Accreditation Audit

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.

With an audit by the Joint Commission (JC) in the near future, Nightingale Community Hospital (NCH) is performing a tracer patient survey to measure our compliance and identify issues that are in need of remediation. The practice of this type of survey tracks a patient’s care for the duration of their stay starting from the admission process and ending when they are discharged. This system allows us to assess our strengths and weaknesses concerning policy, procedures, and systems in place to provide quality care in conjunction with the standards set forth by the JC.

Abbreviations as part of the communication plan; currently Nightingale Community evaluates the non-approved abbreviations monthly and has made improvements during the accreditation audit period. Non

As our Joint Commission audit approaches, Nightingale Community Hospital has conducted a tracer patient survey to assess our compliance. The tracer methodology tracks a selected patient's care from admission to discharge, allowing us to evaluate our systems of providing care and to ensure that we are meeting the Joint Commissions standards of providing safe, quality healthcare.

Second is consistent approach in using evidence –based clinical practice guidelines for the ACS and AMI clientele. Thirdly is the collection and analysis of the four performance measures for chest pain patients. If a chest pain centers program meets all of these qualifications will be awarded certification for a two year period.

Information from the medical case management performance measures were categorized based on different ranges: 90%. According to the information presented for medical visit frequency: 9 recipients reported less than 70%, 9 recipients reported data between 70-79%, 9 recipients reported between 80-89%, and 9 recipients reported data greater than 90%. The information presented for developing a care plan showed: 6 recipients reported data less than 70%, 6 recipients reported data between 70-79%, 7 recipients reported data between 80-89%, and 13 recipients reported data > 90%. The information presented for adherence counseling and assessment showed: 4 recipients reported data less than 70%, 1 recipient reported data between 70-79%, 3 recipients reported data between 80-89%, and 12 recipients reported data greater than 90%.

All six practices were measured utilizing the organizations standards with a 72% average for all questions supported by CABC. The evaluated sites reported 100% for annual review of protocols/polices and measuring utilization of services. In regard to evaluating client satisfaction, evaluation of appropriate services, and clinical practitioner meetings to improve the plan of care there was 83% (n-6) compliance. Participation in data registry scored lowest in the cohort with only two sites following this CABC

CQC Report For North Middlesex Hospital Date of inspection visit: 3-6 June 2014 & 23 June 2014

The current practice in my hospital for assessing the level of pain on a scale of 1-10 with 10 being the worst pain is part of the vital sign procedure. The inpatients are asked to rate their pain and are documented in the electronic health record. If the patient says he/ she is in pain, the first step is to detect the characteristics, by asking when the pain started, the area, what make it worse and how strong the pain is and charting the results. In addition a physical assessment- head to toe-will be conducted by means of inspection, auscultation, palpation, and percussion and notifying the provider about the patient’s condition.

Statistical reports can also be created for the hospital at this point. Other reports can be run to make sure the facility is stating in compliance with state and federal guidelines. Daily census, facility monthly statistics and licensure reports can also be run to help with compliance. Readmission rates can be monitored to see if there is a specific part of the hospital that needs improving.

Within healthcare institutions evaluation of patient satisfaction serves two purposes. First, patient specific needs can be met, rectification can take place, and specifically designed solutions to resolve safety problems and concerns can be implemented. Second, comparisons can be made between institutions and focus is placed on system-wide issues in patient care. This requires an in-depth examination of patient complaints to pinpoint areas of systematic safety and quality, as well issues in standard of care (Reader, 2014).

In order to quantify which hospital provide the patient with enough and sufficient information, each response for each variable in the question was made with a point score (Score sheet explained in details in Appendix 4).

The data are collected from observation of over 100 patients’ visits, 50 of which were observed and audio taped. The research questions that are asked by Davidson are:

This study uses a particular survey within the overall framework of the CAHPS instrument, namely the Clinician and Group survey. The paper will utilize the latest version 3.0 shown in the appendix below. This survey measures patients’ perceptions of technical, process and structural quality of care. In addition, the survey contains a set of questions asking patients to evaluate their experience with the doctor, staff and facility as a whole. In the questionnaires, include both standardized and open ended questions regarding various aspects of patients’ experience. The survey taps patients’ ratings of the quality of responsiveness, communication, respect, coordination and more importantly the quality of the health service provider.

Reference: Dickinson EJ (1991) Quality hospitals: the role of medical audit. Geriatric Medicine 21: 27-8, 31-2. Citations in the text # Use only the author*s/s ' surname(s) and year of publication, with the addition of page number(s) if required, e.g. (Swann, 1981, p. 10). # Where sense demands, the name of the author(s) can be incorporated into the text, e.g. Strauss and Ziegler (1975) outline the main goals of the Delphi technique, with Turoff (1970) identifying four secondary goals. # If two or more works by the same author(s) have the same publication date, they should be distinguished by adding lower case letters after the date, e.g. (Tschudin, 1992b).