Continuous Accreditation Compliance - Task 4
AFT2 Accreditation Audit
October 31st, 2014
Continuous Accreditation Compliance - Task 4
Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment that provides for proper care and emphasizes patient safety. NCH has shown to be 100% compliant with the majority of standards including: Infection Prevention and Control, Right and Responsibilities to Patients, Human Resources, Transplant
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The Joint Commission (n.d.) states that, “Verbal orders are authenticated within the time frame specified by law and regulation”( Joint Commission, n.d., RC.02.03.07 - 4). With so many departments found to be in non-compliance during the process of just one audit this trend proves this issue is likely widespread throughout the entire hospital and that NCH is regularly non-compliant with this issue. The departments that did not show to have this non-complaint issue were: Cardiac Cath Lab, Endoscopy, ICU, OR, and Surgery Pre-op. To fix this issue, it is advisable to ascertain why and how some departments are meeting the standard while others are not. This issue may stem from improper procedures, training, a deficiency in staffing, or a lack of leadership in the non-compliant departments. Comparing and contrasting the departments should assist in resolving this non-compliant issue.
Prohibited Abbreviations There are two prohibited abbreviations that are tracked, “cc” and “qd”, as they are the most common. Throughout the year there has not been consistent improvement in the area. The trending data shows some improvement in parts of the year and then some months, April and September, to have increased spikes of use of prohibited abbreviations. During the PPR it was noted that the following departments were non-compliant concerning using prohibited abbreviations: 3E, 4E, ICU, and Telemetry. The
Preparing for The Joint Commission, Nightingale Community Hospital reviews areas of compliance and non-compliance. A periodic performance review, which is a self-evaluation, is utilized by Nightingale Community Hospital, to prepare for The Joint Commission. The Joint Commission has eighteen accreditation requirements. (Commission, 2013) The periodic performance review found the hospital to be compliant and non- compliant in the following areas:
The history of the Joint Commission on Accreditation of Hospitals is a story of the health professions’ commitment to patient care of high quality in the 20th century. According to Dr. Ernest Codman, founder of the accreditation system, which would enable hospitals to track every patient it treat long enough to determine whether or not the treatment was effective. If not, the hospital would figure out how to prevent similar failures in the future (Roberts, Coale & Redman, 1987).
The IC department performs about 20 reviews a quarter utilizing the Bloodstream surveillance checklist tool to monitor for PICC/Central Line compliance. Hand sanitizer rewards are now being given to staff that has 100% in the process measure to increase CLABSI compliance. Our facility is engaged in the Hospital Improvement and Innovative Network (HIIN) formerly the Maryland-Virginia HAI Improvement Network is the hospital-wide collaborative to reduce CLABSIs. This 5-year initiative is an affiliation of the Medicare Quality Innovation Network Quality Improvement Organization for Maryland and Virginia, through Centers for Medicare & Medicaid Services (CMS). The initiative offers support efforts to improve health care quality and achieve
The issue of quality improvement should be addressed with a multi-faceted approach. Once implemented, continuous oversight and monitoring must be conducted by an experienced staff member/case manager who can verify data in the EHR, as well as conduct a daily Braden Score assessment and confer with the staff nurse and physician, as needed. While HAPU/Braden
Patient care is the central focus in all of nursing. Understanding and adapting to patient needs is what separates the good nurses from the best nurses. The Hospital Consumer Assessment of Healthcare Providers and Systems is a 27 question survey that is given to patients in order to obtain an objective opinion of hospital staff, facilities, and equipment. It is standardized across the healthcare spectrum, and is a way to measure patient experience first hand (). It can be used to measure how well nurses are doing their jobs, and how well nursing students are being taught.
Why medical abbreviations should not be use in the medical field? Abbreviations can be used to save time, space, and have become be available everywhere in prescriptions and medical records. It help save times and space on the paper while writing on document such as prescription or medical record, but it have also causes misinterpreted and involvement in harmful medication errors. Therefore medical abbreviation should not be use when you are trying to communicate with medical information. Giving the wrong prescription to a patients can be harmful and sometimes life threatening. Another reason why medical abbreviation should not be use to communicate is there are frequency a confusion and you can also put your medical practice at risk.
| A milky white aqueous suspension of magnesium hydroxide use as antacid and a laxative.
November of 2004, medical abbreviations supported the "Do Not Use" list. They created a website and in approximately four weeks, Joint Commission received tons and tons of responds and comments. And more than 80% supported the "do not use "list. Reason why so many use it is because some pharmacists in the forms misunderstand some of the stuff that is written. In 2001, The Joint Commission a Sentinel Event Alert on the subject of medical abbreviations. They are also the ones that in 2004, The Joint Commission created its "do not use" list.
The use of abbreviations shortens length of many words thus really help healthcare professionals in saving time spent in writing notes. Abbreviations however do not always provide positive contributions due to misconceptions, misunderstandings, and misinterpretations leading to commitment of errors in the practice. Similarities in abbreviations for instance could root to a grave mistake. For instance the q.d. which an inscriber would like to indicate as every day could be erroneously interpreted as q.i.d. which means four times a day. Such error could result to over dosage when a certain medication is taken four times in a day instead of just once. Though some abbreviations can be easily
This is what is scary with today's health care systems. Many older healthcare Providers knows that bad habits are hard to break; they consistently give verbal orders to just about anyone who is wearing a uniform. They are too busy to find out what role he or she plays on the health care team. At my institution, even with the EPIC system, if a physician gives a verbal order, that order has to be sign when he or she gets to the hospital.
These hospitals perform well when the management team and employees work together to accomplish a higher quality of health care. When monitoring performance, hospitals review quality performance, quality assurance, compliance with regulatory and accreditation, and suggestions to improve organizational performance issues. Hospitals measure performance by comparing patient outcomes with expected outcomes usually done in quarterly predictions. The outcome will affect the medical facilities performance measures and reimbursement for government programs. Poorly performing health care facilities
In the article, Error-Prone Abbreviations, I learned so many more abbreviations that are commonly mistaken. Like “OJ” for example: it is mistaken for “OD” or “OS.” The person that misinterpreted the abbreviation may give a drug the patient’s eye that was just supposed to be diluted in orange juice. People also misinterpret drug names. “ARA A” is mistaken for cytarabine (ARA C), but it really is vidarabine. Getting drugs mixed up is very dangerous for a patients health and well-being. Using complete names will help solve the
Quality management departments collect and analyze data to ensure quality care that is safe and effective for patients. Positive outcomes are crucial for success, and are measured objectively to monitor, and revise improvement programs implemented. Regulatory and accreditation agencies set the standards for patient safety defining quality indicators that health care organizations measure, and evaluate to sustain accreditation with compliance. Data proves compliance with best practices and positive outcomes, increasing reimbursement and the number of individuals who will come to the organization for care. Administration leadership has found that
Hello Shekinah , I found your discussion post informative. I agree with you it can be a major problem if you mess up an medical abbreviations. In addition, medication errors can cause death and injuries to patients. There are numerous ways that an errors can occurs in medical treatment.
Okay so you've already heard how its okay to use abbreviations but…….. Is it really? Okay so it's actually proven that when kids use abbreviations that it gets stuck in their mind and when they go to type a paper or if they do it all their life then when they get older their gonna use abbreviations in a job interview and maybe not get it ,especially if it's a typing job.