Essay on Accreditation Task 2

1116 Words Jul 14th, 2013 5 Pages
A1
EXECUTIVE SUMMARY Nightingale Community Hospital is a 180-bed acute care center that provides a myriad of services for our local community. From our state of the art Vascular Lab to our Neuroscience Unit we strive to provide cutting edge technology with exceptional care. Our vision is to be the hospital of choice for patients, employees, physicians, volunteers and the community. Our mission is to create a healing environment, with a passionate commitment to healthcare excellence. Through our vision and mission, Nightingale Hospital strives to meet and exceed all expectations during our next Joint Commission visit. Before we address the aspects of our upcoming visit from Joint Commission, we must address the foundation
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UP.01.01.01 Conduct a preprocedure verification process
2. UP.01.02.01 Mark the procedure site
3. UP.01.03.01 A time-out is performed before the procedure
The reason that we are addressing the three identified above is because elements of these can be traced back to deficiencies from our last JCAHO survey. The past deficiencies are:
1. RC.02.01.03 The patient’s medical record documents operative and other high-risk procedures and the use of moderate or deep sedation or anesthesia. a. JCAHO found – An operative progress note was not evident in 2 of 21 closed medical records. 2. LC.04.01.05 The hospital effectively manages its programs, services, sites or departments. a. JCAHO found- Failure of communication in regards to functional screening criteria. Nurses were not aware of the processes put in place by the hospital. 3. PC.03.01.01 The hospital plans operative or other high-risk procedures a. JCAHO found- Medical records of patients undergoing procedure were not complete. To address all of these findings we need to look at our current protocol and make adjustments so it is in line with current JCAHO requirements. Our current protocol is broken down into the following subsections: Policy, Preoperative/Preprocedure Verification Process, Marking the Operative/Invasive Site, Patient Procedure and Site Verification, Time-Out Procedures and finally Bedside Procedures. In the following sections the

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