Nightingale Community Hospital
Joint Commission Accreditation of Health care Organizations (JCAHO) or The Joint Commission (TJC) as it is known now, is a non profit organization in the United States which focuses on identifying and resolving problems faced by health care organizations and inspire them to improve the safety and quality of care and services provided. The Organization was founded in the year 1917 and has over 19,000 hospitals under its accreditation programs that focus on systems critical to the safety and the quality of care of treatment, and services. The accreditation process involves periodic performance review of health care organizations to ascertain if they follow the standards of safe medical practice as spelt by TJC. These findings are then made available to the public to help them in making educated choices for their health care needs. Many State governments and presently the Federal government recognize that compliance to TJC standards meet the conditions of participation for Medicaid and Medicare respectively.
In this article we will review the readiness for the accreditation audit of Nightingale Community Hospital. The PPR done on the afore-mentioned health care organization came up with the following results.
Current Compliance Status of Nightingale Community Hospital
The health care organization was found to be non compliant on some patient care services and Organization and delivery of health care services. In this section we will review the non-compliance of safety measures and delivery of health care services to the public, as stated in the TJC standards.
Health care organizations are required to conduct fire drills in all in patient facilities and ambulatory surgery centers at least 1 per shift in a quarter in order to maintain an Environment of Care. Their fire drill chart showed insufficient frequency in all of the above. Fire and smoke walls installed in the 1st and 4th floors of the Hospital showed penetrations that were improperly sealed. The capacity to hold fire within them was deduced to be less than 3 hours according to UL testing standards. This is against hospital safety standards, which require 4-hour fire containment. Hallways were cluttered with surgical equipments, mobile computers and other non- essentials, which pose a safety threat to patients. Placing of linen carts, stretchers and others in front of fire extinguishers affect Fire response methods. Fire sprinklers of retail outlets like gift shops did not have the required clearance of 18”. Alarm panels for medical gases have to be tested annually as per the rules laid down by the National Fire Protection Association (NFPA 99). Apart from these all valves must be checked for obstructions, leakage. The testing also makes sure that all shut-off valves are in perfect working condition as leakage of thee medical gases are safety hazards. These leakages cannot be gauged effectively if alarm panels are not checked and maintained in perfect working condition.
Interim Life Safety Methods (ILSM) that, require regular monitoring of construction sites within premises were not followed. It is important for hospital administration personnel to make sure activities of contractors do not pose safety risk to patients and visitors and hospital staff by obstructing emergency exit doors, keeping open doors wedged, not building a temporary wall enclosure around construction site, smoking in non-designated areas and other non-compliances.
Trends evident in the case study that proves that Nightingale Hospital is not compliant with the Joint Commission standards for patient care.
According to the data collected during the Periodic Performance review we see that the primary care institution has shown non-compliance to certain standards as required by the Joint Commission Standards for Patient Care. The report showed many patients rights to information was not followed.
Upon interview with staff it was noted that nurses did not follow a standard range order policy while administering medications. There was a discrepancy in procedures between the execution of orders issued and the standard practises of the health care organization. It is common practise of physicians to only prescribe a treatment or medication. The method of administering the medication is not specified and is a responsibility that falls on the nurse’s expertise. Health care organizations have guidelines and procedural methods specific to their organization. Nurses are supposed to follow the guidelines laid down by the organization they work in. Nurses in Nightingale community hospital were unclear of these guidelines and each followed different methods. This inconsistency goes against hospital procedures and compromises patient centered care. This trend was noticed in 4 East (4E) and in the Intensive Care Unit (ICU).
There was evidence of usage of prohibited abbreviations in notes prepared by nurses and physicians, which failed to provide accurate or assessable information for physicians as well as patients and patient’s family regarding the patient’s illness and status of recovery. Usage of the prohibited abbreviations “qd” and “cc” were analyzed as used in Intensive care units (ICU), 3 East oncology section (3E) and, 4East (4E) showed alarming 47% usage of “cc” and an average of 39% usage of “qd”. Joint commission standards prohibit the usage of these abbreviations because they can lead to careless mistakes. “q.d.” when referring to dosage means “every day”. The period in between the letters can be easily mistaken for “o” and read as “qod” which means “every other day”. Similarly “cc” can be used to refer to volume as well as the word “Chief complaint”. Interchanging of the meanings of these words can have dangerous repercussions.
Verbal orders were not authenticated by nurses and approved by physicians as is necessary thus indirectly affecting the continuity of effective treatment procedures to the patient. Lax in communication and failure to authenticate interferes with the ability of the health care institutions to keep track, conduct effective follow up and record history of treatment procedures. Verbal orders need to be recorded and approved within 48 hours as, it reflects on the time line of the treatment based on symptoms and reactions of patients to a certain medication or treatment. This trend was noticed in Emergency Division (ED), 5 East (5E), Principal Investigation (PI) data and Telemetry,
There was inconsistency of pain assessment. Patient’s pain level assessment is a methodical analysis that is based on previous medical history, reactions to situations, behavioural patterns and, patient’s threshold for pain among other things. This is then periodically reassessed during continual treatment to assess progress and effectivity of treatment. The health care center showed a lack of reassessment records also.
