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Accreditation Audit









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Nightingale Community Hospital
Communication Priority Focus Area Executive Summary

Nightingale Community Hospital is a not-for-profit, acute care hospital consisting of a
total180-beds. Service area specializations include: general medical/surgical services, critical
care and emergency services, oncology, telemetry care, vascular lab, neuroscience unit,
orthopedics, imaging services, obstetrics, endoscopy, and finally, a level II nursery. Nightingale
Community Hospital prides itself on providing leadership in quality health services. In particular,
they provide compassionate and cost-effective service in the lines of treatment and prevention.
The vision of the hospital is to be the hospital of choice for patients, employees, physicians,
volunteers, and the community. To further this vision the mission is to create a healing
environment with a passionate commitment to healthcare excellence.
Nightingale Community Hospital is an active participant with the Joint Commission in
order to receive Joint Commission Accreditation. Approximately two years ago, the Joint
Commission provided findings as a result of their survey audit. The Hospital is now just 13
months away from the next Joint Commission visit and therefore actively engaged in the process
of preparation. The remainder of this paper will focus on the audit findings that specifically
relate to the Communication Priority Focus Area. Ultimately these findings have provided the
impetus for the hospital to pursue a corrective action plan. Said plan includes specific patient
safety goal data which has been generated through rigorous internal hospital assessment and
analysis. This data will then be incorporated into the overall hospital implementation strategy as
it relates to the Communication Priority Focus Area.


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Communication Priority Focus Area
According to the Joint Commission Priority Focus Process Summary, communication is
the process by which information is exchanged between individuals, departments or
organizations. Effective communication successfully permeates every aspect of a health care
organization, from the provision of care to performance improvement, resulting in a marked
improvement in the quality of care delivery and functioning. Sub-processes of communication
include:
Provider and/or staff-patient/client/resident communication
Patient/client/resident and family education
Staff communication and collaboration
Information dissemination
Multidisciplinary teamwork (pg. 2)
The Joint Commission provided findings as a result of their survey audit that were directly
pertinent to the Communication Priority Focus Area. Specifically, they pertain to Joint
Commission standard LD.04.01.05.
Joint Commission Standard LD.04.01.05 states The Hospital effectively manages its
programs, services, sites, or departments. The survey audit finding illustrated:
It was evidenced through interview with three staff nurses that the leaders had not
effectively communicated to the nursing staff the policy related functional screening
criteria. Interview of three staff nurses revealed that they were not aware of the functional
screening process the hospital had implemented


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Joint Commission findings
As mentioned previously, one of the findings during the survey audit was that effective
communication had not occurred with staff nurses to ensure that the policy related functional
screening process was being implemented. Naturally, this level of communication is vital in
order to assure that the patient is receiving the proper care.
Following the audit a rigorous internal hospital assessment and analysis was undertaken in
order to quantitatively assess patient safety goal data. This assessment provided a baseline of
data and enabled clearer insights into the findings of the audit. As a result of the aforementioned
occurrence, the following data was observed:
Hospital-wide compliance of reporting critical results within 60 minutes (Jan-Dec)
Low: 56% (June); High: 82% (Aug, Nov) ; Average: 69.8%
Verbal Order/ Read Back Audits (Fiscal Year to Date)
Low: 62% (Orthopedic); High: 100% (Emergency Dept.); Average: 92.5%
Time Out Hospital-Wide (Jan-Dec) has steadily increased each month to a high of
100% in Dec
Hospital-wide compliance of reporting critical results within 60 minutes appears to be a
systemic problem within the hospital. The data provided during the calendar year does include a
trend for improvement during the latter part of the year (Sept-Dec): however, these percentages
range from 77%, 78%, 82%, and 80% respectively. It should be noted that the high was in
August coming off a yearly low of 56% and 57% in June and July. Reporting critical results
within 60 minutes will be discussed in additional detail later in this report.
Verbal order/ Read back audits was an area of concern for three service areas, namely
orthopedics (62%), surgical units (91%), and medical units (96%). All other service areas
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achieved effectiveness of communication at 97% or higher. The three service areas mentioned
will be discussed in additional detail later in this report in order to propose a plan of action for
proper implementation of verbal order/ read back audits.
Hospital-wide time out has been very effective; nonetheless, additional information will be
provided in order to assure that Joint Commission standards are being achieved.
Critical Results
According to Singh (2010), health care organizations continue to struggle to ensure that
critical findings are communicated and then acted on in a timely manner. Singh highlights
research associated with communication breakdowns along the entire test result spectrum.
Simply put, the risks of communication breakdown apply not only to critical values but also to
non-life threatening test results as well. A non-life threatening test result should be treated with
prompt, professionalism for the following reason. Suppose an outpatient clinic performs a chest
x-ray wherein a suspicious shadow is discovered. Naturally, this discovery warrants an additional
level of professional coordination in an expeditious manner to ensure the patient receives a
timely evaluation. Although it may not necessarily be a critical result/finding it most certainly
becomes escalated within the process.
Hospital-wide compliance of reporting critical results within 60 minutes appears to be a
systemic problem within the hospital. The data provided during the calendar year includes a
trend for improvement during the latter part of the year (Sept-Dec); however, these percentages
range from 77%, 78%, 82%, and 80% respectively. It should be noted that the high was in
August coming off a yearly low of 56% and 57% in June and July. The average over the 12
month period was 69.8%.

