Periodic Performance Review A Periodic Performance Review is a compliance evaluation instrument used to assist organizations with their ongoing observation of performance and routine development actions. The PPR is an outlines for constant standards compliance and concentrations on the direction and processes that affect patient safety and care. Noncompliant Trends The Joint Commission medical staff standards defines evaluation standards, the commission pushes hospitals toward unbiased and evidence-based decisions in credentialing and privileging.
In this scenario the rules and policies are clearly mapped out, yet they are not being properly followed. The verbal order audit results seem to have no consistency. These standards now outdate a lot of hospital policies and practices prevailing equally internal and external peer review, and call for a comprehensive revision to comply with Joint Commission performance evaluations. The month of March is the highest, while August is the lowest month. The months in between were about the same from eighty-two to eighty-eight. The issue that needs to be address is what took place between March and August.
After carefully looking over the charts provided for both 3 & 4-east, there isn’t a huge indicator that supports the similarity for falls vs. nursing care hours per patient. November and April were the only two months that a noticeable improvement was made, meaning the nursing hours increased and the falls decreased. Although, the very next month the falls increased drastically, it went from two to eleven falls, while only one hour was increased. Staffing Patterns The safety and quality of patient care is honestly correlated to the size and experience of the staff.
These working conditions have deteriorated in this facility because the hospitals have not kept up with the growing demand for medical staff. The Joint Commission along with some state regulations measures some bare minimum level of staffing that all hospitals must meet regardless of the types and severity of patients. Pressure ulcer prevalence vs. nursing care hours was more of a parallel comparison, as the staffing hours increased the pressure ulcer prevalence decreased. While the intensive care unit was very noticeable in relating the falls vs. ours. In September when the nursing hours per patients dropped it was evident that the number of patient falls increased and they came was with VAP vs. hours. The corrective action plan should take this data into consideration to improve the staffing model, to also decrease patient falls which was be shown through this root cause analysis. The hospital requires at least one fire drill per shift per quarter. It seems that only the 1st shift is in compliance. Both the 2nd and 3rd shift have no rhyme or rhythm to how they are conducting the fire drills.
This needs to be address immediately by a member of management. Also, a manager or assistant should be required for scheduling the fire drill and must sign off on completion. Moderate Sedation Monthly Audit is overall in the ninety percentile there are still many areas for improvement. Any of the area that was below the ninety marks is an area for opportunity. Such as Mallampati Classification, ASA, Sedation Plan. Reassessment, and oxygen saturation monitored for thirty minutes, all of these area were below ninety percent for all for quarters.
Therefore, it’s a trend that needs to be addressed. The number of falls in the 4-East wings is disturbing when it’s put next to the targeted number, this is unacceptable. A substitute process that has the possibility to improve staffing issues and improve payment to hospitals would be to frankly connect the costs and billing for inpatient health care with hospital reimbursement. The action plan needs to provide
Staffing Plan There are two sides to the staffing issues. One side would be the nurses point to confirmation linking quality patient care to higher nurse-to-patient staffing ratios. While the other side would be hospital economic teams are being asked to discover ways to improve manage costs in expectation of declining expenditure under health development. The argument is not new. Nursing and financial management have had long debates on how to staff efficiently and make certain the right number/mix of nurses to meet patient needs.
An action plan needs to be put into place and monitored extremely closely by a member of management. There is no reason why they actually and targeted number are so off track. A patient care assistant should be there to assist patients with movements, especially for those patients who have a history of falls or injuries. Reviewing the overall hospital falls and injuries I noticed that it’s closer to the targeted number, but there are still many areas for development. The suggestion is that hospital must address conflict of interest when credentialing, privileging and conducting peer reviews of physicians. |