Accreditation Audit Essay Sample

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Nightingale Community Hospital (NCH) is a hospital that states they are leaders in quality healthcare. To remain a leader in hospital care it is crucial for the hospital to adhere to standards developed by the Joint Commission Accreditation on Healthcare Organizations (JCAHO). JCAHO is the organization that accredits and certifies hospitals that meet certain performance standards nationally. Only those hospitals that have the JCAHO accreditation are ensured to be in compliance with specific guidelines in each Priority Focus Areas: Infection control, Communication, Medication Management, and Information Management. Here at Nightingale Community Hospital safety is our top core value and in recent evaluations done by JACHO it obvious that there is are some problematic areas in Communication preventing us to pass compliance standards with 100% marks. I will review current Communication policies and assess proposed changes that can be implemented to increase the future compliance standard percent. Priority Focus Areas standards of Communication in each Element of Performance are as follows: A.

UP.01.01.01: Conduct a pre-procedure verification process – The first Element of Performance within the PFA of the Communication policies within NCH requires the hospital to conduct a pre-procedure verification process to ensure that the correct procedures being performed will be done on the correct person and site. The current standard of conducting a pre-procedure verification process is written in the policy, however, on the Hand-off form there is no area to verify the patient, procedure or site, only if the site has been marked. In the second Element of Performance of this standard, NCH is not in compliance in communicating what equipment will be needed and identified with the patient and the procedure to be done. Again, the Procedure Hand-off form lacks the information that identifies items needed for the procedure and how the items will be matched with the patient.

UP.01.02.01: Mark the procedure site – NCH has a policy in place that is required by JCAHO standards regarding marking the operative/ invasive site, however not all Elements of Performance standards are in compliance with JACHO. The first Element of Performance is met by NCH, insofar, as stating that sites needing markings need to be identified, while also noting that spinal procedures require additional imaging for exact vertebrae location. However, in this element the policy is noncompliant in relating to breasts can be identified by needle localization for biopsies. NCH is in compliance with the second element as it is included in their policy that the procedure site needs to be marked.

The policy is not fully compliant in the third Element of Performance in stating that the patient shall mark their operative site. NCH is compliant in the forth element of performance as their policy does so include sites will be marked unambiguous for specific sides indicating RT, LT, Bil, or C, T, or L for the spine with a permanent marker. NCH is only in compliance with the fifth Element of Performance in this section as their policy states justification must be documented for non markings of sites and discloses the body parts that do not need marking while noncompliant in this area as the NCH policy has no mention of how to mark premature infants prior to a procedure.

UP.01.03.01: A time-out is performed before the procedure – NCH has initiated a standardized policy in adherence to the JCAHO requirement to conduct a final assessment of patient, procedure, and site to take place, known as a time-out. The time-out will ensure that right before a procedure is going to take place it is the correct person, procedure, and site. This policy meets most requirements of JCAHO. Although the NCH policy does have a designated member of the team to initiate the time out, it is not compliant in the first Element of Performance their policy states that the time-out be conducted immediately prior to the “procedure” rather than the exact wording invasive procedure or the incision. In the second Element of Performance, JACHO names each team member of the team while NCH’s policy only says all members of the team leaving it uncertain who is part of the team. In compliance with JACHO, NCH fails to comply with the third Element of Performance in that they have no policy stating that a separate time-out needs to be initiated if the patient is having two or more procedures and the person performing the procedures changes. A1. Plan for Compliance

Nightingale Community Hospital has some adjustments to make to their current policy relating to the PFA of Communication to ensure that they are compliant with JCAHO’s standards. Suggested adjustments for each standard to meet JCAHO standards:

UP.01.01.01: Conduct a pre-procedure verification process. 1.Revision to NCH Hand-off form to include an area for the patient’s name, the specific procedure and exact site.
2.To comply with the second Element of Performance additional data needs to be added to the Hand-off form stating equipment needed for the patient’s procedure and an initial for noting that the equipment was matched with the patient. UP.01.02.01: Mark the procedure site.

1.NCH policy has an extensive list of site markings, however the area stating that breasts needle localization may be used to identify breast lesions is stated nowhere in the JACHO standard, as it does so state that sites are marked when there is more that one possible location. In this section, NCH needs to add that the breast being treated needs to be marked for the procedure and delete the previous statement. 2. NCH is in compliance with the second Element of Performance including in their policy that procedure site must be marked with involvement of the patient. 3. The third Element of Performance is 100% non-compliant in that NCH states that the patient is to mark their procedure site.This section of their policy needs to be omitted and revised with the correct wording from JACHO standard that the procedure is to be marked by a licensed independent practitioner who is accountable and will be present for the procedure or an individual delegated by the practitioner that is qualified according to JACHO standards. 4.The fourth Element of Performance is met by NCH following the JACHO standard of markings being unambiguous. Their policy states how sites must be marked and with permanent marking. 5.For NCH to become compliant in the fifth Element of Performance their policy needs to be revised to include in their written justification, the alternative process not only for those patients that are not marked, but wording to include the alternative for premature infants that cannot be permanently marked.

UP.01.03.01: A time-out is performed before the procedure
1.The first Element of Performance will need editing in the NCH policy’s wording. The words missing in this clause are “invasive procedure” and “incision.” Upon completion to inserting those words after “a time-out is called prior to” , the policy will be compliant to JACHO standard. 2.In the second Element of Performance, the NCH policy lacks in one area as JACHO standard states that each member of the team be involved in the time-out and lists team members. NCH needs to have a place where each member of the team present during the procedure be listed to complete compliance in this area 3.According to JACHO standard the third Element of Performance in this section requires an additional time-out occur if two or more procedures are to occur on the same patient (JACHO, 2012). To become compliant NCH will need to revise their current policy adding that if patients have more than one procedure a time-out is needed before each one. 4.NCH is compliant in the fourth Element of Performance in this standard.

NCH policy states that all involved personnel audibly and verbally agree on correct patient, side and site, and procedure. 5.NCH is compliant in the fifth Element of Performance in this standard. NCH policy states that the duration of the time-out be documented in the record, in which the patient’s chart will be used as a reference when calling the time-out. A2. Communication Priority Focus Area was selected for review because it is such an important process in the health field and not a complicated process to implement changes for resolution. Communication in a hospital setting is very valuable in the care of each patient being treated. Lack or error in communication can be very detrimental to the health and care of the patient, as well as the reputation of the hospital.

When a patient is scheduled for an invasive procedure it is stressful enough for the patient to have to worry about their health they should have complete trust in the staff and hospital that they will be having their procedure in. According to Mulloy & Hughes (2009), wrong site surgeries were found by the Joint Commission to be the third highest sentinel events. Implementing and following a policy that adheres to the Joint Commission on Accreditation of Healthcare Organizations will ensure compliance with JACHO. Ensuring that the hospital and its healthcare professionals are in compliance with communication standards will reduce unacceptable errors regarding patient procedures and care.


Site identification and verification policy. (2012). Nightingale Community Hospital Mulloy, D.F., & Hughes, R.G., (1999) Wrong-site surgery: a preventable medical error, Chapter 36, retrieved from December 26, 2012 from Universal communication protocol. In (2012). Nightingale Community Hospital

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