the read back process, the method of collecting data will be a random review of 10 critical value reports in the EMR each month in each clinical area with the scores of each area being provided to the performance improvement department for review and feedback. To ensure the best patient safety, the compliance goal will be 100% of all critical value reports having proper documentation. At Nightingale Community Hospital, our goal is to keep patients safe and provide excellent care to all patients. Through this collaborative effort, we have improved a process to help us achieve this goal.