Patients were not clearly prepared for day surgery. There were insufficient assessment and, reassessment procedures prior to and on the day of procedures. These assessments especially in the case of day surgeries help the hospital to be better planned and not have last minute admissions. These also prepare the patient on what to expect from the procedure and help the family be better prepared for post-operative care and other incidental effects of the procedure. The patents need to be briefed to be very clear on what to expect from the pre-operative stage to the post-operative care. This trend was seen in Emergency Division (ED).
Procedural details for knee arthroscopy were not recorded in the Operating Room (OR). Arthroscopy sites have to be pre-marked and explained to the patients before procedure is commenced. Site marking is also necessary to avoid fatal errors in surgery. This violates patient care and safety rules.
Joint Commission standards require all patients to be monitored when being administered dosages of anaesthesia. All hospitals have to follow an Anaesthesia Information Management System (AIMS) where all events such as administration of drugs, blood products while a patient is under anaesthesia are recorded. Behavioural signs exhibited by the patient are monitored and recorded. Anaesthetist should also follow protocol and provide documented evidence according to hospital specified procedures and JC standards. There was evidence of lack of pre-sedation documentation as required by American Standards Association (ASA) in endoscopy.
Medical staff at Nightingale Hospital showed incompetence in knowledge of clinical procedures, understanding and implementing post procedure care. This Ongoing Professional Practice Evaluation (OPPE) incompetence was ascertained by interview with the medical staff. Unlabeled basins found in the Operating Room (OR), prove a threat to patient safety. Basins medications and other items kept in sterile environments require sterile markings or labels and have to be identified by the Nurses stationed at these environments. Unmarked sedation medications like Propofol syringes in the OR and catheterization laboratory can be dangerous if administered by mistake and in incorrect dosages. There were also instances of pre-packed unit dose syringes, which had not been repacked by hospital administration to ensure correct dosage. Therefore procedures laid by National Patient Safety Goals (NPSG) were not followed.
Staffing in Nightingale Community Hospital:
Analysis of Performance Improvement Standards
Analysis of staffing patterns adopted by Nightingale Community hospital was made in order to determine staffing patterns and suggest plans. There was evidence of unauthorized and unrecorded overtime work by some Nursing staff due to Nurses not clocking in and out as required. Interview with staff revealed that this was because they were short staffed and too busy with nursing duties to maintain this procedure. This resulted in low morale amongst staff.
Measures were taken to reduce percentage of patient falls in ICU and other post procedure recovery departments. Ventilator associated pneumonia (VAP) was reduced by discontinuing sedation for a period to enable the patient to recover and come back to optimum consciousness. This has an indirect effect on staffing pressures. VAP increased the duration of hospitalization per patient as well increased costs. Sedation vacations implemented thus also saw a reduction in patient falls in ICU, oncology and others.
Compliance Grading and Staffing plan proposal
As ascertained by the above research and analysis, Nightingale Community Hospital does not provide a logical discussion of any trends evident in the case study for non-compliance to Organization of health care services. They however provided some logical explanations and employed methods to rectify non-compliance in patient care and staffing patterns thus adhering to TJC standards for accreditation upon rectification of all issues stated above. The hospital has also been able to identify the defects with regards to their staffing pattern and have employed methods to minimize the number of patient falls in the hospital. The staffing plan provided showed detailed research and competent in its proposal to reduce the number of patient falls.
The Agency however also proposed the following plan to improve staffing patterns and service rendered to the patients, which, could also indirectly work towards minimizing the number of patient, falls in the hospital.
1. Easy access to medical equipment and design and layout of patient rooms and nurse station to enable easy access to medical equipment, medication can cut down the time dedicated by nursing staff for getting themselves organized.
2. Automated data recording, Standardized automated procedures for drug administration and organization of medical records and medicine supplies which includes physicians instructions to reduce paperwork and able to spend more time in patient care.
3. A good balance of licensed practitioners and qualified, experienced nursing personnel per department to aid quality patient care.
4. Nursing staff should be given access to professionals in their field to aid in counselling, upgrading of their skills.
5. Periodic performance appraisals combined with incentives to be given to nursing staff to motivate and boost staff morale.
Apart from these the administrative staff and management should improvise on communication standards in the organization to prevent unequal work overload in different departments. There should also be periodic analysis conducted to review outcomes of staffing plan methodologies to aid the smooth running of all departments in the Organization.
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