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Critical Results-Action Plan
The Joint Commission has prioritized safe and timely communication of critical test results
as a National Patient Safety Goal (NPSG 02.03.01), Report critical results of tests and
diagnostic procedures on a timely basis. The elements of performance for NPSG 02.03.01 are
as follows:
1. Develop written procedures for managing the critical results of tests and diagnostic
procedures that address the following:
a. The definition of critical results of tests and diagnostic procedures.
b. By whom and to who critical results and tests and diagnostics procedures
are reported.
c. The acceptable length of time between the availability and reporting of
critical results of tests and diagnostic procedures.
2. Implement the procedures for managing the critical results of tests and diagnostic
procedures.
3. Evaluate the timeliness of reporting the critical results of tests and diagnostic
procedures.
Recommendation

Nightingale Community Hospital, in accordance with Joint Commission Safety Goal
2008, shall define critical tests as those that require communication of results regardless of
finding (e.g. normal, abnormal, and critical). Critical tests shall be reported to authorized staff:
(RN, LPN, MA, RP, MD, PA, NP, and APNP.) The acceptable length of time between ordering a
critical test and receipt by the responsible caregiver (regardless of finding) will be within 60
minutes.
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Verbal Orders/ Read Back Audits
Verbal orders/ Read back audits was an area of concern for three service areas, namely
orthopedics (62%), surgical units (91%), and medical units (96%). It is believed these areas are
of particular importance due to the skilled nature of professional medical service being provided
as well as the increased level of communication necessary as a result of said services. The Joint
Commission Accreditation Requirement (PC.02.01.03) stipulates, Before taking action on a
verbal order or verbal report of a critical test result, staff uses a record and read back
process to verify information.
Verbal Orders/Read Back Audits-Action Plan
According to the Singh (2010), At our institution a critical imaging test is defined as any
imaging study, called in to the radiologist by telephone as a STAT exam. The order clearly
defines the complete contact information for the ordering provider. To determine whether the
studies are complete and reported within acceptable time limits, our policy identifies three
critical tests to be completed within 60 minutes of order.
As mentioned in the Critical Results section, it is acceptable for critical results to be
communicated to authorized staff, which would then be accountable for communication to the
responsible caregiver. If/when a patients provider cannot be reached and does not respond to a
call, the call will be repeated in 15 minutes. If successful contact cannot be made then the on-call
physician will be paged. To ensure accurate communication, telephone reporting of results from
critical tests (regardless of finding) requires a read-back of information by the person receiving
the test result. The person receiving the test result will write down the result and read it back to
the person providing the result. The person providing the result will then provide a verbal
confirmation that the information was in fact read back.
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Recommendation

