The Joint Commission Study Essay Example for Free

The adjunction kick Study EssayExecutive SummaryThe Joint Commission is scheduled to visit Nightingale comp some(prenominal) Hospital for its triennial accreditation survey at heart the next 13 months. The purpose of this document is to provide sr. leadership with an outline of the hospitals current meekness status in the Priority concenter Area of Communication. Recommendations for corrective action atomic number 18 included in this document which are designed to knead the judicature into full conformation in the areas where deficits have been identified. The Priority Focus Area of Communication includes 3 Joint Commission (JC) standards relative to planetary Protocol. These 3 standards, which are components of the National Patient Safety Goals, are aimed at ensuring the correct force is performed on the correct patient at the correct site. UP.01.01.01 requires the organization to exculpate a pre- subprogram verification process prior to the start of any procedure . The hospital meets this standard by interest its polity titled Site Identification and Verification (Universal Protocol) which describes the process that is used prior to the start of any private eye or invasive procedure. The hospitals use of the Pre-Procedure Hand-Off checklist provides the documentation required to demonstrate abidance with the standard. Because of the criticality of this standard, I recommend a focused medical record review to measure compliance with the use of the pre-procedure checklist.If the audit reveals the checklist is completed consistently, full compliance with the standard will be verified and no further action will be required. UP.01.02.01 requires the organization to mark the procedure site before the procedure is performed. The Site Identification and Verification form _or_ system of government describes the process for marking the operative site besides the policy as written does not meet the full intent of the standard. The policy states the patient will discern and mark the operative site. Element of Performance 3 of the standard requires the procedure site to be attach by the licensed independent practitioner who is accountable for the procedure and will be present during the procedure. EP 5 requires a written process for patients who refuse site marking or when it is impossible or crazy to mark the site. This written process is absent in the hospitals policy. Nightingales policy and process must be revised immediately to reflect all the required elements of the standard. Hospital physicians and stave mustbe educated on the necessary changes and the revised process must be commit into action. at one time these changes have occurred, I recommend a focused audit to ensure full compliance with the revised policy/process. UP.01.03.01 requires a time-out before the start of the procedure.The Site Identification and Verification policy describes the time-out process however the policy falls short of fully meeting the intent of this standard. EP 2 describes which team members must participate in the timeout, EP 3 requires a time-out before each procedure when two or more procedures are being performed, and EP 5 requires documentation of the time-out. These 3 elements are deficient from the hospital policy/process and therefore revisions to the process/policy are necessary to include these 3 elements. Nightingales Safety Report reveals increasing compliance (nearing 100%) with the time-out process, however as mentioned above, EP 5 requires documentation of the process. In addition to the policy revision, I recommend the development of a ludicrous form which will be used to document completion of the time-out and the names of the participants in the time-out. Once these changes have been implemented, I recommend additional auditing to ensure full compliance with documentation of the time-out process. The Joint Commission reports more than 900 Sentinel Events related to misuse site surgery oc curred between 1995-2010 (The Joint Commission, 2010) Their investigate found that 70% of the time, the root cause of wrong site surgery was communication failure (Mulloy and Hughes 2008).When it occurs, wrong site surgery can be devastating for patients and it can leave a lasting, negative regard on the surgical team. Surgeons are at risk of losing their license and hospitals risk losing reimbursement. When these events occur the risk of litigation exists as well. Wrong-site, wrong-procedure and wrong-person surgery can be prevented The Priority Focus Area of Communication as it relates to Universal Protocol is essential to Nightingale Community Hospital for preventing wrong site surgery and promoting a just environment inside our hospital. The hospitals Site Identification and Verification policy was developed with levelheaded intentions to meet that goal. The 3 key elements to preventing wrong site surgery 1) pre-op verification process 2) marking the operative site and 3) t aking a time out, are all present in the policy however there are additional elements required by the Joint Commission that are missing from the policyand leave the organization and patients at risk.In order to live up to our core value of recourse and to ensure full accreditation with the Joint Commission, it is important for the organization to fully meet all the elements of performance. The changes outlined within this document will strengthen the policies and procedures that are intended to prevent harm to patients and will bring the organization into full compliance with the JC standards. These actions will ultimately ensure that a truly safe environment exists within the walls of Nightingale Community Hospital for the benefit of its patients, associates and the community.ReferencesThe Joint Commission. (2010, 11 23). Sentinel event statistics as of family line 30, 2010. Retrieved from http//www.jointcommission.org/assets/1/18/Stats_with_all_fields_hidden30September2010_(2).p df Mulloy, D. F., Hughes, R. G. (2008). Patient safety quality an evidence-based handbook for nurses. Rockville, MD Agency for Healthcare inquiry and Quality. Retrieved from http//www.nlm.nih.gov/books/NBK2678/