Joint Commission Accreditation Audit Preparation

Executive Summary

In preparation for the next Joint Commission Accreditation Audit, Nightingale Community Hospital is assessing the compliance status of each of the Joint Commission’s Priority Focus Areas (PFAs). This Assessment covers the “Communication” Joint Commission PFA. For the previous Joint Commission audit, there were no findings associated with this standard.

Since The Hospital has recently undergone a great deal of staff turnover in the Standards and Communication Department, several of the Hospital Directors felt that this may be an area that has slipped in relation to compliance with this PFA. The Communication PFA is comprised of three general standards: UP. 01. 01. 01 Conduct a pre-procedure verification process. UP. 01. 02. 01 Mark the procedure site. UP. 01. 03. 01 A time-out is performed before the procedure. Each of these standards has elements of performance that Nightingale Community Hospital should be implementing through policies, protocols and checklists.

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Compliance with the performance elements s summarized in a compliance matrix. The matrix identifies the standard, the performance elements of the standard, and how the performance element is implemented. This matrix is an effective tool to assess where compliance gaps exist and it forms the basis for developing corrective action plans. The compliance matrix for the Communication standard in included at the end of this summary. Nightingale Community Hospital is implementing most of the performance standards.

There is no documented implementation for the following performance elements. Labeled diagnostic and radiology test results (for example, radiology images and scans, or pathology and biopsy reports) that are properly displayed (UP. 01. 01. 01) 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. (UP. 01. 03. 01) The Hospital is out of compliance with element of performance 3 under standard UP. 01. 02. 01.

This performance element should be implemented in the Site Identification and Verification Protocol. The protocol does not identify who is responsible for marking. Additionally, the protocol specifically states that marking is not required for bedside procedures if provider is present the entire time. This flexibility is not allowed in the standard. In addition to these deficiencies, two opportunities for improvement were identified. The Handoff procedure checklist is a useful tool, but there is no mention of this checklist in the Site Identification and Verification Protocol.

Also, the Protocol does not address premature infants and the allowance to not perform marking when the mark may cause a permanent tattoo A corrective action plan will be focused on ensuring that the identified noncompliances are corrected and evaluating opportunities for improvement. Specific elements of the corrective action plan are:

1. Revise the Site Identification and Verification Protocol to remove the incorrect information on bedside procedures. Target completion Date: 2/1/2012. Actionee: Standards and Communication Director.
2. Revise the Handoff Checklist to include “labeled diagnostic and radiology test results (e. . , radiology images and scans, or pathology and biopsy reports)”. Target completion Date: 4/1/2012. Actionee: Standards and Communication Director.
3. Revise the Site Identification and Verification Protocol to include reference to the Handoff Checklist. Target completion Date: 4/1/2012. Actionee: Standards and Communication Director. The results of this corrective action plan will be examined approximately six months prior to the Joint Commission audit. That will give adequate time to develop and implement further corrective actions, if necessary.

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