Nightingale Community Hospital, in accordance with The Joint Commission Accreditation
Requirement PC.02.01.03, will ensure that before taking action on a verbal order or verbal report
of a critical test result, staff uses a record and read back process to verify information. In order
to accomplish this goal the following departmental verbal order/ read back policy will be
implemented:
General medical unit/surgical unit/ orthopedics: The Patient Service Representative (PSR)
responds to notification of a critical result by notifying the appropriate nurse or medical
assistant via phone. The nurse or medial assistant will notify the provider of the critical
result and complete the NPSG Reporting Critical Results worksheet. If the phone line is
unavailable, the PSR will initiate the NPSG Reporting Critical Results worksheet,
completing the patient name, birth date, and PSR Section of the worksheet. The PSR then
hand delivers said worksheet to the appropriate nurse or medical assistant. Said nurse or
medical assistant will then notify the provider of the critical result and complete the NPSG
Reporting Critical Results worksheet.
Time Out
Nightingale Community Hospital recognizes the importance of verification and
communication prior to, and during medical procedures. As such, The Hospital has formally
implemented the Site Identification and Verification (Universal Protocol) Policy. This policy
recognizes that wrong-site, wrong-procedure, and wrong-person surgery can be prevented.
When an individual begins the preliminary intake they embark on the Preoperative/Pre-
procedure Verification Process wherein verification of the correct person, procedure, and site
occurs. From here, the next step is marking the Operative/Invasive Site wherein identification
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and marking occurs on the skin and is confirmed by the MD as well as the patient. Finally, once
in the OR a Time-Out Procedure is performed. All members of the team are participants in the
time-out; the nurse or technologist verbally conveys the following to the participants:
Correct patient identity
Correct side and site
Correct procedure to be performed
Correct patient position
Availability of correct implants and any special equipment
Once the nurse or technologist conveys the above all members shall verbally affirm
agreement. Any/all team members may request clarification at any time. Patients who are awake
during the time-out process should be active participants.
Time-Out-Action Plan
Hospital-wide time-out has been very effective for Nightingale Community Hospital. From
the time period January through December, Time-Out percentages have steadily increased each
month to a high of 100% in December. This is in large part to the implementation of the Site
Identification and Verification (Universal Protocol) Policy mentioned previously. This Protocol
utilizes the Joint Commission standards mentioned below; due to their effectiveness in attaining
time-out goals these standards will continue to be utilized.
Recommendation

The Joint Commission understands that wrong patient errors occur in virtually all stages of
diagnosis and treatment. As such, they formally adopted National Patient Safety Goal (NPSG
01.01.01), which states Conduct a pre-procedure verification process. The elements of
performance for NPSG 01.01.01 are as follows:
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1. Implement a pre-procedure process to verify the correct procedure, for the correct
patient, at the correct site.
2. Identify the items that must be available for the procedure and use a standardized
list to verify their availability.
3. Match the items that are to be available in the procedure area to the patient.
The next National Patient Safety Goal is (NPSG 01.02.01), which states Mark the
procedure site. The elements of performance for NPSG 01.02.01are as follows:
1. Identify those procedures that require marking of the incision site. At a minimum,
sites are marked when there is more than one possible location for the procedure in
a different location would negatively affect quality or safety.
2. Mark the procedure site before the procedure is performed and, if possible, with the
patient involved.
3. The procedure site is marked by a licensed independent practitioner who is
ultimately accountable for the procedure and will be present when the procedure is
performed.
Finally, National Patient Safety Goal is (NPSG 01.03.01), which states A time out is
performed before the procedure. The elements of performance as follows:
1. Conduct a time-out immediately before starting the invasive procedure or making
the incision.
2. The time-out is: defined by the hospital; initiated by a designated member of the
team; involves the immediate members of the procedure team.
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3. 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.
4. During the time-out, the team members agree, at a minimum, on the following:
correct patient identity, correct site, the procedure to be done.
5. Document the completion of the time-out.

Conclusion
Nightingale Community Hospital will be better prepared for the Joint Commission audit
by adhering to the aforementioned recommendations. Ultimately, increased levels of
communication provide innumerable opportunities for the Hospital to achieve its vision of being
the hospital of choice for patients, employees, physicians, volunteers, and the community.
Through a renewed effort to: increase hospital wide compliance of reporting critical results;
improve verbal order/read back audit performance; and, continue hospital-wide time-out protocol
the Hospital will reach its vision. And, in doing so it will also reach the pinnacle benchmark
standards set by the Joint Commission.

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References
Singh, H. (2010). Eight Recommendations for Policies for Communicating Abnormal Test
Results. The Joint Commission Journal on Quality and Patient Safety, 36, 226-232.
The Joint Commission, E-dition. Retrieved May 24, 2013 from: https://e-
dition.jcrinc.com/MainContent.aspx
The Joint Commission, Priority Focus Process Summary. Retrieved May 22, 2013 from:
http://www.jointcommission.org/about/jointcommissionfaqs.aspx